1, 2 I would have pursued this more aggressively and taken further biopsies and the additional diagnosis of histoplasmosis might then have been made at an earlier stage. The physicians confirmed the diagnosis of tuberculosis by biopsy but they were informed there was one yeast visible which resembled histoplasmosis and in retrospect this was important information. However, lymphoma can cause a similar picture and other mycobacterial disease, particularly Mycobacterium avium complex, must be considered.
The most obvious differential diagnosis of an abdominal mass, fever, and anaemia in an HIV infected patient originating from sub-Saharan Africa is tuberculosis. In the abdomen moderate hepatomegaly and splenomegaly were again present but no other masses were detected. Cardiovascular and respiratory examination was unremarkable. There was persistent lymphadenopathy in the distribution previously noted. A papular rash with lesions resembling molluscum contagiosum, some of which were ulcerated, was present on the medial aspect of the upper right arm and neck (fig 2). On examination he was markedly pyrexial, temperature 39.5☌, and he had lost 3 kg in weight since his last clinic visit. He was adamant that he had adhered to the antituberculous therapy. He had also developed an itchy rash on his right shoulder. Eight weeks after discharge the patient reattended the emergency clinic at which time he was complaining of intermittent high fevers, sweats, and watery diarrhoea. He was discharged from hospital and at outpatient review 2 and 4 weeks later, further improvements in symptoms and signs were reported. Over the course of the following 7 days a marked reduction in the size and tenderness of the abdominal mass was observed which was paralleled by resolution of the patient's fever. In view of the patient's weight loss and poor caloric intake, a feeding gastrostomy was inserted percutaneously. On the basis of these findings a diagnosis of abdominal tuberculosis was made and antituberculous therapy was initiated with rifampicin, isoniazid, ethambutol, and pyrazinamide in conventional doses. A CT guided attempt to obtain a further specimen from the mass was unsuccessful. The presence of a single yeast was questioned but not confirmed. Histological examination of the material obtained was reported as showing lymph node tissue containing areas of granulomatous inflammation in association with acid and alcohol fast bacilli. An ultrasound guided percutaneous needle biopsy of the mass was performed. These confirmed that the mass involved the distal ileum and caecum and showed an ileocolic fistula. Barium studies were performed in order to better define the mass. Hepatomegaly, moderate splenomegaly, and mesenteric and retroperitoneal lymphadenopathy were also noted. A computed tomograph (CT) scan of the abdomen and pelvis demonstrated a mass apparently comprising matted loops of distal ileum and lymph nodes (fig 1). An abnormal bowel gas pattern in the region of the mass was seen on a supine abdominal film. Cysts of Cryptosporidium parvum were detected, but all other microbiological investigations were negative.Ī chest radiograph was normal. Stool was examined for the presence of bacterial pathogens, ova cysts and parasites, and Clostridium difficile toxin. Bacterial and mycobacterial blood cultures, serum cryptococcal antigen, and blood, urine, and throat specimens for cytomegalovirus early antigen detection were all performed.
The aspartate aminotransferase (AST) and albumin were abnormal at 75 IU/l (normal range 0–37 IU/l) and 29 g/l (normal range 33–47 g/l) respectively, and the rest of the blood biochemistry was otherwise unremarkable. The mean cell volume was low at 75 fl with a ferritin level within normal limits. Neurological examination was unremarkable.īaseline investigations showed the haemoglobin was 10.7 g/dl, total white cell count was 3.2 × 10 9/l, and platelet count was 122 × 10 9/l. In the abdomen he had a large, tender, irregular non-mobile right iliac fossa mass that was dull to percussion which extended from the pelvis to below the level of the umbilicus. There were no cardiovascular or respiratory abnormalities. Bilaterally, shotty, non-tender lymph nodes were present in the cervical, axillary, and inguinal regions. Scarring from his recent attack of shingles was present on the left anterior thigh in the distribution of the L2 dermatome. On examination he was thin and mildly pyrexial at 37.5☌.
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