This is a report of a 32-year-old man who in January 2021 was diagnosed with HIV (human immunodeficiency virus); HIV classification C3: (< 100 CD4). Retroviral treatment was initiated: Tenofovir, Emtricitabine, Efavirenz. Due to depression and initiation of antidepressants, Efavirenz was discontinued and Raltegravir was added. He presented some adenopathy in his neck and abdomen; therefore a computed tomography scan (CT scan) was requested, reporting bilateral cervical lymphadenopathies, being the largest 11 x 10 cm. In March 2021 he presented abdominal pain associated with fever and sweating, therefore, an abdominal computed tomography scan was performed showing retroperitoneal superior paraaortic-adenopathies and inferior interaortocaval being the largest 3.5 cm x 2 cm. Subsequently, Lymph node cervical biopsy (March 2021) and bone biopsy (May 2021) were performed without evidence of neoplastic infiltration, fungal infection, or TB. As he continued with symptoms, a positron emission tomography scan; PET SCAN (May 2021) was requested, showing hypermetabolic intra-abdominal adenopathy of SUV 17.6 with high suspicion of lymphoma. CA 19-9 was normal.
In June 2021 the aforementioned patient arrived at the emergency room for acute band abdominal pain radiating to the back, asthenia, adynamia, night fewer and diaphoresis. At physical examination he presented moist oral mucosa, no injuries, globed, soft and depressible abdomen not painful to palpation, no masses, and no megalias, no jaundice. An abdominal ultrasound reported an increase in the volume of the pancreatic head, poorly defined borders, heterogeneous echogenicity, reaching dimensions of 53 cm x 50 cm x 55 cm, with very high amylase (700 U/L) and lipases (1400 U/L). A contrast-enhanced abdominal computed tomography revealed and intra- and extrahepatic bile duct dilation with intra- and retroperitoneal lymphadenopathy of origin to be determined and a mass in the head of the pancreas (Fig. 1).
Thus, the following studies were requested: serial sputum BK with a negative result, skin test of purified protein derivative (PPD) with result 0 mm (negative), genexpert with a negative result, and culture for mycobacteria with the pending result. Chest CT was also requested reporting micronodular diffuse pattern and centrilobular distribution without consolidations, suggesting an infectious or inflammatory process.
Consequently, two new exams were requested: bronchoscopy and EUS fine needle aspiration needle No. 22 Acquire , Boston Scientific Corporation, Natick, MA, USA, of the mass in the head of the pancreas, both of them reported no evidence of microorganisms or malignancy. Unclear about the etiology of the mass in the head of the pancreas, a new endoscopic ultrasound (EUS) with biopsy (fine needle biopsy FNB) of the pancreatic head mass was performed using needle No. 19 Acquire , Boston Scientific Corporation, Natick, MA, USA.
On the 26th of June 2021, the report of sputum culture for mycobacteria in liquid medium was received; (it was carried out on 11th of June), being positive for the mycobacterium tuberculosis complex. Immediately, TBC treatment was indicated following the Colombian guide for the treatment of tuberculosis called supervised short-term treatment according to the district secretary of Colombia. Thereafter, the outcomes of the second-pancreas-lesion biopsy reported a necrotizing process with acid-fast bacilli, compatible with tuberculosis, without evidence of malignancy. Regarding concurrent tuberculosis treatment, disseminated TB must comply with a total of 196 doses. Phase 1: eight weeks monday to Saturday: isoniazid, rifancipin, pyrazinamide, ethambutol Phase 2: eighteen weeks twice a week: rifancipin, isoniazid. Change in therapy was made on May 19, 2022, antiretroviral therapy was adjusted to the use of rifampicin. Prophylaxis was given with trimethoprim valganciclovir. The patient had good treatment adherence and the two-phases-TB treatment was completed.
On June 12, 2022, a follow-up contrast-enhanced computed tomography of the abdomen and pelvis was performed. The results reported the pancreas and the spleen with normal shape, size and contours with a complete resolution of the mass in the head of the pancreas (Fig. 2). However, the presence of retroperitoneal left para-aortic adenopathies with diameters of up to 1.2 cm at the infrarenal level were identified and are still under study. Currently, the patient is in good general conditions, follows HIV treatment regimen and an improvement in his CD4 level was seen as follows: CD4: 33 04/01/2020, CD4:35 04/30/2021, CD4:70 09/24/2021, CD4: 138 06/24/2022.