71. A man in his thirties living with HIV with rectal pain after antiretroviral initiation
Session: Posters in the Park: Posters in the Park
Wednesday, October 3, 2018: 5:30 PM
Room: N Hall D Opening Reception and Posters in the Park Area
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  • Final Diagnosis:

    Syphilis presenting as a rectal ulcer in an HIV-positive man undergoing immune reconstitution due to Kaposi’s Sarcoma.

    Brief history of the Present Illness:

    A man in his thirties living with HIV presented with 2 weeks of constant rectal pain, straining and liquid leakage through the anus without fecal incontinence. He denied fevers, chills, night sweats, hematochezia, skin or genital lesions.

    Past Medical History including allergies (if relevant):

    HIV infection had been diagnosed one year before in the setting of weight loss and diarrhea with a baseline RNA viral load of 692,000 copies/mL CD4+ count of 65 cells/µL (normal range 359 – 1519 , and negative VDRL, hepatitis B surface antigen and hepatitis C antibody. The patient began ARV therapy with EFV/FTC/TDF but did not achieve plasma HIV RNA levels below the lower limits of detection after 24 weeks of treatment.

    A genotypic resistance-test was performed revealing the following mutations: K65R, M184V for nucleoside/nucleotide reverse transcriptase inhibitors; L100I, K103N for non-nucleoside reverse transcriptase inhibitors; and M36M/I, A71A/V for Protease inhibitors.

    Key Medications (if relevant):

    Eight weeks prior to the patient’s present illness ARV therapy was changed to ATV/r+3TC/AZT. He was also taking Tramadol and Etoricoxib as necessary for his pain.

    Epidemiological history (if relevant, such as habits, social and family history, animal exposures or travel):

    He was born and lived in northern Mexico. He had a remote history of having sex with men but reported that he hadn’t had sexual partners in the last five years. He didn’t smoke, drink alcohol or use illicit drugs.

    Physical Examination:

    The patient appeared well and had vital signs within normal limits. Head, cardiac and pulmonary exam was normal. Abdominal examination revealed mild hypogastric tenderness not associated with rebound. Genitourinary examination was unremarkable. There was no rash. Normal anal tone without identifiable rectal masses or irregularities but with diffuse tenderness starting at 3 cm from the sphincter.

    Studies:

    The complete blood count was normal as were the tests of renal and liver function. An MRI was obtained observing thickening of the rectum with extensive inflammation of the perirectal tissue with multiple enlarged lymph nodes (figure 1).

    Clinical Course Prior to Diagnosis:

    The decision was made to perform an anoscopy where diffuse violaceous lesions were observed biopsied. The lesion was CD31, CD34, ERG and HHV-8 positive and Kaposi’s sarcoma (KS) was diagnosed (figure 2). The sarcoma was ulcerated and contained a lesion where the vascular structures were surrounded by lymphocytes, macrophages, plasma cells, and fibroblasts (figure 3).

    Differential Diagnosis:

    1. Plasmablastic Lymphoma
    2. Mycosis fungoides
    3. Treponema pallidum
    4. Mycobacterium tuberculosis
    5. Klebsiella granulomatis

    Diagnostic Procedure(s) and Result(s):

    Warthin–Starry and anti–Treponema pallidum immunohistochemical stains were ordered and were reported as positive for the presence of spirochetes (figure 4).

    Treatment/Follow-up:

    Neurosyphilis was ruled-out and intramuscular benzathine penicillin was administered. A new RNA viral load was obtained and confirmed adequate virologic response to the new ARV and CD4+ cell count increased to 265 cells/µL. The patient is scheduled to start anthracycline treatment for his sarcoma.

    Brief Discussion of Differential/Major Teaching points of case:

    Our patient had not previously been diagnosed with Kaposi’s sarcoma and debuted with gastrointestinal involvement in the absence of cutaneous disease. This happened in the context of a CD4 count less than 100 cells/µL, adequate virologic and immunological response and a temporal association between the start of second line ARV therapy and the present illness. All the above seem to be compatible with Immune reconstitution inflammatory syndrome (IRIS).

    The cumulative 1-year incidence of IRIS has been reported to be 29% after ARV initiation1. Risk factors for developing KS-IRIS include advanced tumor stage, an HIV viral load >5 log10 copies/mL, and initiation of ARV without concurrent chemotherapy2. Cases as the one presented here represent a challenge as the absence of dermatologic abnormalities delay the diagnosis.

    The patient was diagnosed with syphilis although he had a negative VDRL. False-negative serologic test results and delayed appearance of seroreactivity has also been reported in patients living with HIV. Thus the U.S. Center for Disease Control recommends alternative tests when clinical findings are suggestive of syphilis, but serologic tests are nonreactive3.

    The clinician and the pathologist must have a high index if suspicion when diagnosing patients infected by HIV since illness like syphilis can occur covertly in the context of the diagnosis of another opportunistic infection.

    Final Diagnosis:

    Syphilis presenting as a rectal ulcer in an HIV-positive man undergoing immune reconstitution due to Kaposi’s Sarcoma.

    References:

    1. Achenbach CJ, Harrington RD, Dhanireddy S, Crane HM, Casper C, Kitahata MM. Paradoxical immune reconstitution inflammatory syndrome in HIV-infected patients treated with combination antiretroviral therapy after AIDS-defining opportunistic infection. Clin Infect Dis. 2012;54(3):424-433. doi:10.1093/cid/cir802. PMID: 22095568
    2. Letang E, Lewis JJ, Bower M, et al. Immune reconstitution inflammatory syndrome associated with Kaposi sarcoma: Higher incidence and mortality in Africa than in the UK. Aids. 2013;27(10):1603-1613. doi:10.1097/QAD.0b013e328360a5a1. PMID: 23462220.
    3. Workowski KA, Bolan GA. Sexually Transmitted Diseases Treatment Guidelines, 2015. MMWR Recomm Rep. 2015;64:1–137. PMID: 26042815

    IMAGES:

    Figure #, location of image, type of image, legend

    1. Studies, MRI, Pelvic MRI showing diffuse thickening of the rectum with extensive inflammation of the perirectal tissue with multiple enlarged lymph nodes.
    2. Clinical Course Prior to Diagnosis, laboratory slide, Immunohistochemical stains positive for HHV-8
    3. Clinical Course Prior to Diagnosis, laboratory slide, Hematoxylin and eosin staining showing vascular structures surrounded by lymphocytes, macrophages, plasma cells, and fibroblasts
    4. Diagnostic Procedure(s) and Result(s) , laboratory slide Anti–Treponema pallidum immunohistochemical stains positive for spirochetes.
    Eduardo Perez-Alba, MD1, Horacio Decanini-Arcaute, MD2, Jose Sanchez-Beiza, MD3 and Javier Ramos-Jimenez, MD, PhD1, (1)Infectious Diseases, Hospital Universitario "Dr. José Eleuterio González". Universidad Autónoma de Nuevo León, Monterrey, Mexico, (2)Pathology, Christus Muguerza, Hospital Alta Especialidad, Monterrey, Mexico, (3)Centro Ambulatorio para la Prevención y Atención del SIDA e Infecciones de Transmisión Sexual, Monterrey, Mexico

    Disclosures:

    E. Perez-Alba, None

    H. Decanini-Arcaute, None

    J. Sanchez-Beiza, None

    J. Ramos-Jimenez, None

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