Acute Appendicitis as the Initial Clinical Presentation of Primary HIV-1 Infection

Acute Appendicitis as the Initial Clinical Presentation of Primary HIV-1 Infection Open Forum Infectious Diseases BRIEF REPORT presentation of PHI. Appendicitis and HIV-1 have previously Acute Appendicitis as the Initial been linked in 2 ways. First, in untreated immune-compromised Clinical Presentation of Primary HIV-1 HIV-1-infected individuals, opportunistic infections (eg, cyto- Infection megalovirus [CMV], Streptococcus pneumoniae, Mycobacterium 1 1,2 1 avium complex, and Cryptosporidium parvum) have been shown Mariane H. Schleimann, Steffen Leth, Astrid R. Krarup, 3 4 2 Jesper Mortensen, Bente Barstad, Matthias Zaccarin, to cause appendicitis [6–9]. Second, at initiation of antiretroviral 1,5 2 Paul W. Denton, and Rajesh Mohey therapy (ART), HIV-1-infected individuals have a risk of devel- Department of Infectious Diseases, Aarhus University Hospital, Skejby, Denmark; oping immune reconstitution inflammatory syndrome (IRIS), 2 3 Department of Medicine and Department of Nuclear Medicine, Herning Hospital, Herning, 4 5 Denmark; Institute of Pathology, Holstebro Hospital, Holstebro, Denmark; Department of which initiates a pathological inflammatory response to a previ- Clinical Medicine, Aarhus University, Aarhus, Denmark ous infection resulting in appendicitis [10, 11]. We present a third and novel association of HIV-1 and appen- We report a case of an adolescent who presented at our emer- dicitis. We describe a case with an adolescent male presenting gency department with acute abdominal pain. While the initial to our clinic with symptoms of acute appendicitis coincident diagnosis was acute appendicitis, a secondary and coincidental with his clinical presentation of PHI. Subsequent examina- diagnosis of primary HIV-1 infection was made. Concurrent tions and findings suggest HIV-1 as the causative agent of the and subsequent clinical and molecular biology findings form appendicitis. the basis of our argument that primary HIV-1 infection was the cause of acute appendicitis in this individual. CASE PRESENTATION Keywords. acute appendicitis; diagnosis; immunohisto- A 17-year-old male of Mediterranean origin was admitted to chemistry; in situ hybridization; primary HIV-1. the emergency department at a regional hospital with a 2-day history of diffuse abdominal pain and diarrhea. One month Globally, 1.8 million people were newly diagnosed with HIV-1 prior to the admission, the patient had returned to Denmark in 2016 [1]. However, signs and symptoms of primary HIV-1 from a vacation in the western part of Turkey. The patient had infection (PHI) are frequently lacking, which creates an obstacle a medical history of kidney neuroblastoma at the age of 3. After to timely diagnoses of PHI and early treatment initiation chemotherapy and radical surgery, he received a bone mar- [2, 3]. On occasions when clinical presentations of PHI do row–derived autologous CD34+ stem cell transplantation. This occur, they are typically u-li fl ke symptoms (eg, fever, rash, treatment was successful, and he showed no signs of relapse at aches, and swollen glands) [4]. Other clinical presentations of scheduled follow-up visits. PHI most frequently originate from the gastrointestinal tract At presentation to the emergency department, he was alert, [4]. In 1 case, an atypical clinical presentation of PHI was char- oriented, and febrile. Abdominal palpation elicited both direct acterized as “appendicitis-like illness that resulted in explorative and rebound tenderness. Biochemical tests showed an elevated laparotomy,” but appendicitis was not confirmed [4]. Because C-reactive protein (CRP) level of 216  mg/L, a leucocytosis 9 9 gastrointestinal tract–related complaints oen a ft re encountered (13.2 ×  10 /L) with lymphocytosis (9.18 ×  10 /L), and a dis- in routine health care settings, this category of patients poses a cretely elevated bilirubin level (32  μmol/L). The patient was potential risk of missing an HIV-1 diagnosis. closely observed, and the fever resolved spontaneously. The Although HIV-1-infected individuals have a 4-fold higher abdominal symptoms abated to the extent that the diagnosis of prevalence of appendicitis than HIV-1-negative individuals appendicitis could not be upheld. The next day, his CRP levels [5], appendicitis has never been reported as the initial clinical had reduced to 145  mg/L. A  tentative diagnosis of infectious diarrhea was made, and as the patient had improved, he was discharged to subsequent follow-up in the case that his condi- Received 24 October 2017; editorial decision 22 December 2017; accepted 7 January 2018. tion worsened. Correspondence: R.  Mohey, MD, PhD, Department of Medicine, Herning Hospital, Gl. On day 14 aer t ft he primary contact, the patient returned to Landevej 61, 7400 Herning, Denmark (rajemohe@rm.dk). the emergency department with complaints of diffuse abdom- Open Forum Infectious Diseases © The Author(s) 2018. Published by Oxford University Press on behalf of Infectious Diseases inal pain, multiple diarrheas, pain upon swallowing, headache, Society of America. This is an Open Access article distributed under the terms of the Creative a rash primarily on the torso and spreading to the limbs, severe Commons Attribution-NonCommercial-NoDerivs licence (http://creativecommons.org/licenses/ by-nc-nd/4.0/), which permits non-commercial reproduction and distribution of the work, in any fatigue, a dry cough, severe shortness of breath during physical medium, provided the original work is not altered or transformed in any way, and that the work activity, and an unintended weight loss (6  kg). Upon examin- is properly cited. For commercial re-use, please contact journals.permissions@oup.com ation, the patient was febrile and had rebound tenderness in the DOI: 10.1093/ofid/ofy006 BRIEF REPORT • OFID • 1 Downloaded from https://academic.oup.com/ofid/article-abstract/5/2/ofy006/4794682 by Ed 'DeepDyve' Gillespie user on 16 March 2018 right-lower abdominal quadrant and a maculopapular rash. No negative. The patient was observed for 2 days. At discharge, he lymphadenopathy was detected. Biochemical tests showed an was afebrile with a slightly elevated CRP value of 153 mg/L and elevated CRP level of 135 mg/L, leucopenia (1.9 ×  10 /L) with leucocytes within the normal range. 9 9 lymphopenia (0.7 × 10 /L), thrombocytopenia (72 × 10 /L), and On day 18, the patient returned to the emergency department a normal hemoglobin level of 8.7 mmol/L. A computed tomog- with persistent abdominal pain and a skin rash, as well as fever, raphy (CT) scan of the thorax and abdomen revealed a thick- headache, and neck stiffness. Biochemical tests showed an ele- walled and distended appendix with surrounding inflammation vated CRP level of 81 mg/L, normal leucocytes (4.4 × 10 /L) but 9 9 (Figure  1A). Laparoscopy revealed that a mild fibrin exudate lymphopenia (0.8 ×  10 /L), thrombocytopenia (146 ×  10 /L), was present at the base of the appendix. Furthermore, promi- and a normal hemoglobin level of 8.3  mmol/L. Meningitis nent and enlarged periappendiceal lymph nodes were observed. was suspected, and a lumbar puncture was performed. The er Th efore, an appendectomy was performed. Appendicitis was cerebrospinal fluid (CSF) exhibited 87  ×  10 /L leucocytes (of 6 6 confirmed using histopathological examination. Specifically, which 83 × 10 /L were mononuclear), 21 × 10 /L erythrocytes, tissue inflammation and ulceration of the mucosal membrane normal protein levels, and normal glucose levels. Penicillin were observed in hematoxylin and eosin–stained tissue sec- (3 g quater in die [QID, 4 times a day]), ceftriaxone (4 g once tions. Standard immunohistochemical stains of the appendix daily  [OD]), and acyclovir (10  mg/kg/d) were initiated intra- for an immediate early and an early CMV antigen were both venously as empiric treatment. CSF was negative by standard A B CT Scan In situ hybridization 200µm 20µm 20µm 20µm Immunohistochemistry CXCL10 ISG15 MxA MPO 50µm 50µm 50µm 50µm 13µm 13µm 13µm 13µm Figure 1. (A) Abdominal computed tomography (CT) scans reveal a dilated appendix with surrounding inflammation. The appendix is indicated by red arrows. (B) In situ hy- bridization (ISH) of the appendix base. The red ISH signal indicates the presence of HIV-1 RNA transcripts. The upper left image is low magnification. Boxes surround regions of the appendix depicted in higher magnification in the connected images. (C) Immunohistochemistry images of the appendix body. The brown signal indicates the presence of the inflammatory markers, C-X-C motif chemokine 10 (CXCL10), interferon stimulated gene 15 (ISG15), myxovirus resistance protein 1 (MxA), or myeloperoxidase (MPO) indi- cated for the specific panel. The top column is low magnification. Boxes in the upper column images indicate the region depicted in higher magnification in the bottom column. 2 • OFID • BRIEF REPORT Downloaded from https://academic.oup.com/ofid/article-abstract/5/2/ofy006/4794682 by Ed 'DeepDyve' Gillespie user on 16 March 2018 clinical polymerase chain reaction (PCR) tests for common weeks later. ART consisted of emtricitabine 200  mg/tenofovir pathogens (including Neisseria meningitidis, Streptococcus disoproxil fumarate 245  mg (Truvada) in combination with pneumoniae, varicella zoster, and herpes simplex virus 1 and 2). darunavir 800 mg/ritonavir 100 mg once daily. Six months aer ft Direct microscopic assessment of the CSF was negative for bac- initiating ART, the CD4 cell count had increased to 850/μL, and teria. Neither CSF nor blood cultures showed evidence of bac- plasma HIV-1 RNA was fully suppressed. teria. Therefore, the patient was treated according to national To investigate the etiology of this appendicitis and assess guidelines for culture-negative meningitis. A  new CT scan of whether this case represents a novel clinical presentation of the abdomen revealed mild and anticipated postoperative find- PHI, the appendix was subsequently examined by in situ hy- ings and was otherwise considered normal. bridization and immunohistochemistry. In situ hybridization On day 21, the patient was still febrile and exhibiting leuco- revealed high levels of HIV-1 RNA-producing cells throughout penia. At this point, the antibiotic treatment was modified the appendix base, body, and tip (Figure  1B; Supplementary considering the travel history to Turkey and exposure to raw Figure  1, A  and B). Large red nuclei-associated spots repre- unpasteurized milk. Specifically, the antibiotic regimen was sent cell profiles expressing HIV-1 RNA. The levels of product- switched to ceftriaxone 4 g OD with the addition of ciproflox- ively infected cells observed in this appendix are comparable to acin 400 mg bis in die (BID; 2 times a day), due to clinical sus- those observed in lymph nodes of individuals with untreated picion of brucellosis. No known genetic mutations related to HIV-1 infection [13]. Furthermore, immunohistochemical Mediterranean fever were identified. The patient was tested for stains against the inflammatory markers CXCL10, ISG15, and hepatitis A, B, and C virus serology/antigens, CSF 16S PCR ana- MxA reveal a robust production of these proteins throughout lysis, and CMV/Epstein-Barr virus (EBV)/brucellosis serology. the tissue indicative of a stimulation of the IFN-alpha and On day 29, the patient remained febrile despite ongoing anti- IFN-gamma immune responses (Figure  1C; Supplementary biotic treatment. The patient was tested for Coxiella burnetii and Figure  1C). Interestingly, no massive neutrophil (MPO) infil- parvovirus B19 serology. A  blood smear was also performed. tration into the inflamed organ was detected (Figure 1C), which Additionally, a fludeoxyglucose (FDG) positron emission tom- supports that this case was not bacterial-induced appendicitis. ography (PET) CT revealed pathologic FDG uptake in mul- METHODS tiple lymph node sites. To rule out relapse of neuroblastoma, the urine was tested for vanillylmandelic acid and found to be Fixation of Appendix negative. Further investigation into the patient’s medical history Immediately after the appendectomy, the appendix was fixed revealed that the patient had tested negative for HIV-1 88 days overnight in 10% neutral buffered formalin, then cut into earlier at his general practitioner (HIV p24 Ag/Ab Combo, 6 pieces (base, body, and tip, alternating longitudinal and Abbott), and the patient acknowledged having sex with men as cross-sections representing the appendix in full length), and an HIV risk factor. Therefore, a new HIV-1 diagnostic test was each piece was then embedded in paraffin. ordered (HIV p24 Ag/Ab Combo, Abbott). In Situ Hybridization Of the extensive panel of assays performed to detect an in- As we previously described [14], in situ hybridization for fectious etiology in this case, CMV, EBV and HIV were posi- HIV-1 RNA was performed using the RNAScope 2.0 RED assay tive. Regarding CMV, IgM and IgG antibodies against this virus (Advanced Cell Diagnostics) and treated as described in the were present in serum, but immunohistochemistry performed Supplementary Methods. immediately aer t ft he appendectomy found the appendix to be Immunohistochemistry negative for CMV proteins that would have indicated active Immunohistochemistry (IHC) to detect C-X-C motif chemok- viral replication. Regarding EBV, the patient was positive for ine 10 (CXCL10), interferon stimulated gene 15 (ISG15), myxo- antibodies against EBV-EBNA, negative for IgM against virus virus resistance protein 1 (MxA), or myeloperoxidase (MPO) capsid antigen, and negative for EBV DNA in blood. These find- was performed according to previously published protocols [15, ings together indicate prior CMV and EBV infections and sero- 16] and treated as described in the Supplementary Methods and conversions well beyond the time frame of this case. Regarding Supplementary Table 1. HIV-1, the day 29 sample was positive for both p24 antigen and anti-HIV antibodies, but negative for p31 antigen (INNO-LIA Ethical Statement HIV I/II Score, Fujirebio). These findings place the patient in Written informed consent was obtained for subsequent analyses HIV Fiebig stage V [12] at HIV-1 diagnosis. and the publication of this report. e p Th atient’s CD4 cell count was 680/μL, and his plasma HIV-1 DISCUSSION RNA level was 1 ×  10 copies/mL. HIV in the CSF fluid was 16 × 10 copies of HIV-1 RNA per mL. Antibiotics were ceased Here we argue for primary HIV infection as a novel etiology aer a t ft otal of 14 treatment days. Intensive HIV counseling was for acute appendicitis. The lack of neutrophil infiltration and immediately begun, and the patient was ready to begin ART 2 the observance of a robust interferon response in the appendix BRIEF REPORT • OFID • 3 Downloaded from https://academic.oup.com/ofid/article-abstract/5/2/ofy006/4794682 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Financial support. This work was supported by e Th Danish Council support a viral etiology for the inflammation. Although we can- for Independent Research (DFF grant #5053-00090), Aarhus University not completely rule out a bacterial or other etiology, we did rule Research Foundation (AUFF-E-2016-FLS-8–9), Aarhus University, and out CMV or EBV as the cause of this appendicitis. Further, the Aarhus University Hospital, Denmark. The funders had no role in the study patient’s CSF was negative for varicella zoster, HSV-1, and HSV-2 design, data analyses, data interpretation, or writing of the article. Potential coni fl cts of interest. e Th authors declare no conflict of inter - replication. Our in situ hybridization analysis of the appendix est. All authors have submitted the ICMJE Form for Disclosure of Potential revealed the presence of HIV-1 RNA-positive cells throughout Conflicts of Interest. Conflicts that the editors consider relevant to the con- the entire organ. This observation is consistent with the facts tent of the manuscript have been disclosed. that (i) the appendix, along with Peyer’s patches and isolated lymphoid follicles, is a gut-associated lymphoid tissue that func- References 1. World Health Organisation (WHO). Fact sheet on HIV/AIDS. Updated July 2017. tions as an inductive site for mucosal B and T cells [17] and (ii) Available at: http://www.who.int/mediacentre/factsheets/fs360/en/. Accessed 2 immune inductive sites are primary sites of HIV-1 replication August 2017. and pathogenesis [18]. While the primary HIV-1 infection might 2. Lundgren JD, Babiker AG, Gordin F, et  al; INSIGHT START Study Group. Initiation of antiretroviral therapy in early asymptomatic HIV infection. N Engl J be purely coincidental and PHI as the cause of the appendicitis Med 2015; 373:795–807. cannot be unequivocally proven, the evidence strongly supports 3. Robb ML, Eller LA, Kibuuka H, et al; RV 217 Study Team. Prospective study of acute HIV-1 infection in adults in East Africa and Thailand. N Engl J Med 2016; PHI as the etiology of the appendicitis in this case. 374:2120–30. er Th e is no confirmed precedent for acute appendicitis as 4. Braun DL, Kouyos RD, Balmer B, et  al. Frequency and spectrum of unex- pected clinical manifestations of primary HIV-1 infection. Clin Infect Dis 2015; PHI, as indicated by Braun et  al. in their compilation of rare 61:1013–21. atypical clinical presentations of PHI [4]. Other atypical clin- 5. Crum-Cianflone N, Weekes J, Bavaro M. Appendicitis in HIV-infected patients during the era of highly active antiretroviral therapy. HIV Med 2008; 9:421–6. ical presentations of PHI include opportunistic infections (eg, 6. Tucker RM, Swanson S, Wenzel RP. Cytomegalovirus and appendiceal perfora- Candida stomatitis, Candida esophagitis) or damage to the cen- tion in a patient with acquired immunodeficiency syndrome. South Med J 1989; tral nervous system (eg, encephalitis, paresis, acute psychiatric 82:1056–7. 7. Clark JA, Keroack MA. Pneumococcal appendicitis in a man with HIV infection. disorders). Also, tonsillitis, pneumonia, renal failure, or skin N Engl J Med 1993; 328:1282. and soft tissue infections have been confirmed as the initial clin- 8. Livingston RA, Siberry GK, Paidas CN, Eiden JJ. Appendicitis due to Mycobacterium avium complex in an adolescent infected with the human immu- ical presentation of PHI [4]. Our case supports considering PHI nodeficiency virus. Clin Infect Dis 1995; 20:1579–80. as a differential diagnosis in patients undergoing appendec- 9. Buch K, Nguyen S, Divino CM, et  al. Cryptosporidiosis presenting as acute appendicitis: a case report. Am Surg 2005; 71:537–8. tomy, who subsequently experience low platelets, lymphopenia, 10. Shelburne SA, Visnegarwala F, Darcourt J, et  al. Incidence and risk factors for prolonged fever, and are refractory to conventional diagnostics immune reconstitution inflammatory syndrome during highly active antiretro- viral therapy. AIDS 2005; 19:399–406. and treatment. Overall lessons from this case include a practical 11. Faldetta KF, Kattakuzhy S, Wang HW, et  al. Cytomegalovirus immune recon- reinforcement of the fact that clinical presentations of PHI are stitution inflammatory syndrome manifesting as acute appendicitis in an HIV- oen a ft typical. Our putative finding that the initial clinical pres- infected patient. BMC Infect Dis 2014; 14:313. 12. Fiebig EW, Wright DJ, Rawal BD, et al. Dynamics of HIV viremia and antibody entation of PHI in this case was acute appendicitis underscores seroconversion in plasma donors: implications for diagnosis and staging of pri- the importance of meticulously noting the history of sexual risk mary HIV infection. AIDS 2003; 17:1871–9. 13. Embretson J, Zupancic M, Ribas JL, et  al. Massive covert infection of helper T behavior and performing HIV tests in high-risk patients pre- lymphocytes and macrophages by HIV during the incubation period of AIDS. senting with an acute illness not typically associated with PHI. Nature 1993; 362:359–62. 14. Bjerg Christensen A, Dige A, Vad-Nielsen J, et al. Administration of panobinostat is associated with increased IL-17A mRNA in the intestinal epithelium of HIV-1 Supplementary Data patients. Mediators Inflamm 2015; 2015:120605. Supplementary materials are available at Open Forum Infectious Diseases 15. Estes JD, Wietgrefe S, Schacker T, et  al. Simian immunodeficiency virus-in- online. Consisting of data provided by the authors to benefit the reader, duced lymphatic tissue fibrosis is mediated by transforming growth factor beta the posted materials are not copyedited and are the sole responsibility of 1-positive regulatory T cells and begins in early infection. J Infect Dis 2007; the authors, so questions or comments should be addressed to the corre- 195:551–61. sponding author. 16. Krarup AR, Abdel-Mohsen M, Schleimann MH, et  al. The TLR9 agonist MGN1703 triggers a potent type I  interferon response in the sigmoid colon. Mucosal Immunol. In press. Acknowledgments 17. Brandtzaeg P, Kiyono H, Pabst R, Russell MW. Terminology: nomenclature of We thank Helene M. Andersen for her assistance with sectioning samples mucosa-associated lymphoid tissue. Mucosal Immunol 2008; 1:31–7. in paraffin blocks and Dr. Jacob D. Estes (Frederick National Laboratory for 18. Brenchley JM, Douek DC. HIV infection and the gastrointestinal immune sys- Cancer Research) for IHC protocols and staining advice. tem. Mucosal Immunol 2008; 1:23–30. 4 • OFID • BRIEF REPORT Downloaded from https://academic.oup.com/ofid/article-abstract/5/2/ofy006/4794682 by Ed 'DeepDyve' Gillespie user on 16 March 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Open Forum Infectious Diseases Oxford University Press

Acute Appendicitis as the Initial Clinical Presentation of Primary HIV-1 Infection

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Abstract

Open Forum Infectious Diseases BRIEF REPORT presentation of PHI. Appendicitis and HIV-1 have previously Acute Appendicitis as the Initial been linked in 2 ways. First, in untreated immune-compromised Clinical Presentation of Primary HIV-1 HIV-1-infected individuals, opportunistic infections (eg, cyto- Infection megalovirus [CMV], Streptococcus pneumoniae, Mycobacterium 1 1,2 1 avium complex, and Cryptosporidium parvum) have been shown Mariane H. Schleimann, Steffen Leth, Astrid R. Krarup, 3 4 2 Jesper Mortensen, Bente Barstad, Matthias Zaccarin, to cause appendicitis [6–9]. Second, at initiation of antiretroviral 1,5 2 Paul W. Denton, and Rajesh Mohey therapy (ART), HIV-1-infected individuals have a risk of devel- Department of Infectious Diseases, Aarhus University Hospital, Skejby, Denmark; oping immune reconstitution inflammatory syndrome (IRIS), 2 3 Department of Medicine and Department of Nuclear Medicine, Herning Hospital, Herning, 4 5 Denmark; Institute of Pathology, Holstebro Hospital, Holstebro, Denmark; Department of which initiates a pathological inflammatory response to a previ- Clinical Medicine, Aarhus University, Aarhus, Denmark ous infection resulting in appendicitis [10, 11]. We present a third and novel association of HIV-1 and appen- We report a case of an adolescent who presented at our emer- dicitis. We describe a case with an adolescent male presenting gency department with acute abdominal pain. While the initial to our clinic with symptoms of acute appendicitis coincident diagnosis was acute appendicitis, a secondary and coincidental with his clinical presentation of PHI. Subsequent examina- diagnosis of primary HIV-1 infection was made. Concurrent tions and findings suggest HIV-1 as the causative agent of the and subsequent clinical and molecular biology findings form appendicitis. the basis of our argument that primary HIV-1 infection was the cause of acute appendicitis in this individual. CASE PRESENTATION Keywords. acute appendicitis; diagnosis; immunohisto- A 17-year-old male of Mediterranean origin was admitted to chemistry; in situ hybridization; primary HIV-1. the emergency department at a regional hospital with a 2-day history of diffuse abdominal pain and diarrhea. One month Globally, 1.8 million people were newly diagnosed with HIV-1 prior to the admission, the patient had returned to Denmark in 2016 [1]. However, signs and symptoms of primary HIV-1 from a vacation in the western part of Turkey. The patient had infection (PHI) are frequently lacking, which creates an obstacle a medical history of kidney neuroblastoma at the age of 3. After to timely diagnoses of PHI and early treatment initiation chemotherapy and radical surgery, he received a bone mar- [2, 3]. On occasions when clinical presentations of PHI do row–derived autologous CD34+ stem cell transplantation. This occur, they are typically u-li fl ke symptoms (eg, fever, rash, treatment was successful, and he showed no signs of relapse at aches, and swollen glands) [4]. Other clinical presentations of scheduled follow-up visits. PHI most frequently originate from the gastrointestinal tract At presentation to the emergency department, he was alert, [4]. In 1 case, an atypical clinical presentation of PHI was char- oriented, and febrile. Abdominal palpation elicited both direct acterized as “appendicitis-like illness that resulted in explorative and rebound tenderness. Biochemical tests showed an elevated laparotomy,” but appendicitis was not confirmed [4]. Because C-reactive protein (CRP) level of 216  mg/L, a leucocytosis 9 9 gastrointestinal tract–related complaints oen a ft re encountered (13.2 ×  10 /L) with lymphocytosis (9.18 ×  10 /L), and a dis- in routine health care settings, this category of patients poses a cretely elevated bilirubin level (32  μmol/L). The patient was potential risk of missing an HIV-1 diagnosis. closely observed, and the fever resolved spontaneously. The Although HIV-1-infected individuals have a 4-fold higher abdominal symptoms abated to the extent that the diagnosis of prevalence of appendicitis than HIV-1-negative individuals appendicitis could not be upheld. The next day, his CRP levels [5], appendicitis has never been reported as the initial clinical had reduced to 145  mg/L. A  tentative diagnosis of infectious diarrhea was made, and as the patient had improved, he was discharged to subsequent follow-up in the case that his condi- Received 24 October 2017; editorial decision 22 December 2017; accepted 7 January 2018. tion worsened. Correspondence: R.  Mohey, MD, PhD, Department of Medicine, Herning Hospital, Gl. On day 14 aer t ft he primary contact, the patient returned to Landevej 61, 7400 Herning, Denmark (rajemohe@rm.dk). the emergency department with complaints of diffuse abdom- Open Forum Infectious Diseases © The Author(s) 2018. Published by Oxford University Press on behalf of Infectious Diseases inal pain, multiple diarrheas, pain upon swallowing, headache, Society of America. This is an Open Access article distributed under the terms of the Creative a rash primarily on the torso and spreading to the limbs, severe Commons Attribution-NonCommercial-NoDerivs licence (http://creativecommons.org/licenses/ by-nc-nd/4.0/), which permits non-commercial reproduction and distribution of the work, in any fatigue, a dry cough, severe shortness of breath during physical medium, provided the original work is not altered or transformed in any way, and that the work activity, and an unintended weight loss (6  kg). Upon examin- is properly cited. For commercial re-use, please contact journals.permissions@oup.com ation, the patient was febrile and had rebound tenderness in the DOI: 10.1093/ofid/ofy006 BRIEF REPORT • OFID • 1 Downloaded from https://academic.oup.com/ofid/article-abstract/5/2/ofy006/4794682 by Ed 'DeepDyve' Gillespie user on 16 March 2018 right-lower abdominal quadrant and a maculopapular rash. No negative. The patient was observed for 2 days. At discharge, he lymphadenopathy was detected. Biochemical tests showed an was afebrile with a slightly elevated CRP value of 153 mg/L and elevated CRP level of 135 mg/L, leucopenia (1.9 ×  10 /L) with leucocytes within the normal range. 9 9 lymphopenia (0.7 × 10 /L), thrombocytopenia (72 × 10 /L), and On day 18, the patient returned to the emergency department a normal hemoglobin level of 8.7 mmol/L. A computed tomog- with persistent abdominal pain and a skin rash, as well as fever, raphy (CT) scan of the thorax and abdomen revealed a thick- headache, and neck stiffness. Biochemical tests showed an ele- walled and distended appendix with surrounding inflammation vated CRP level of 81 mg/L, normal leucocytes (4.4 × 10 /L) but 9 9 (Figure  1A). Laparoscopy revealed that a mild fibrin exudate lymphopenia (0.8 ×  10 /L), thrombocytopenia (146 ×  10 /L), was present at the base of the appendix. Furthermore, promi- and a normal hemoglobin level of 8.3  mmol/L. Meningitis nent and enlarged periappendiceal lymph nodes were observed. was suspected, and a lumbar puncture was performed. The er Th efore, an appendectomy was performed. Appendicitis was cerebrospinal fluid (CSF) exhibited 87  ×  10 /L leucocytes (of 6 6 confirmed using histopathological examination. Specifically, which 83 × 10 /L were mononuclear), 21 × 10 /L erythrocytes, tissue inflammation and ulceration of the mucosal membrane normal protein levels, and normal glucose levels. Penicillin were observed in hematoxylin and eosin–stained tissue sec- (3 g quater in die [QID, 4 times a day]), ceftriaxone (4 g once tions. Standard immunohistochemical stains of the appendix daily  [OD]), and acyclovir (10  mg/kg/d) were initiated intra- for an immediate early and an early CMV antigen were both venously as empiric treatment. CSF was negative by standard A B CT Scan In situ hybridization 200µm 20µm 20µm 20µm Immunohistochemistry CXCL10 ISG15 MxA MPO 50µm 50µm 50µm 50µm 13µm 13µm 13µm 13µm Figure 1. (A) Abdominal computed tomography (CT) scans reveal a dilated appendix with surrounding inflammation. The appendix is indicated by red arrows. (B) In situ hy- bridization (ISH) of the appendix base. The red ISH signal indicates the presence of HIV-1 RNA transcripts. The upper left image is low magnification. Boxes surround regions of the appendix depicted in higher magnification in the connected images. (C) Immunohistochemistry images of the appendix body. The brown signal indicates the presence of the inflammatory markers, C-X-C motif chemokine 10 (CXCL10), interferon stimulated gene 15 (ISG15), myxovirus resistance protein 1 (MxA), or myeloperoxidase (MPO) indi- cated for the specific panel. The top column is low magnification. Boxes in the upper column images indicate the region depicted in higher magnification in the bottom column. 2 • OFID • BRIEF REPORT Downloaded from https://academic.oup.com/ofid/article-abstract/5/2/ofy006/4794682 by Ed 'DeepDyve' Gillespie user on 16 March 2018 clinical polymerase chain reaction (PCR) tests for common weeks later. ART consisted of emtricitabine 200  mg/tenofovir pathogens (including Neisseria meningitidis, Streptococcus disoproxil fumarate 245  mg (Truvada) in combination with pneumoniae, varicella zoster, and herpes simplex virus 1 and 2). darunavir 800 mg/ritonavir 100 mg once daily. Six months aer ft Direct microscopic assessment of the CSF was negative for bac- initiating ART, the CD4 cell count had increased to 850/μL, and teria. Neither CSF nor blood cultures showed evidence of bac- plasma HIV-1 RNA was fully suppressed. teria. Therefore, the patient was treated according to national To investigate the etiology of this appendicitis and assess guidelines for culture-negative meningitis. A  new CT scan of whether this case represents a novel clinical presentation of the abdomen revealed mild and anticipated postoperative find- PHI, the appendix was subsequently examined by in situ hy- ings and was otherwise considered normal. bridization and immunohistochemistry. In situ hybridization On day 21, the patient was still febrile and exhibiting leuco- revealed high levels of HIV-1 RNA-producing cells throughout penia. At this point, the antibiotic treatment was modified the appendix base, body, and tip (Figure  1B; Supplementary considering the travel history to Turkey and exposure to raw Figure  1, A  and B). Large red nuclei-associated spots repre- unpasteurized milk. Specifically, the antibiotic regimen was sent cell profiles expressing HIV-1 RNA. The levels of product- switched to ceftriaxone 4 g OD with the addition of ciproflox- ively infected cells observed in this appendix are comparable to acin 400 mg bis in die (BID; 2 times a day), due to clinical sus- those observed in lymph nodes of individuals with untreated picion of brucellosis. No known genetic mutations related to HIV-1 infection [13]. Furthermore, immunohistochemical Mediterranean fever were identified. The patient was tested for stains against the inflammatory markers CXCL10, ISG15, and hepatitis A, B, and C virus serology/antigens, CSF 16S PCR ana- MxA reveal a robust production of these proteins throughout lysis, and CMV/Epstein-Barr virus (EBV)/brucellosis serology. the tissue indicative of a stimulation of the IFN-alpha and On day 29, the patient remained febrile despite ongoing anti- IFN-gamma immune responses (Figure  1C; Supplementary biotic treatment. The patient was tested for Coxiella burnetii and Figure  1C). Interestingly, no massive neutrophil (MPO) infil- parvovirus B19 serology. A  blood smear was also performed. tration into the inflamed organ was detected (Figure 1C), which Additionally, a fludeoxyglucose (FDG) positron emission tom- supports that this case was not bacterial-induced appendicitis. ography (PET) CT revealed pathologic FDG uptake in mul- METHODS tiple lymph node sites. To rule out relapse of neuroblastoma, the urine was tested for vanillylmandelic acid and found to be Fixation of Appendix negative. Further investigation into the patient’s medical history Immediately after the appendectomy, the appendix was fixed revealed that the patient had tested negative for HIV-1 88 days overnight in 10% neutral buffered formalin, then cut into earlier at his general practitioner (HIV p24 Ag/Ab Combo, 6 pieces (base, body, and tip, alternating longitudinal and Abbott), and the patient acknowledged having sex with men as cross-sections representing the appendix in full length), and an HIV risk factor. Therefore, a new HIV-1 diagnostic test was each piece was then embedded in paraffin. ordered (HIV p24 Ag/Ab Combo, Abbott). In Situ Hybridization Of the extensive panel of assays performed to detect an in- As we previously described [14], in situ hybridization for fectious etiology in this case, CMV, EBV and HIV were posi- HIV-1 RNA was performed using the RNAScope 2.0 RED assay tive. Regarding CMV, IgM and IgG antibodies against this virus (Advanced Cell Diagnostics) and treated as described in the were present in serum, but immunohistochemistry performed Supplementary Methods. immediately aer t ft he appendectomy found the appendix to be Immunohistochemistry negative for CMV proteins that would have indicated active Immunohistochemistry (IHC) to detect C-X-C motif chemok- viral replication. Regarding EBV, the patient was positive for ine 10 (CXCL10), interferon stimulated gene 15 (ISG15), myxo- antibodies against EBV-EBNA, negative for IgM against virus virus resistance protein 1 (MxA), or myeloperoxidase (MPO) capsid antigen, and negative for EBV DNA in blood. These find- was performed according to previously published protocols [15, ings together indicate prior CMV and EBV infections and sero- 16] and treated as described in the Supplementary Methods and conversions well beyond the time frame of this case. Regarding Supplementary Table 1. HIV-1, the day 29 sample was positive for both p24 antigen and anti-HIV antibodies, but negative for p31 antigen (INNO-LIA Ethical Statement HIV I/II Score, Fujirebio). These findings place the patient in Written informed consent was obtained for subsequent analyses HIV Fiebig stage V [12] at HIV-1 diagnosis. and the publication of this report. e p Th atient’s CD4 cell count was 680/μL, and his plasma HIV-1 DISCUSSION RNA level was 1 ×  10 copies/mL. HIV in the CSF fluid was 16 × 10 copies of HIV-1 RNA per mL. Antibiotics were ceased Here we argue for primary HIV infection as a novel etiology aer a t ft otal of 14 treatment days. Intensive HIV counseling was for acute appendicitis. The lack of neutrophil infiltration and immediately begun, and the patient was ready to begin ART 2 the observance of a robust interferon response in the appendix BRIEF REPORT • OFID • 3 Downloaded from https://academic.oup.com/ofid/article-abstract/5/2/ofy006/4794682 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Financial support. This work was supported by e Th Danish Council support a viral etiology for the inflammation. Although we can- for Independent Research (DFF grant #5053-00090), Aarhus University not completely rule out a bacterial or other etiology, we did rule Research Foundation (AUFF-E-2016-FLS-8–9), Aarhus University, and out CMV or EBV as the cause of this appendicitis. Further, the Aarhus University Hospital, Denmark. The funders had no role in the study patient’s CSF was negative for varicella zoster, HSV-1, and HSV-2 design, data analyses, data interpretation, or writing of the article. Potential coni fl cts of interest. e Th authors declare no conflict of inter - replication. Our in situ hybridization analysis of the appendix est. All authors have submitted the ICMJE Form for Disclosure of Potential revealed the presence of HIV-1 RNA-positive cells throughout Conflicts of Interest. Conflicts that the editors consider relevant to the con- the entire organ. This observation is consistent with the facts tent of the manuscript have been disclosed. that (i) the appendix, along with Peyer’s patches and isolated lymphoid follicles, is a gut-associated lymphoid tissue that func- References 1. World Health Organisation (WHO). Fact sheet on HIV/AIDS. Updated July 2017. tions as an inductive site for mucosal B and T cells [17] and (ii) Available at: http://www.who.int/mediacentre/factsheets/fs360/en/. Accessed 2 immune inductive sites are primary sites of HIV-1 replication August 2017. and pathogenesis [18]. While the primary HIV-1 infection might 2. Lundgren JD, Babiker AG, Gordin F, et  al; INSIGHT START Study Group. Initiation of antiretroviral therapy in early asymptomatic HIV infection. N Engl J be purely coincidental and PHI as the cause of the appendicitis Med 2015; 373:795–807. cannot be unequivocally proven, the evidence strongly supports 3. Robb ML, Eller LA, Kibuuka H, et al; RV 217 Study Team. Prospective study of acute HIV-1 infection in adults in East Africa and Thailand. N Engl J Med 2016; PHI as the etiology of the appendicitis in this case. 374:2120–30. er Th e is no confirmed precedent for acute appendicitis as 4. Braun DL, Kouyos RD, Balmer B, et  al. Frequency and spectrum of unex- pected clinical manifestations of primary HIV-1 infection. Clin Infect Dis 2015; PHI, as indicated by Braun et  al. in their compilation of rare 61:1013–21. atypical clinical presentations of PHI [4]. Other atypical clin- 5. Crum-Cianflone N, Weekes J, Bavaro M. Appendicitis in HIV-infected patients during the era of highly active antiretroviral therapy. HIV Med 2008; 9:421–6. ical presentations of PHI include opportunistic infections (eg, 6. Tucker RM, Swanson S, Wenzel RP. Cytomegalovirus and appendiceal perfora- Candida stomatitis, Candida esophagitis) or damage to the cen- tion in a patient with acquired immunodeficiency syndrome. South Med J 1989; tral nervous system (eg, encephalitis, paresis, acute psychiatric 82:1056–7. 7. Clark JA, Keroack MA. Pneumococcal appendicitis in a man with HIV infection. disorders). Also, tonsillitis, pneumonia, renal failure, or skin N Engl J Med 1993; 328:1282. and soft tissue infections have been confirmed as the initial clin- 8. Livingston RA, Siberry GK, Paidas CN, Eiden JJ. Appendicitis due to Mycobacterium avium complex in an adolescent infected with the human immu- ical presentation of PHI [4]. Our case supports considering PHI nodeficiency virus. Clin Infect Dis 1995; 20:1579–80. as a differential diagnosis in patients undergoing appendec- 9. Buch K, Nguyen S, Divino CM, et  al. Cryptosporidiosis presenting as acute appendicitis: a case report. Am Surg 2005; 71:537–8. tomy, who subsequently experience low platelets, lymphopenia, 10. Shelburne SA, Visnegarwala F, Darcourt J, et  al. Incidence and risk factors for prolonged fever, and are refractory to conventional diagnostics immune reconstitution inflammatory syndrome during highly active antiretro- viral therapy. AIDS 2005; 19:399–406. and treatment. Overall lessons from this case include a practical 11. Faldetta KF, Kattakuzhy S, Wang HW, et  al. Cytomegalovirus immune recon- reinforcement of the fact that clinical presentations of PHI are stitution inflammatory syndrome manifesting as acute appendicitis in an HIV- oen a ft typical. Our putative finding that the initial clinical pres- infected patient. BMC Infect Dis 2014; 14:313. 12. Fiebig EW, Wright DJ, Rawal BD, et al. Dynamics of HIV viremia and antibody entation of PHI in this case was acute appendicitis underscores seroconversion in plasma donors: implications for diagnosis and staging of pri- the importance of meticulously noting the history of sexual risk mary HIV infection. AIDS 2003; 17:1871–9. 13. Embretson J, Zupancic M, Ribas JL, et  al. Massive covert infection of helper T behavior and performing HIV tests in high-risk patients pre- lymphocytes and macrophages by HIV during the incubation period of AIDS. senting with an acute illness not typically associated with PHI. Nature 1993; 362:359–62. 14. Bjerg Christensen A, Dige A, Vad-Nielsen J, et al. Administration of panobinostat is associated with increased IL-17A mRNA in the intestinal epithelium of HIV-1 Supplementary Data patients. Mediators Inflamm 2015; 2015:120605. Supplementary materials are available at Open Forum Infectious Diseases 15. Estes JD, Wietgrefe S, Schacker T, et  al. Simian immunodeficiency virus-in- online. Consisting of data provided by the authors to benefit the reader, duced lymphatic tissue fibrosis is mediated by transforming growth factor beta the posted materials are not copyedited and are the sole responsibility of 1-positive regulatory T cells and begins in early infection. J Infect Dis 2007; the authors, so questions or comments should be addressed to the corre- 195:551–61. sponding author. 16. Krarup AR, Abdel-Mohsen M, Schleimann MH, et  al. The TLR9 agonist MGN1703 triggers a potent type I  interferon response in the sigmoid colon. Mucosal Immunol. In press. Acknowledgments 17. Brandtzaeg P, Kiyono H, Pabst R, Russell MW. Terminology: nomenclature of We thank Helene M. Andersen for her assistance with sectioning samples mucosa-associated lymphoid tissue. Mucosal Immunol 2008; 1:31–7. in paraffin blocks and Dr. Jacob D. Estes (Frederick National Laboratory for 18. Brenchley JM, Douek DC. HIV infection and the gastrointestinal immune sys- Cancer Research) for IHC protocols and staining advice. tem. Mucosal Immunol 2008; 1:23–30. 4 • OFID • BRIEF REPORT Downloaded from https://academic.oup.com/ofid/article-abstract/5/2/ofy006/4794682 by Ed 'DeepDyve' Gillespie user on 16 March 2018

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