Non-traumatic perforation of the jejunum in a human immunodeficiency virus-infected patient receiving combination antiretroviral therapy

Abstract

Rationale: Non-traumatic bowel perforation caused by cytomegalovirus (CMV) and Mycobacterium avium complex (MAC) infections has become rare among patients with acquired immunodeficiency syndrome (AIDS) in the era of combination antiretroviral therapy (cART); however, CMV-associated and MAC-related immune reconstitution inflammatory syndrome (IRIS) has subsequently emerged owing to the wide use of integrase inhibitor-based regimens. Here we report a case of spontaneous perforation of the jejunum in a patient with human immunodeficiency virus (HIV) infection with good compliance to cART. Patient concerns: A 32-year-old HIV-infected man developed CMV disease and DMAC infection, as unmasking IRIS, 3 days after the initiation of cART. After appropriate treatment for opportunistic infections, intermittent fever with enlarged lymph nodes in the abdomen occurred as paradoxical IRIS. The patient was administered prednisolone with subsequent tapering according to his clinical condition. Diagnoses: Unexpected perforation of hollow organ during the titration of steroid dose with clinical presentations of severe abdominal pain was diagnosed by chest radiography. Interventions: He underwent surgical repair with peritoneal toileting smoothly. Outcomes: He was discharged well with a clean surgical wound on post-operative day 10. Lessons: Bowel perforation may be a life-threatening manifestation of IRIS in the era of cART. Steroids should be avoided, if possible, to decrease the risk of bowel perforation, especially in IRIS occurred after opportunistic diseases involving the gastrointestinal tract.

Double trouble: Concomitant unmasking and paradoxical immune reconstitution inflammatory syndrome in a patient with newly diagnosed HIV

“…Although there have been reports of both forms of IRIS occurring in patients against a single pathogen [11] , the finding of both forms of IRIS occurring in a patient against two distinct opportunistic infections remains rare, with only scarce reports described: Lee et al presented the case of a 32-year-old man who was diagnosed with CMV retinitis and disseminated MAC due to unmasking IRIS 3 days following initiation of ART, for which appropriate treatment was begun with resolution of symptoms. Seven weeks later, he developed acute abdominal pain with fever and was found to have a jejunal perforation secondary to MAC, which was deemed to be a paradoxical IRIS reaction [12] . While “double” IRIS does not require any specific change in management compared to treating each in isolation, the combined forms of IRIS have the potential to add to the overall morbidity and mortality associated with the underlying advanced HIV.…”

Multiple small bowel perforations due to cytomegalovirus related immune reconstitution inflammatory syndrome in an HIV patient

“…Only five CMV-associated IRIS bowel perforations, including ours, have been reported in the literature, [1][2][3][4] and are summarized in Table 2. The duration of time from ART initiation to the development of bowel perforation was within 2 months and the majority of cases lacked the prodromal symptom of diarrhea.…”

“…Severe complications include gastrointestinal bleeding, colonic perforation, bowel obstruction, and toxic megacolon [2] . Although it is very rare, bowel perforation could be the presenting feature of CMV-related immune reconstitution inflammatory syndrome (IRIS) in HIV-infected patients [3–6] . This is a case report of a 28-year old man with HIV infection who presented with multiple small bowel perforations 26 days after the initiation of antiretroviral therapy (ART), without any prodromal gastrointestinal symptoms.…”

The Presentation of Multiple Perforations in the Small Bowel as Cytomegalovirus Related Immune Reconstitution Inflammatory Syndrome in an HIV-infected Patient: a Case Report

“…The multiple small bowel perforations in this case were associated with CMV related immune reconstitution in ammatory syndrome (IRIS). Up to now, only ve IRIS-associated cases including our case were reported [1][2][3][4] (summarized in Table 1). Most cases lacked prodromal symptom of diarrhea.…”