Here we describe the case of a 26-year-old female patient with an HIV-1 infection (PLWHA) initially revealed by a pulmonary tuberculosis correctly treated and cured, who was on a combined antiviral triple therapy based on efavirenz/ emtricitabine/tenofovir disoproxil (TDF/FTC/EFV) for three years, but which she stopped one year before the present hospitalization. She sought the emergency department for a one month complaint of melena with chronic liquid diarrhea at a rate of three stools a day, accompanied by fever and weight loss, but without rectal syndrome. On admission, the patient was conscious, presented with a Glasgow coma score of 15/15, was hemodynamically and respiratory stable, febrile with a body temperature of 38  C, heart rate of 100 per min, respiratory rate of 20 cycles per min, blood pressure of 110/40 mmHg, weighting 46 kg, in addition to an oral candidiasis with possible esophageal involvement. On the abdominal examination, the patient had pain on the right upper quadrant, epigastric tenderness associated with a homogeneous hepatomegaly (21 cm) and splenomegaly (14 cm) and the hernia orifices were free. The abdominal ultrasound showed multiple collections at the level of the segments I, IV, and V related to liver abscesses of which the largest lesion measured 5.8 by 4.2 cm with hepatomegaly associated with an anechoic peritoneal effusion of moderate abundance (Figure 1). The patient was treated empirically with ceftriaxone, metronidazole and gentamicin for the liver abscesses, fluconazole for oral and esophageal candidiasis, and a medication to slow down the intestinal transit.
On the blood count, the patient had normochromic normocytic anemia, 5.8 g/dL of hemoglobin (11.5 - 16.5), lymphopenia, with 840/mm3 (1,000 - 4,000), normal leukocytes - 6,040/mm3, (3,600 - 11,000), normal neutrophils - 4,490/mm3 (1,800 - 7,500), and a normal platelet count of 166,000/mm3, (140,000 - 400,000), and the CD4 - positive T cell count was 27 cells/mm3. She had hepatitis flares and cholestasis with AST 162 IU/L (5N) (< 30), ALT 55 IU/L (N) (< 50), ALP 495 IU/L (5 N) (30-100), gammaGT 280 IU/L (6 N) (<45), CRP 117 mg/L (< 5 mg/L), normal renal function; negative serology to hydatid, amebiasis, hepatitis B virus (HBV), hepatitis C virus (HCV), syphilis and toxoplasmosis, while serology to CMV IgG was positive but negative to IgM, COVID-19 RT-PCR and IgG antibodies raised to SARS-CoV-2 were negative, and the patient also presented with negative sputum evaluated by the Xpert MTB/RIF (Genexpert  Cepheid Inc, California, USA) and three Acid-Fast Bacilli (AFB) smear microscopy, three cultures of stool and parasitological stool examination were also negative, in addition to a blood culture.
An ultrasound-guided puncture was performed which revealed the presence of a Salmonella enterica subsp. enterica in the purulent secretion that was only resistant to cefalotin, cefoxitin, gentamicin, amikacin, but was sensitive to amoxicilline (Figure 2). The Genexpert  on the purulent secretion was negative. A wet smear was negative for Entamoeba histolytica trophozoite. Next, we stopped metronidazole and gentamicin and we continued the treatment with intravenous amoxicillin plus clavulanic acid 1 g tid for eight days; then we switched to oral amoxicillin 1 g tid during three weeks and the antiretroviral therapy was restarted. Ten days after the treatment, the patient improved clinically and the CRP decreased to 13 mg/L. A follow-up ultrasound showed that the size of the abscess had decreased and the patient had a favorable outcome.