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Intraabdominal and retroperitoneal tuberculous lymphadenopathy in AIDS
AJG – September, Suppl., 2001
696 Intraabdominal and retroperitoneal tuberculous lymphadenopathy in AIDS Dirce B LimaUE*, Vale´ ria R GomesUE, Eduardo X PozzobonUE and Izabella Barau´ naUE. 1Internal Medicine, UERJ, Rio de Janeiro, Rio de Janeiro, Brazil. Purpose: Tuberculosis(TB) is a common opportunistic infection in AIDS. Three cases of disseminated TB with unusual clinical manifestations are reported. Case 1. A 26-year-old man was admitted with fever, malaise, weightloss and abdominal pain. Physical exam revealed anemia, cervical/axillary lymphadenopathy, hepatomegaly, splenomegaly and mesogastric mass. Labs were Hb 8.2g/dl,954 lymphocytes/mL,Alk Phos 1020 IU/mL,␥GT 170 IU/mL,PPD negative. Abdominal sonogram showed mesenteric infiltration with small bowel involvement and renal/hepatic hilar lymphadenopathy. Lymph nodes and liver cultures for M. tuberculosis were positive. At first he took rifampin, isoniazid, pyrazinamide and after this ethambutol, ethionamide, streptomycin. He abandoned the treatment and was admitted with fever and abdominal pain. Abdominal sonogram showed retroperitoneal lymphadenopathy and psoas muscle hypoechoic imaging suggesting psoitis. The material obtained through puncture was M. tuberculosis culture positive. He died with E. coli sepsis. Case 2. A 38-year-old man was admitted with fever and abdominal pain. Physical exam revealed hepatomegaly/splenomegaly. Labs were Alk Phos 381 IU, PPD negative, liver biopsy with granulomatous hepatitis. Abdominal CT showed lymphadenopathy and intraperitoneal abscess. M. tuberculosis was isolated in the material collected through puncture. He died with another opportunistic infection. Case 3. A 36-year-old man was admitted with fever and back pain. Physical exam revealed cervical/axillary lymphadenitis. Labs were CD4 135cels/mL, viral load 80 copies(NASBA), PPD negative, marrow biopsy histopathology suggested Mycobacteria infection. Abdominal sonogram showed hepatomegaly, retroperitoneal lymphadenopathy, imaging suggesting psoas abscess right side. M. tuberculosis grew in the abscess material. He is taking rifampin, isoniazid and pyrazinamide. Conclusions: Disseminated and serious TB occur in AIDS patients with severe immunodeficiency. Only the third patient had the opportunity to take antiretroviral drugs. The patients take part of an AIDS patients’ cohort started in March 1985.
697 Cerebrospinal fluid ascites and chronic peritonitis George F Longstreth, MD, FACG.*. 1Gastroenterology, Kaiser Permanente, San Diego, California, United States. Purpose: Ascites after ventriculoperitoneal (VP) shunting is rare and usually of unknown cause. Pathological findings in my patient support an inflammatory reaction to silicone shunt tubing as its etiology. Methods: A 28-year-old woman presented with abdominal distension of 3 months’ duration. She had undergone VP shunting at 6 months of age for hydrocephalus and subsequently required multiple revisions and replacements of silicone elastomer shunts. There was no history of shunt infection or of abdominal or pelvic infection or surgery. She took valproic and carbamazepine for seizures. Physical examination revealed ascites. Results of routine blood and urine tests and a chest roentgenogram were normal. Computerized tomography of the abdomen and pelvis showed extensive ascites but was otherwise normal. Paracentesis revealed clear fluid with 150 leukocytes/cubic mm (95% mononuclear) and a protein content of 2.8 g/dL.; cytologic examination showed no malignant cells. The serum-ascites albumin gradient was 2.5. No organisms grew in ascites cultures. Abdominal ultrasonography, echocardiography and a liver biopsy specimen were normal. Despite diuretic therapy, she required multiple therapeutic paracenteses that totalled 18 L over 6 months. Laparoscopy revealed extensive abdominopelvic adhesions, numerous tiny nodules on the visceral and parietal peritoneum and inferior surface of the liver, and a shunt-tube
Abstracts
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fragment. The laparoscopist extracted the fragment and removed 5 L ascites. Peritoneal-biopsy specimens revealed lymphohistiocytic nodules and fibrosis but no microorganisms by auramine and Gomori’s methenamine-silver staining nor any polarizable material. Therapy with prednisone, 60 mg qd for 4 weeks, failed to prevent recurrence of ascites. After she stopped the drug, a neurosurgeon removed the peritoneal catheter and placed a ventriculoatrial shunt. Within 2 weeks, her abdominal discomfort disappeared, and no ascites was eviden by ultrasonography 1 1/2 years later. Results: In patients with cerebrospinal fluid (CSF) ascites, impaired CSF absorption across an inflamed peritoneum has been proposed, and diversion of CSF from the abdomen is effective. However, chronic peritonitis is seldom proven; we know of only one case of published documentation. Silicone and its constituents do not cause specific immune responses, but silicone shunt devices can degrade over time and elicit nonspecific tissue inflammation. Conclusions: The findings in this case suggest that diffusion of one or more VP shunt-tube components throughout the peritoneal cavity, resulting in widespread inflammation, may cause the disorder.
698 Hyperbaric oxygen treatment for intractable diarrhea due to Pneumatosis coli Alexander M Lustberg, M.D., George T Fantry, M.D. and Peter E Darwin, M.D.*. 1Medicine, University of Maryland School of Medicine, Baltimore, Maryland, United States. Purpose: Pneumatosis coli is an uncommon condition characterized by multiple gas-filled submucosal cysts of varying size, most commonly found in the colon. This may be associated with COPD, collagen vascular disease, sarcoidosis, ischemic bowel or pseudomembranous colitis. Pneumatosis coli is often an incidental finding, although some patients may present with abdominal distension, abdominal pain, or intermittent diarrhea. Oxygen therapy is believed to lower the partial pressure of other gases in the surrounding tissues causing the cysts to deflate, however, normobaric oxygen has resulted in pulmonary toxicity and has required in-patient treatment. We describe a unique case of a patient successfully treated with hyperbaric oxygen (HBO)therapy for chronic incapacitating diarrhea due to Pneumatosis coli. Methods: A 64 year old woman with a history of DM, CAD, HTN, and smoking presented with a 6 month history of up to 20, small volume, watery bowel movements daily with tenesmus and fecal incontinence. Physical exam was unremarkable except for a mildly distended abdomen and peripheral neuropathy. Stool studies were negative for fecal leukocytes, culture, C. difficle toxin and O&P. A qualitative fecal fat was positive. CBC, LFTs, amylase, lipase, calcium and TSH were normal. The patient initially refused endoscopic evaluation. Empiric trials of Asacol and antibiotics for potential colitis and bacterial overgrowth were instituted without success. Antimotility agents including Imodium or Lomotil were poorly tolerated. Subsequent colonoscopy revealed normal mucosa. Numerous large submucosal cysts were seen occupying most of the colon and rectum which were air-filled on biopsy. Pathology was consistent with pneumatosis coli without evidence of microscopic colitis. EGD with duodenal biopsies and small bowel follow through were unremarkable. Results: The patient was diagnosed with pneumatosis coli and started on a course of daily outpatient HBO therapy for 2 weeks. After the second treatment, the diarrhea resolved and her bowel habit returned to normal. Repeat colonoscopy showed near complete resolution of cysts. Mild diarrhea recurred which resolved with a second course of HBO therapy, including a tapering course of therapy over 6 weeks. Conclusions: Pneumatosis coli is a rare cause of severe chronic diarrhea which can be successfully treated with HBO therapy. HBO is a convenient, well tolerated treatment option which may be beneficial for patients with pneumatosis coli and persistent symptoms despite conservative measures. A 2 week course of daily treatments followed by a tapering course is appropriate to avoid recurrent symptoms.
696 Intraabdominal and retroperitoneal tuberculous lymphadenopathy in AIDS Dirce B LimaUE*, Vale´ ria R GomesUE, Eduardo X PozzobonUE and Izabella Barau´ naUE. 1Internal Medicine, UERJ, Rio de Janeiro, Rio de Janeiro, Brazil. Purpose: Tuberculosis(TB) is a common opportunistic infection in AIDS. Three cases of disseminated TB with unusual clinical manifestations are reported. Case 1. A 26-year-old man was admitted with fever, malaise, weightloss and abdominal pain. Physical exam revealed anemia, cervical/axillary lymphadenopathy, hepatomegaly, splenomegaly and mesogastric mass. Labs were Hb 8.2g/dl,954 lymphocytes/mL,Alk Phos 1020 IU/mL,␥GT 170 IU/mL,PPD negative. Abdominal sonogram showed mesenteric infiltration with small bowel involvement and renal/hepatic hilar lymphadenopathy. Lymph nodes and liver cultures for M. tuberculosis were positive. At first he took rifampin, isoniazid, pyrazinamide and after this ethambutol, ethionamide, streptomycin. He abandoned the treatment and was admitted with fever and abdominal pain. Abdominal sonogram showed retroperitoneal lymphadenopathy and psoas muscle hypoechoic imaging suggesting psoitis. The material obtained through puncture was M. tuberculosis culture positive. He died with E. coli sepsis. Case 2. A 38-year-old man was admitted with fever and abdominal pain. Physical exam revealed hepatomegaly/splenomegaly. Labs were Alk Phos 381 IU, PPD negative, liver biopsy with granulomatous hepatitis. Abdominal CT showed lymphadenopathy and intraperitoneal abscess. M. tuberculosis was isolated in the material collected through puncture. He died with another opportunistic infection. Case 3. A 36-year-old man was admitted with fever and back pain. Physical exam revealed cervical/axillary lymphadenitis. Labs were CD4 135cels/mL, viral load 80 copies(NASBA), PPD negative, marrow biopsy histopathology suggested Mycobacteria infection. Abdominal sonogram showed hepatomegaly, retroperitoneal lymphadenopathy, imaging suggesting psoas abscess right side. M. tuberculosis grew in the abscess material. He is taking rifampin, isoniazid and pyrazinamide. Conclusions: Disseminated and serious TB occur in AIDS patients with severe immunodeficiency. Only the third patient had the opportunity to take antiretroviral drugs. The patients take part of an AIDS patients’ cohort started in March 1985.
697 Cerebrospinal fluid ascites and chronic peritonitis George F Longstreth, MD, FACG.*. 1Gastroenterology, Kaiser Permanente, San Diego, California, United States. Purpose: Ascites after ventriculoperitoneal (VP) shunting is rare and usually of unknown cause. Pathological findings in my patient support an inflammatory reaction to silicone shunt tubing as its etiology. Methods: A 28-year-old woman presented with abdominal distension of 3 months’ duration. She had undergone VP shunting at 6 months of age for hydrocephalus and subsequently required multiple revisions and replacements of silicone elastomer shunts. There was no history of shunt infection or of abdominal or pelvic infection or surgery. She took valproic and carbamazepine for seizures. Physical examination revealed ascites. Results of routine blood and urine tests and a chest roentgenogram were normal. Computerized tomography of the abdomen and pelvis showed extensive ascites but was otherwise normal. Paracentesis revealed clear fluid with 150 leukocytes/cubic mm (95% mononuclear) and a protein content of 2.8 g/dL.; cytologic examination showed no malignant cells. The serum-ascites albumin gradient was 2.5. No organisms grew in ascites cultures. Abdominal ultrasonography, echocardiography and a liver biopsy specimen were normal. Despite diuretic therapy, she required multiple therapeutic paracenteses that totalled 18 L over 6 months. Laparoscopy revealed extensive abdominopelvic adhesions, numerous tiny nodules on the visceral and parietal peritoneum and inferior surface of the liver, and a shunt-tube
Abstracts
S219
fragment. The laparoscopist extracted the fragment and removed 5 L ascites. Peritoneal-biopsy specimens revealed lymphohistiocytic nodules and fibrosis but no microorganisms by auramine and Gomori’s methenamine-silver staining nor any polarizable material. Therapy with prednisone, 60 mg qd for 4 weeks, failed to prevent recurrence of ascites. After she stopped the drug, a neurosurgeon removed the peritoneal catheter and placed a ventriculoatrial shunt. Within 2 weeks, her abdominal discomfort disappeared, and no ascites was eviden by ultrasonography 1 1/2 years later. Results: In patients with cerebrospinal fluid (CSF) ascites, impaired CSF absorption across an inflamed peritoneum has been proposed, and diversion of CSF from the abdomen is effective. However, chronic peritonitis is seldom proven; we know of only one case of published documentation. Silicone and its constituents do not cause specific immune responses, but silicone shunt devices can degrade over time and elicit nonspecific tissue inflammation. Conclusions: The findings in this case suggest that diffusion of one or more VP shunt-tube components throughout the peritoneal cavity, resulting in widespread inflammation, may cause the disorder.
698 Hyperbaric oxygen treatment for intractable diarrhea due to Pneumatosis coli Alexander M Lustberg, M.D., George T Fantry, M.D. and Peter E Darwin, M.D.*. 1Medicine, University of Maryland School of Medicine, Baltimore, Maryland, United States. Purpose: Pneumatosis coli is an uncommon condition characterized by multiple gas-filled submucosal cysts of varying size, most commonly found in the colon. This may be associated with COPD, collagen vascular disease, sarcoidosis, ischemic bowel or pseudomembranous colitis. Pneumatosis coli is often an incidental finding, although some patients may present with abdominal distension, abdominal pain, or intermittent diarrhea. Oxygen therapy is believed to lower the partial pressure of other gases in the surrounding tissues causing the cysts to deflate, however, normobaric oxygen has resulted in pulmonary toxicity and has required in-patient treatment. We describe a unique case of a patient successfully treated with hyperbaric oxygen (HBO)therapy for chronic incapacitating diarrhea due to Pneumatosis coli. Methods: A 64 year old woman with a history of DM, CAD, HTN, and smoking presented with a 6 month history of up to 20, small volume, watery bowel movements daily with tenesmus and fecal incontinence. Physical exam was unremarkable except for a mildly distended abdomen and peripheral neuropathy. Stool studies were negative for fecal leukocytes, culture, C. difficle toxin and O&P. A qualitative fecal fat was positive. CBC, LFTs, amylase, lipase, calcium and TSH were normal. The patient initially refused endoscopic evaluation. Empiric trials of Asacol and antibiotics for potential colitis and bacterial overgrowth were instituted without success. Antimotility agents including Imodium or Lomotil were poorly tolerated. Subsequent colonoscopy revealed normal mucosa. Numerous large submucosal cysts were seen occupying most of the colon and rectum which were air-filled on biopsy. Pathology was consistent with pneumatosis coli without evidence of microscopic colitis. EGD with duodenal biopsies and small bowel follow through were unremarkable. Results: The patient was diagnosed with pneumatosis coli and started on a course of daily outpatient HBO therapy for 2 weeks. After the second treatment, the diarrhea resolved and her bowel habit returned to normal. Repeat colonoscopy showed near complete resolution of cysts. Mild diarrhea recurred which resolved with a second course of HBO therapy, including a tapering course of therapy over 6 weeks. Conclusions: Pneumatosis coli is a rare cause of severe chronic diarrhea which can be successfully treated with HBO therapy. HBO is a convenient, well tolerated treatment option which may be beneficial for patients with pneumatosis coli and persistent symptoms despite conservative measures. A 2 week course of daily treatments followed by a tapering course is appropriate to avoid recurrent symptoms.