a woman in her 30s with acquired immunodeficiency syndrome ( aids ) diagnosed by the fourth - generation hiv testing , with a cd4 count of 3 ( 1% ) cells / mm , presented with weight loss and cachexia . she was started on lamivudine , zidovudine , and nevirapine and then developed hypersensitivity rash and hepatitis . at that time , she also had pancytopenia ( white blood cells 2,950/l , neutrophils 79% , lymphocytes 13% , hemoglobin 9.6 g / dl , hematocrit 29% , platelets 325,000  10/l ) and intra - abdominal lymphadenopathy .
she was treated initially for presumptive disseminated mycobacterial infection with isoniazid , rifampicin , pyrazinamide , ethambutol , and clarithromycin .
she improved clinically , and her antiretroviral regimen was restarted after three weeks with lamivudine , tenofovir , and efavirenz .
later on , she had gained weight , and laboratory results showed the resolution of pancytopenia and hepatitis .
two months later , the antibiotic regimen was readjusted to ciprofloxacin , clarithromycin , and streptomycin injection ( for one month ) according to the susceptibility , and her clinical improvement was remarkable .
two months after the initiation of antiretroviral therapy ( art ) , she had an hiv viral load of < 40 copies / ml and a cd4 count of 1 ( 2% ) cell / mm ; however , she had recurrent transaminitis .
she was given prednisolone 20 mg / day with a tapered dose for five weeks for the treatment of hepatitis possibly due to immune reconstitution inflammatory syndrome .
five months after the initiation of art , her cd4 count was 13 ( 3% ) cells / mm , with an hiv viral load of < 40 copies / ml .
she developed cytomegalovirus retinitis and received intravitreal ganciclovir injection and oral valganciclovir for six weeks .
she then developed abdominal pain , with a palpable large suprapubic mass , for three weeks .
a computed tomography ( ct ) scan of the abdomen showed a large lobulated mass ( 8.5  10 cm ) with the epicenter at the right adnexa and with the invasion of the uterus , right ovary , right lateral wall of the sigmoid colon , appendix , superior wall of the urinary bladder , and right distal ureter , causing right ureter obstruction and a moderate degree of right hydronephrosis .
multiple matted lymph nodes were present along the mesenteric root and in the para - aortic , aortocaval , and retrocaval regions .
focal circumferential wall thickening of the left side of the jejunum caused moderate intraluminal narrowing , with evidence of small bowel obstruction ( fig .
she underwent exploratory laparotomy ; intraoperative findings revealed a large pelvic mass with nodular surface and with dense adhesion to the omentum , the anterolateral wall of the uterus , the bladder , and the sigmoid colon
. only partial resection of the omentum and a biopsy of the mass at the anterior aspect of the uterus were performed .
acid - fast and gomori methenamine stains of the tissue specimen were negative ; however , microbial culture was not sent for laboratory analysis .
her hospital course was complicated by wound infection / dehiscence , with the formation of an enterocutaneous fistula .
she suffered from abdominal pain as well as malnutrition due to the nature of the unresectable residual mass and the enterocutaneous fistula .
she was discharged home on palliative care , with antimicrobial therapy , and was lost to follow - up . disseminated m. simiae infection presented with pancytopenia , hepatitis , and lymphadenopathy , similar to mycobacterium avium infection in an aids patient.1 effective antimicrobial treatment of m. simiae included rifampicin and ciprofloxacin .
our patient had an abnormal host immune response to infection , malakoplakia , which occurred after m. simiae infection , a condition that has not been previously described in the literature .
however , we were unable to demonstrate a direct correlation due to the lack of microbiological data from tissue specimens .
malakoplakia has a gross appearance of round , oval , or mushroom - shaped yellowish structures.2 histologically , there is a proliferation of histiocytes with abundant granular eosinophilic cytoplasm ( known as von hansemann histiocytes ) that contain the pathognomonic michaelis 
gutmann bodies.2 these bodies are round to oval in shape and are visible as deeply basophilic structures , which are typically described as target - like and are periodic acid 
schiff stain - positive and calcium - positive.2 pathogenesis of malakoplakia is associated with the lysosomal dysfunction of macrophages in the intracellular killing process of ingested organisms and/or a defect in elimination , resulting in the accumulation of partially degraded bacteria within the cytoplasm and phagolysosomes of histiocytes , forming michaelis 
gutmann bodies around the undigested bacteria.2 the most common infectious etiologies described are bacteria , such as escherichia coli , rhodococcus equi , pasteurella multocida , and mycobacterium tuberculosis.211 malakoplakia often occurs in immunocompromised patients , such as those with aids , organ transplant recipients ( mostly solid organ transplants ) , and in one case a patient who had undergone stem cell transplantation.5,1114 malakoplakia affecting a major organ could result in various organ dysfunctions .
one of the most serious adverse events reported was irreversible renal allograft dysfunction due to malakoplakia in a renal transplant recipient with e. coli infection , pyelonephritis , and bacteremia.14 in an allogeneic stem cell transplant recipient , pleural malakoplakia caused by r. equi , presenting with a large tumor mass , required a lobectomy.12 in patients with residual disease , successful results have been reported by treating the underlying infection , reducing immunosuppression , improving the bactericidal activity of monocytes with a cholinergic agonist , such as bethanechol , and administering a multivitamin supplement.4,15,16 this is the first report of malakoplakia occurring after m. simiae infection .
 malakoplakia in an acquired immunodeficiency syndrome ( aids ) patient with disseminated mycobacterium simiae infection presented with a large pelvic mass that caused organ dysfunction from mimicking a tumor . 
 malakoplakia is a rare , chronic granulomatous abnormal host response toward infectious agents , presenting as a tumor - like lesion . 
 this is the first report of pelvic malakoplakia after disseminated m. simiae infection in an aids patient . 