A 35-year-old woman of African descent with chronic alcohol and nicotine abuse was admitted to our hospital in November 2007 with a two-day history of lower left-sided abdominal pain as well as febrile temperatures of 38.8 C and elevated inflammation parameters. Her past medical history included HIV infection that was first diagnosed in 2001 and treated with a combination of lamivudin 150 mg plus zidovudin 300 mg (Combivir) and efavirenz 50 mg/200 mg (Sustiva). In that same year, the patient underwent surgery (a longitudinal incision laparotomy) for an ovarian cyst. The patient did not tolerate antiretroviral treatment (due to side effects) and stopped taking her HIV medication in 2006, one year prior to her current admission. In November 2007, the viral load was 59.000 copies/mL and CD4 count was 13% or 159 cells/muL. As a secondary finding, a chronic hepatitis B infection with a low viral load was detected during this hospitalization, whereas a hepatitis C infection was excluded. A prior history of tuberculosis was denied by the patient.
On ultrasound examination a 5 x 6 cm cystic mass lesion in the area of the left adnexa could be displayed (Figure 1). Several surgical procedures including laparoscopy with subsequent drainage, laparotomy, exstirpation of the cyst, and one-sided ovarectomy were discussed with the patient. First, a diagnostic laparoscopy was performed, revealing several intraabdominal adhesions of the intestine as well as a severe pus-filled abdominal cavity. Therefore, a median longitudinal laparotomy had to be performed. After taking microbial samples, abdominal adhesions were divided and extensively rinsed. Afterwards, a tubectomy on the left side was performed and a drainage system was inserted. Following the operation, an intravenous antibiotic therapy with ciprofloxacin and metronidazol was started and the pelvis minor was rinsed twice daily. Afterwards, the patient recovered quickly from the surgical intervention. Ten days later, the patient was discharged from the hospital in a good general state of health.
Due to the known HIV-infection, detailed analysis of pus obtained during the operation was necessary. In spite of this, cultures for aerobic and anaerobic microbes, cultures of Mycobacterium tuberculosis, as well as Chlamydia trachomatis and Chlamydia pneumoniae were negative. Histopathological studies showed a granulomatous salpingitis with central necrosis of the left fallopian tube (Figure 2) and subsequent PCR demonstrated evidence for M. Tb-complex specific PCR products. Special stains (Ziehl-Neels en and Auramin) for acid-fast organisms remained negative. Interestingly, chest X-ray analysis performed days after the surgical procedure did not demonstrate any signs of tuberculous involvement of the lung.
Because of her underlying HIV disease, the patient was referred to our infectious diseases unit and was treated according to current recommendations with a standardized short-course chemotherapeutic regimen of isoniazid/vitamin B and rifampicin for 6 months and pyrazinamid and ethambutol for 2 months. Due to her low CD4 counts (170 cells/muL = 12%) prophylactic antibiotic therapy with cotrimoxazole was initiated (this has been shown to decrease mortality in HIV/TB- coinfected patients). She responded promptly to antibiotic therapy as evidenced by declining liver enzymes and CRP after two, three, and seven weeks, respectively. Her WBC remained constant within commonly accepted limits.
Initiation of an antiretroviral treatment (ART) against HIV was to be started at a later time point (between 2 weeks and 2 months later) in order to not interfere with tuberculosis regimens.