A 34-year-old Indonesian male presented with a four week history of diffuse abdominal pain, nausea, vomiting, odynophagia, dyspnea on exertion, and a 20-pound unintentional weight loss. The patient had a past medical history significant for intravenous drug abuse, alcohol abuse and 15 packs per year smoking history. The patient had moved to United States from Indonesia 7 years ago. Physical exam revealed a cachectic male with oropharyngeal candidiasis and crackles bilaterally. Diffuse abdominal tenderness on palpation was also noted. Laboratory studies revealed a normal complete blood count (CBC), hyponatremia with sodium of 122 mEq/L, and abnormal liver function tests: AST 442 U/L, ALT 150U/L, and ALP 295 U/L. A fourth-generation HIV antigen/antibody test (Abbott Laboratories) was confirmed positive with a MultiSpot positive for HIV-1 antibodies. Hepatitis C antibody testing was also reactive. Additional testing revealed a CD4 count of 2 cells/mm3 and a HIV-1 titer of 427,000 copies/ml determined by a Quantitative HIV-1 RNA PCR assay (COBAS AmpliPrep/COBAS Taqman Analyzer, v2.0, Roche Diagnostics). Chest imaging was concerning for either multifocal pneumonia and/or possible opportunistic infection (Fig. 1A). Abdominal CT revealed necrotic mesenteric lymphadenopathy (Fig. 1B), micro-abscesses in the liver (Fig. 1C), and a 2.9 x 2.4 x 2.0 cm fluid attenuation collection posterolateral to the prostate suggestive of an abscess (Fig. 1D-E). Urine analysis showed 2+ protein, 1+ urobilinogen, 3 red blood cells, and 2 white blood cells. Multiple routine urinary cultures showed no growth. Three sputum samples were collected and all showed 4+ acid-fast bacilli (AFB) (> 36 AFB organisms per field of view at 400 x magnification) by auramine-rhodamine stain and grew pure Mycobacterium tuberculosis complex in less than 7 days post-collection in the BACTEC   Mycobacterial Growth Indicator Tube (MGIT). Following culture, drug sensitivity testing was performed, and the mTB isolate was susceptible to first line drugs, including isoniazid (MIC-0.2 mcg/mL), rifampin (MIC-1.0 mcg/mL), ethambutol (MIC-5.0 mcg/mL), pyrazinamide (MIC-100 mcg/mL) and streptomycin (MIC-2.0mcg/mL). The patient was started on rifampin-300 mg twice daily, isoniazid-300 mg daily, pyrazinamide-1500 mg daily and ethambutol-1200 mg daily (RIPE therapy). Antiretroviral therapy was not initiated at this time. Twelve days later, on follow-up imaging, the prostatic abscess remained unchanged and a CT guided approach was utilized to drain the abscess. Purulent fluid (2 mL) was drained and sent for AFB culture. The purulent fluid revealed 4+ AFB by auramine-rhodamine stain (Fig. 2A) and grew mTB complex. The direct Kinyoun stain is shown in Fig. 2B. Patient clinically improved on RIPE therapy and was discharged with isolation precautions. 3 weeks post discharge, antiretroviral therapy with dolutegravir and Truvada (HAART) was initiated. Post-discharge (28 days), the patient was brought to the emergency department with acute onset of drowsiness and incomprehensible speech. The patient had been compliant with his medications. At this point, differential diagnosis of Immune reconstitution inflammatory syndrome (IRIS), and a new opportunistic infection including toxoplasmosis were considered. MRI of the brain revealed multiple ring enhancing lesions with surrounding edema in the cerebral hemispheres bilaterally, the midbrain, and the cerebellar hemispheres bilaterally as well (Fig. 3A,B). The patient was started on steroids, empiric toxoplasmosis therapy with pyrimethamine, sulfadiazine, and folinic acid. HAART and mTB therapy were continued. A lumbar puncture was performed that showed cerebrospinal fluid glucose of 54, protein of 116, RBC count of 7, and WBC count of 0. The cryptococcal antigen was non-reactive. Toxoplasmosis IgG was >5; however, Toxoplasma gondii PCR was negative. The patient's hospital stay was also complicated by both hyponatremia and also hypertension attributed to SIADH. The patient gradually improved on the aforementioned therapeutic regimen and nearly two months later, brain MRI showed a decrease in the size of the lesions. The patient's mental status also improved and the patient was deemed fit for discharge. The patient was lost to follow-up after relocating to another state.
(A) CT chest showing patchy involvement of the lung with nodules, one shown here measuring 3.1 cm in greatest dimension.