A 23-year-old female presented with features of small bowel obstruction. She complained of vomiting for the past 3 days, failure to pass stools for 5 days and abdominal distension. She was diagnosed with HIV four years earlier, and had a CD4 count of 294 x 10 cells/microL with an undetectable viral load at presentation. Her cART comprised daily fixed combination of tenofovir, emtricitabine and efavirenz for the past four years. She reported no fever, weight loss or night sweats. On physical examination, she had an elevated blood pressure of 156/106 mmHg and a tachycardia of 150 beats per minute; however, she was apyrexial with a normal respiratory rate. Her abdomen was markedly distended, firm and generally tender. She had involuntary guarding and rebound tenderness. Digital rectal examination revealed an empty rectum. Per vaginal examination and assessment of other systems were unremarkable.
The patient's biochemistry results are shown in Table 1. Patient's elevated white cell count (WCC) and inflammatory marker C-reactive protein (CRP) as well as neutrophilia indicated a systemic infection. Haemoglobin level was also abnormally low at 4.7 g/dL. All other parameters, including renal and liver function tests as well as arterial blood gas analysis (ABG), were normal.
Air fluid levels were demonstrable on erect abdominal X-rays (see Figure 1). Computed tomography (CT) scan showed target signs with small bowel wall thickening and dilation. Intra-abdominal fluid collection was also evident (see Figure 2). The following differential diagnoses were considered: Abdominal tuberculosis, lymphomas, small bowel neuroendocrine tumours, gastrointestinal stromal tumours (GIST) and sarcomas. The radiological findings suggested intussusception, complicated by small bowel obstruction.
After fluid resuscitation, the patient was prepared for an exploratory laparotomy. Intraoperative findings included a reducible intussusception at the ileo-caecal juncture and another at the mid-jejunum, which needed a wedge resection and a jejunostomy (see Figure 3). Bilateral ovarian tumours were observed, with the left larger than the right. Multiple intramural granulomatous masses, measuring approximately 1.5 cm x 1.5 cm, were disseminated over the entire small bowel. Some granulomas in the small bowel had broken down to release pus. The small bowel looked oedematous and had areas of haematoma. Jejunal intussusception and left ovary specimens were sent for histological analysis. A high-grade large B-cell NHL was found in the two specimens. The patient fully recovered from the bowel obstruction and gained full functional health while awaiting chemotherapy.