Abstract
Introduction/Objective
Infection with Pneumocystis jirovecii remains a common cause of pneumonia in patients with Acquired Immune Deficiency Syndrome (AIDS). Extrapulmonary manifestations, however, are exceedingly rare. We describe a rare case of coinfection of the small bowel by Pneumocystis jirovecii and cytomegalovirus (CMV).
Methods/Case Report
A 48-year-old female with a history of HIV/AIDS, remote history of Pneumocystis jirovecii pneumonia, and previous non-compliance with HAART, presented to the emergency department with right lower quadrant abdominal pain, fever, and chills for 1 week. Her recent medical history included a hospital admission 1 month prior for community-acquired pneumonia with CD4 count and viral load of 12 cells/mcl and >680,000 copies/mL, respectively; upon discharge she restarted HAART. When she presented to the emergency department in our case, she demonstrated leukocytosis (14.3 K/mcl), tachycardia (131 bpm), and hypotension (87/58 mmHg). An abdominal CT scan showed free air with concern for perforated viscus and multi-station lymphadenopathy with gastrohepatic and retrocaval nodes >2 cm. A chest x-ray showed nodular and cavitary lesions, stable from prior imaging. The differential diagnoses in an AIDS patient with a gastrointestinal mass includes Kaposi’s sarcoma, lymphoproliferative process, or infection. The surgeons were concerned for tuberculosis as well, due to the hospital’s patient population, her bulky lymphadenopathy, and immune-compromised status. An exploratory laparotomy was performed and found jejunal perforations, mesenteric lymphadenopathy, and 3L of fluid in the abdomen. Pathology received 4 soft lymph nodes and a 57 cm segment of thickened small bowel with purulent perforation but no discrete mass. Microscopic examination showed a perforating pseudotumor and acute serositis extending to the margins of the specimen. Lymph node flow cytometry was negative for clonal populations. GMS stains highlighted innumerable “crushed-ping-pong-ball”-like fungal forms consistent with Pneumocystis in the jejunum and all 4 lymph nodes. A CMV immunohistochemical stain highlighted infected cells with nuclear enlargement and nuclear inclusions in the jejunum.
Results (if a Case Study enter NA)
NA
Conclusion
Extrapulmonary Pneumocystis infection is rare but clinicians, pathologists, and microbiologists must keep it in the differential of HIV patients, especially those who are not controlled on antiretroviral therapy.
Small Bowel Obstruction Caused by Internal Hernia through a Peritoneal Defect of the Pouch of Douglas: Report of a Case and Review of the Literature