A Rare Case of Disseminated Mycobacterium avium-intracellulare Presenting as Proctitis

Abstract

Mycobacterium avium intracellulare (MAI) infections are common in Human Immuno-deficiency Virus (HIV) positive patients. MAI infection can have localized or disseminated presentation, patients with low CD4 count presenting with disseminated infection. Fever, abdominal pain, diarrhea, and weight loss are generally the presenting symptoms of disseminated MAI. We present a rare case of a patient with HIV and low CD4 count presenting with proctitis as manifestation of disseminated MAI infection. A 25 year-old-man with HIV came to the emergency room (ER) with complaints of intermittent rectal bleeding for two months. His CD4 count was less than 20 cells/µL. He was MSM (men having sex with men) and has receptive anal intercourse with men. His stool work-up was unrevealing for infectious etiology. Swabs for gonorrhea and chlamydia were negative. Colonoscopy revealed erythematous, congested, friable rectal mucosa with two superficial ulcers. Biopsies of the ulcer were positive for acid fast staining bacteria and the culture grew MAI. His blood culture was negative for growth of acid-fast bacteria (AFB). However, liver biopsy performed for elevated alkaline phosphatase of 958 units/L revealed noncaseating granuloma. Gastro-duodenoscopy with duodenal biopsy did not reveal any mucosal abnormality. He was managed as with disseminated MAI infection using clarithromycin, ethambutol, and rifabutin in addition to HAART therapy. Interval Colonoscopy in 20 months showed resolution of rectal ulcer. The gut is often involved in patients with disseminated MAI infection, with the duodenum being the most common site. MAI infection should be suspected as possible etiology for proctitis in HIV positive patient with low CD4 count, as proctitis, though infrequent can be the sole presentation for disseminated MAI infection in patients with HIV and low CD4 count.

Disseminated MAI in an HIV Patient-An Unusual Presentation

“…The cornerstone of treatment for MAI is a dual therapy regimen consisting of ethambutol and macrolides [ 2 , 3 , 6 ]. While it will never be confirmed whether the patient had true antiretroviral resistance as the testing was not available in our hospital and was typically done in an outpatient setting, the patient elected to pursue hospice in lieu of further testing and antimicrobial treatment.…”

“…MAI infections can have localized or disseminated presentations. The classic symptoms of disseminated MAI are fever, night sweats, abdominal pain, diarrhea, anorexia, fatigue, and malaise [ 4 , 5 , 6 ]. Along with the classic presentation of disseminated MAI, it is common to find infections spreading through the bloodstream and to the lymph nodes and liver.…”

“…With adherence to Highly Active Antiretroviral Therapy (HAART), there has been a decrease in the MAI epidemic; however, nonadherence to HAART can decrease the CD4 count and hence increase susceptibility to MAI infection [ 7 , 8 , 9 ]. Through the development of HAART and subsequent adherence to the therapy, it has been shown in Human Immuno-deficiency Virus (HIV) infection-positive individuals to postpone the progression of MAI infection [ 6 ]. Immunocompromised patients with localized or disseminated MAC infections are normally treated for at least 12 months with a dual therapy regimen of a macrolide and ethambutol; however, those presenting with constant high numbers of mycobacteria or failing antiretroviral therapy (ART) are given a third agent, such as rifampin, to overcome their infection [ 2 , 3 , 6 ].…”