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Open Access Highly Accessed Case report

Cytomegalovirus immune reconstitution inflammatory syndrome manifesting as acute appendicitis in an HIV-infected patient

Kimberly F Faldetta1, Sarah Kattakuzhy2, Hao-Wei Wang3, Irini Sereti1 and Virginia Sheikh1*

Author Affiliations

1 Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA

2 Laboratory of Immunoregulation, Leidos Biomedical Research, Inc, Frederick National Laboratory for Cancer Research, Frederick, MD 21702, USA

3 Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA

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BMC Infectious Diseases 2014, 14:313  doi:10.1186/1471-2334-14-313

Published: 9 June 2014

Abstract

Background

Appendicitis occurs with increased frequency in HIV infected compared to HIV uninfected persons. CMV-related appendicitis specifically presents with typical appendicitis symptoms including surgical abdomen, fever and leukocytosis and may have a more severe course with higher mortality than other types of infective appendicitis. We report the first case of CMV appendicitis as a manifestation of Immune Reconstitution Inflammatory Syndrome (IRIS).

Case presentation

The patient was a 38 year old woman with a recent diagnosis of HIV infection who complained of right lower quadrant pain, anorexia, nausea and fevers two weeks after initiating antiretroviral therapy. Acute appendicitis was suspected and the patient underwent an appendectomy. Pathologic examination of the resected appendiceal tissue demonstrated inflammation with perforation and cytopathic changes typical of CMV that were positive for CMV by immunostain. This presentation of CMV abruptly after antiretroviral therapy initiation with a pronounced cellular infiltration of the tissue, is consistent with CMV-IRIS presenting as appendicitis.

Conclusions

Appendicitis can be a rare manifestation of CMV-IRIS in HIV-infected patients who start antiretroviral therapy. Evaluation of appendiceal tissue for cytopathic changes and CMV should be considered in acute appendicitis in HIV infected persons.

Keywords:
Cytomegalovirus; Immune reconstitution inflammatory syndrome; Opportunistic infections; HIV