A 31-year-old man was evaluated in the emergency room (ER) of our institution for persistent diarrhea of 3 weeks duration. He also reported abdominal pain along with lightheadedness. He described the abdominal pain as vague, diffuse, nonradiating, and mild in intensity without any precipitating or relieving factors. He reported up to 10 episodes of watery diarrhea which did not contain any blood. He also complained of fever and dysuria. About 3 weeks before the current presentation, the patient had presented to the ER with dysuria, abdominal pain, and intermittent diarrhea. At that time he was admitted and treated for a urinary tract infection (UTI) with ciprofloxacin and later discharged home. As per patient, his diarrhea had worsened after taking the antibiotics and had presented with the current symptoms. There was no nausea, vomiting, constipation, fever, and early satiety or appetite changes. He had a prior history of HIV/AIDS, had not been adherent to antiretroviral therapy or PCP prophylaxis. He had a high viral load and low CD4 count.
He was a current smoker and admitted smoking 4 or more cigarettes per day but denied using alcohol except on social occasions or illicit drugs. He did not have a family history of liver, stomach, or colon cancer. His medications included acetaminophen and ciprofloxacin.
On examination, he was found to have a temperature of 39.1 C, blood pressure of 108/52 mmHg, a pulse rate of 99 beats per minute, and a respiratory rate of 16 breaths per minute. The patient was alert, fully oriented, and communicative. The abdomen was scaphoid, nontender, and nondistended with normal bowel sounds. There was no palpable hepatomegaly; however, the spleen was palpable. Shotty cervical and inguinal lymph nodes were palpated. The rest of the physical examination was unremarkable.
Routine laboratory tests showed a hemoglobin level of 8 g/dL, white blood cell count of 3.7 k/uL, serum potassium level of 3.4 mEq/L, and albumin level of 1.7 g/dL. Stool studies including Clostridium difficile cytotoxin, fecal leucocyte stain, and fecal fat were negative. His blood and stool cultures were negative for the growth of Mycobacterium avium complex. A chest X-ray revealed a right lower lobe consolidation and bilateral pleural effusions. The patient was initiated on broad spectrum antibiotics for hospital-acquired infection. A CT of the chest was done as a part of workup revealed moderate right and small left pleural effusions, consolidation in the dependent lung bases, nodular opacities in both lungs, some cavitary in nature, and patchy ground glass opacity in both lungs (Figure 1). Sputum for acid-fast bacilli (AFB) was negative, ruling out pulmonary tuberculosis. CT abdomen and pelvis done for chronic diarrhea and abdominal pain revealed a hypodense lesion within the cephalad aspect of the spleen, a 6.7 cm splenic mass with adjacent small nodule, multiple hypodense hepatic lesions, measuring up to 12 mm in diameter, and mild ascites in the upper abdomen (Figure 2). Magnetic resonance imaging (MRI) abdomen showed a heterogeneous lesion within the upper pole of the spleen measuring 5.2 x 4.3 cm in size with absent enhancement centrally, with some enhancement along the peripheral aspect of the lesion, suggesting central necrosis (Figure 3). He underwent an ultrasound-guided core biopsy with an 18-gauge (18G) needle. Two core biopsies were obtained for histologic analysis of the splenic mass. The histopathology revealed necrotizing granulomas on hematoxylin and eosin stain (Figures 4 and 5) with Pneumocystis jirovecii infection on Grocott-Gomori's methenamine silver (GMS) stain (Figures 6(a) and 6(b)). A fiberoptic bronchoscopy with transbronchial biopsy was also done revealing P. jirovecii pneumonia, while bronchoalveolar lavage was negative for malignant cells. His alpha fetoprotein (AFP) level was 3.2 ng/ml. Results of the rest of the laboratory parameters are given in Table 1. The patient was started on sulfamethoxazole with trimethoprim, and no steroids were given. Antiretroviral therapy was not started at the time of discharge due to concerns over IRS (immune reconstitution syndrome). He continued to follow-up at our hospital as an outpatient.