D IC A L
O U R N A L
A b d o m in a l m y c o b a c te ria l in fe c tio n in a c q u ire d
im m u n o d e fic ie n c y sy n d ro m e p a tie n ts
Emergency Service o/the Hospital Ipiranga - Sao Paulo, Brazil
T h e a u th o rs stu d ie d 1 2 p a tie n ts w ith A ID S a n d a b d o m in a l m yco b a cte rio sis h o sp ita lize d in th e H o sp ita l I p ira n g a (S a o P a u lo , B ra zil), fro m Ju n e 1 9 a 9 to Ja n u a ry 1 9 9 2 . D ia g n o sis w a s co n firm e d b y th e h isto p a th o lo g ica l e xa m in a tio n o f o rg a n sp e ci-m e n s co lle cte d d u rin g la p a ro to m y, w h ich , in m o st ca se s, w a s ca rrie d o u t d u e to a n e m e rg e n cy situ a tio n . O b se rva tio n s in clu d e d p e rfo ra tio n o f th e ile u m , se ro p u ru le n t flu id in vo lve d a n d b lo ke d b y visce ra , e p ip lo o n , a n d fib rin . H e p a to e sp le n o m e g a ly w a s p re se n t in a ll p a tie n ts a n d g e n e ra lize d g ra n u lo m a to u s p e rito n itis w a s o b se rve d in m o re th a n 5 0 % . A p a tie n t d ie d in th e im m e d ia te p o st-o p p e rio d , fo u r a fte r a n a ve ra g e p e rio d o f 5 5 d a ys in th e h o sp ita l. A p a tie n t e vo lve d w ith ste rco ra l fistu la a n d a ske d to b e d isch a rg e d . S ix p a tie n ts w e re d isch a rg e d a fte r a n a ve ra g e h o sp ita liza tio n p e rio d o f 2 7 d a ys. T h e a u th o rs stre ss th a t in d e ve lo p in g re g io n s w h e re tu b e rcu lo sis in cid e n ce is h ig h , a p a tie n t w ith A ID S a n d a p a in fu l a n d irrita tive a b d o m in a l p ictu re sh o u ld a lw a ys le a d to th e h yp o th e sis o f m yco b a cte rio sis.
U N IT E R M S : A b d o m in a l tu b e rcu lo sis. T u b e rcu lo sis a n d A id s. A b d o m in a l m yco b a cte rio sis. S u rg e ry a n d A id s. A b d o m in a l In fe ctio n a n d A id s.
IN T R O D U C T IO N
I
is v e r ynF ir s t W o r lds e ld o m c o u n tr ie s ,o b s e r v e d a b d o m in a lin n o n - im m u n o s u p p r e s s e dm y c o b a c te r io s is p a tie n ts ( 3 ,1 1 ,1 2 ) .T h e p e r ito n e a l in v o lv e m e n t b y m y c o b a c te r ia o c c u r s m o r e o f te n in r e g io n s w h e r e e n v ir o n m e n ta l s a n ita tio n is d e f ic ie n t ( 7 ,1 7 ) .
T h e r e s u r g e n c e o f tu b e r c u lo s is in g e n e r a l, a ty p ic a l b a c illa r f o r m s a n d th e ir d is s e m in a tio n p a r tic u la r ly in th e a b d o m e n , c a n b e r e la te d to th e b o o m o f A I D S e p id e m ic s a n d th e d e te r io r a tio n o f liv in g c o n d itio n s o f m in o r itie s th a t to o k p la c e in th e la s t d e c a d e ( 6 ,7 ,1 5 ,1 6 ) .
A d d re s s fo r c o rre s p o n d e n c e : R u g g e ro B e rn a rd o G u id u g li A v . N a z a re , 2 8 - Ip ira n g a
S a o P a u lo - S P - B ra s il - C E P 0 4 2 6 2 -0 0 0
M a jo r c h a lle n g e s p r e s e n te d to c lin ic a l e v a lu a tio n a r e th e v e r y little e lu c id a tiv e c lin ic a l p ic tu r e o f a b d o m in a l m y c o b a c te r io s e s a n d th e n e e d f o r a n e a r ly d ia g n o s is , in o r d e r to r e v e r t th e p r o g n o s is .
T h is r e tr o s p e c tiv e s tu d y o f a b d o m in a l b a c te r ia l in f e c tio n s in p a tie n ts w ith A I D S , tr e a te d in th e H o s p ita l I p ir a n g a , in th e la s t th r e e y e a r s , is a n a tte m p t to b r in g to th e s u r f a c e im p o r ta n t a s p e c ts o f th is a s s o c ia tio n in o u r e n v ir o n m e n t.
M E T H O D
A m o n g p a tie n ts s e e n a t th e E m e r g e n c y S e r v ic e a n d I n f e c tio u s D is e a s e S e r v ic e o f H o s p ita l I p ir a n g a , f r o m J u ly 1 9 8 9 to J a n u a r y 1 9 9 2 , 1 2 w e r e d ia g n o s e d a s h a v in g A c q u ir e d I m m u n o d e f f ic ie n c y S y n d r o m e a n d a b d o m in a l m y c o b a c te r io s is .
c o n firm e d b y h is to p a th o lo g ic a l e x a m in a tio n o f s p e c im e n s o b ta in e d fro m a b d o m in a l v is c e ra , d u rin g la p a ro to m y .
In 9 p a tie n ts , th e s u rg e ry w a s p e rfo rm e d a s a re s u lt o f a c u te a b d o m e n , p ro m p tly d ia g n o s e d in th e E m e rg e n c y S e c to r. In fu s io n o f liq u id a n d e le c tro lite s w a s g iv e n ; b lo o d w a s c o lle c te d fo r b lo o d c o u n t, b io c h e m ic a l p ro file a n d d e te rm in a tio n o f c lo ttin g fa c to rs . A p la in X -ra y w a s u s e d in th e e x a m o f c h e s t a n d a b d o m e n , th e p a tie n t b e in g th e n re fe rre d to th e S u rg ic a l C e n te r fo r la p a ro to m y .
In 3 p a tie n ts , s u rg e ry w a s c a rrie d o u t fo r p rim a ry d ia g n o s is p u rp o s e s , a s a p a in fu l a n d p ro g re s s iv e a b d o m in a l p ic tu re e v o lv e d d u rin g h o s p ita liz a tio n in In fe c tio u s D is e a s e W a rd . L a p a ro to m y b e c a m e m a n d a to ry a fte r th e n o n -in v a s iv e im a g e d ia g n o s tic p ro c e d u re s (u ltra s o u n d , C T s c a n ) h a d b e e n u s e d , s u g g e s tin g g a n g lio n a ry m a s s e s , a c c u m u la tio n o f flu id in th e a b d o m e n o r e v e n s u b -o c c lu s iv e s itu a tio n s .
A s y s te m a tic e x p lo ra tio n o f th e a b d o m in a l c a v ity w a s m a d e d u rin g s u rg e ry . W h e n p e rfo ra tio n s w e re lo c a te d in h o llo w v is c e ra , s u tu re s w ith n o n -a b s o rb a b le m a te ria l w e re m a d e . F lu id a c c u m u la tio n s w e re d ra in e d , o rg a n s w e re b io p s ie d w h e n th e re w a s a s u s p ic io n o f th e ir in v o lv e m e n t, a n d th e c a v ity c lo s e d b y s e p a ra te p la n e s .
P a tie n ts in a c ritic a l s itu a tio n d u rin g th e p o s t-o p p e rio d w e re re fe rre d to th e In te n s iv e C a re U n it. S ta b le p a tie n ts fo llo w e d th e ro u tin e tre a tm e n t in th e In fe c tio u s D is e a s e W a rd .
a n a ty p ic m y c o b a c te rio s is , th e ra p y w o u ld in c lu d e rifa m p y c in , is o n ia z id , e th a m b u to l, c lo fa z im in e a n d c ip ro flo x a c in .
P a tie n ts th a t h a d b e e n h o s p ita liz e d d u e to e m e rg e n c y w e re s till b e in g in v e s tig a te d fo r th e o th e r p a th o lo g ie s o f th e s y n d ro m e . T h e n u tritio n a l s ta tu s w a s n o t o v e rlo o k e d ; m a n y p a tie n ts h a d to re c e iv e e n te ra l a n d p a re n te ra l n u tritio n d u e to th e e x tre m e c a c h e x ia a n d th e p ro lo n g e d ile u m .
A lth o u g h a ll p a tie n ts d is c h a rg e d fro m th e h o s p ita l re c e iv e d in s tru c tio n s to a tte n d th e In fe c tio u s D is e a s e A m b u la to ry , m a n y d id n o t. S o m e p re fe rre d to b e fo llo w e d -u p a t th e A ID S R e fe re n c e a n d T ra in in g C e n te r o f th e H e a lth S e c re ta ry th a t re fe rre d th e m to u s fo r h o s p ita liz a tio n .
R E S U L T S
Patients Data
T w e lv e p a tie n ts u n d e rw e n t s u rg e ry , 8 m a le s a n d 4 fe m a le s , a g e s b e tw e e n 2 1 y e a rs a n d 3 8 y e a rs . A ll b e lo n g e d to s o m e ris k g ro u p fo r A ID S : 9 w e re IV d ru g u s e rs a n d 3 h o m o s e x u a ls (T a b le I).
T a b le I
P a tie n ts w ith A ID S a n d a b d o m in a l m y c o b a c te r io s is th a t u n d e r w e n t s u r g e r y in H o s p ita llp ir a n g a , J u ly 1 9 8 9 to J a n u a r y 1 9 9 2
P a tie n t D a te o f S u rg e ry ID N u m b e r A g e S e x R is k F a c to rs
1 P T S 0 7 .2 1 .8 9 5 3 .7 5 9 3 1 M T o x ic o m a n ia
2 A T S 0 7 .2 4 .8 9 5 6 .0 7 7 2 0 M T o x ic o m a n ia
3 S B 0 7 .2 7 .9 0 6 7 .1 3 8 2 6 F T o x ic o m a n ia
4 L C A 1 0 .3 0 .9 0 7 1 .7 4 5 2 8 M H o m o s e x u a lity
5 R IR 0 2 .2 2 .9 1 7 5 .7 5 2 2 1 M H o m o s e x u a lity
6 M T S 0 2 .2 2 .9 1 7 5 .7 6 5 2 3 M T o x ic o m a n ia
7 D L F 0 3 .0 4 .9 1 7 8 .0 3 3 2 3 M H o m o s e x u a lity
8 A M R M 0 6 .2 0 .9 1 8 3 .0 5 5 2 2 F T o x ic o m a n ia
9 M L C 0 8 .1 3 .9 1 8 4 .0 8 7 2 1 F T o x ic o m a n ia
1 0 H M 0 9 .3 0 .9 1 7 4 .5 9 8 3 8 M T o x ic o m a n ia
1 1 E A A 1 0 .1 0 .9 1 6 7 .2 1 0 2 9 F T o x ic o m a n ia
1 2 M R 1 2 .0 1 .9 2 9 0 .4 2 0 2 4 M T o x ic o m a n ia
8 9 7
Preoperative Clinical Picture
A ll p a tie n ts h a d a p o o r g e n e ra l sta te , w e ig h t lo ss a n d
h y p e rth e rm ia . A n e m ia w a s c o n sta n t a n d le u c o p e n ia
p re d o m in a te s o v e r le u c o c ito sis. T h re e h a d a lso p u lm o n a ry
tu b e rc u lo sis, d e m o n stra te d b y b a c te rio lo g ic a l e x a m in a tio n
o f sp u tu m (T a b le II).
In th e e m e rg e n c y c a se s, th e c lin ic a l p ic tu re o f a c u te
a b d o m e n w a s c h a ra c te ristic (p a in , d iste n sio n /rig id ity ,
su d d e n p a in fu l d e c o m p re ssio n , v o m itin g , n o n -e lim in a tio n
o f g a se s a n d fe c e s).
P a tie n ts w h o u n d e rw e n t la p a ro to m y fo r p rim a ry
d ia g n o stic p u rp o se s h a d th e a b d o m e n in a d a n g e ro u s
situ a tio n , b u t w ith le ss in te n se m a n ife sta tio n s. Im a g in g
d ia g n o sis su g g e ste d th e p re se n c e o f m a sse s, flu id
a c c u m u la tio n , a n d flu id /a ir le v e ls in so m e c a se s (F ig u re
1 ) (T a b le III).
Laparotomy Findings
T h e la p a ro to m y in c isio n s w e re p a ra m e d ia l o n th e
rig h t sid e , a s sy m p to m s w e re p re d o m in a n t o n th is sid e o f
th e a b d o m e n . In 4 e m e rg e n c y c a se s, th e re w a s p e rfo ra tio n
o f th e te rm in a l ile u m (T a b le IV ).
T h e sm a ll in te stin e lo o p s w e re th ic k e n e d , th e ir
m e se n te riu m w ith a la rg e n u m b e r o f ly m p h o n o d i a n d m u c h
fa t tissu e .
T h e p e rfo ra tio n s, w h ic h h a d g ra n u lo u s b o rd e rs a n d
a p p ro x im a te ly 3 m m , w e re p a rtia lly b lo c k e d b y fib rin a n d
b y th e e n ta n g le m e n t o f th e g u t, m e se n te riu m a n d e p ip lo o n
th a t c irc u m sc rib e d a re a s w ith m a jo r c a se o u s n e c ro sis.
T h is a sp e c t o f tw iste d a n d th ic k e n e d lo o p s w o u ld
a lso b e re sp o n sib le fo r th e a b d o m in a l d iste n tio n p re se n t
in 1 1 p a tie n ts (T a b le III). In th e fo rm s d e sc rib e d a s "d ry ",
th e fib rin la y e r fo rm e d a th ic k o u te r la y e r m a k in g it d iffic u lt
to id e n tify th e site o f le a k a g e o r fistu liz a tio n .
A c itro n y e llo w a sc ite s, fre e o r b lo c k e d b y th ic k e n e d
lo o p s, a n d m a rk e d b y in te n se e d e m a a n d c o n g e stio n
c h a ra c te riz e d th e "h u m id " fo rm .
T h e m e se n te ric a d e n itis p re se n t in 7 p a tie n ts w a s se e n
a s a la rg e v o lu m e m a ss, fo rm e d b y a d h e re d ly m p h o n o d i
p ro je c tin g th e p o ste rio r p e rito n e u m .
In th e e le c tiv e la p a ro to m ie s, e fe c tiv e p e rfo ra tio n w a s
n o t o b se rv e d , b u t a re a s o f c a se o u s n e c ro sis w e re p re se n t
in h o llo w v isc e ra w ith in te n se su rro u n d in g in fla m m a to ry
a re a to w h ic h th e e p ip lo o n h a d m o v e d , a tte m p tin g to b lo c k
it.
T h ~ sa m e b lo c k a g e a lso d e lim ite d th e flu id c o lle c tio n
re su ltin g fro m e x su d a tio n a n d ru p tu re o f c a se o u s n o d e s.
A m o d e ra te to v o lu m o u s h e p a to sp le n o m e g a ly w a s
o b se rv e d in a ll p a tie n ts a n d in 5 0 % o f p a tie n ts th e
p e rito n e a l se ro sa w a s sp e c k le d b y c a se o u s m ic ro g ra n u le s.
F ig u re 2 illu stra te s th e se fin d in g s.
Histopathological findings
M a te ria l se n t to h isto lo g ic a l e x a m in a tio n w a s m a in ly
ly m p h o n o d e s. F o u r o f th e m (5 7 % ) sh o w e d e x te n se a re a s
o f c a se o u s n e c ro sis, w ith little su rro u n d in g e p ith e lio id
g ra n u lo m a to u s re a c tio n a n d ra re L a n g h a n s-ty p e g ia n t c e lls.
T h is p ic tu re w a s a lso se e n in th e e x a m in a tio n o f
Table II
Patients with AIDS and abdom inal m ycobacteriosis that underwent surgery in Hospitallpiranga, July 1989 to January 1992
Tem perature and hem ogram at adm ission. Koch bacillus (KB) in sputum confirm ed later.
Patient Tem perature Hem ogram
Ht Hb G .B.
1 37.4 38 11.5 2.300
2 39.0 16 5.1 2.860
3 37.8 25 7.8 6.200
4 39.0 23 7.7 6.000
5 38.4 28 8.1 9.300
6 38.0 35 10.0 4.300
7 37.8 26 6.1 2.400
8 37.7 18 7.2 3.100
9 37.1 23 7.6 3.700
10 37.8 37 11.8 4.160
11 38.0 18 6.2 1.600
12 37.6 22 5.2 4.100
KB in sputum
+
+
+
Table III
P atients w ith A ID S and abdom inal m ycobacteriosis that underw ent surgery in H ospitallpiranga, July 1989 to January 1992
D iagnostic (D ) or em ergency (E ) surgery, abdom inal signs before surgery
P atient Type of surgery P ain D istension R igidity N ausea! Interruption of gas and feces V om iting elim ination
1 U + + + + +
2 U + + + +
3
0 + +4
U + + + + +5
U + + + + +6
U + + + + +7 U + + + +
8
0 + + +9 0 + +
10 U + + + + +
11 U + + + + +
12 U + + + + +
FIG U R E 1 - P lain X -ray of the abdom en of a patient w ith A ID S and abdom inal m ycobaterial infection. O bserve the fluid/air levels
as a consequence of a suboclusion and density increase,
suggesting the presence of fluid sam ples in the cavity.
2
FIG U R E 2 - A bdom inal M ycobaterial Infection In P atients W ith A ids
S urgical findings
1. parietal and visceral peritoneum speckled by granulom as 2. H epatoesplenom egaly
3. H ypertrophy of the m esenteric Iym phonodi
4. S eptate fluid accum ulations (ascites or seropurulent secretions) 5. Fibrin adherences and septations
6. Increase of m esenteric fat
7. Fistula and perforations of hollow viscera blocked by epiploon 8. H ypertrophy, stenosis and entanglem ent of the term inal ileum
899
T a b le IV
P a tie n ts w ith A ID S a n d a b d o m in a l m y c o b a c te rio s is th a t u n d e rw e n t s u rg e ry in H o s p ita llp ira n g a , J u ly 1 9 8 9 to J a n u a ry 1 9 9 2
In d ic a tio n fo r la p a ro to m y a n d s u rg ic a l fin d in g
Patient
1 2 3 4 5 6 7 8 9 1 0 1 1 1 2Indication
P e rfo ra te d a c u te a b d o m e n P e rfo ra te d a c u te a b d o m e n D ia g n o s is
In fla m a to ry a c u te a b d o m e n P e rfo ra te d a c u te a b d o m e n a c c u m u la tio n s
In fla m a to ry a c u te a b d o m e n P e rfo ra te d a c u te a b d o m e n + o b s tru c tio n
D ia g n o s is D ia g n o s is
In fla m a to ry a c u te a b d o m e n In fla m a to ry a c u te a b d o m e n H e m o rrh a g ic a c u te a b d o m e n (p o s t-b io p s y )
Surgical finding
P e rfo ra tio n o f te rm in a l ile u m w ith b lo c k a g e P e rfo ra tio n o f te rm in a l ile u m w ith b lo c k a g e
G ra n u lo m a to u s p e rito n itis , m e s e n te ric ly m p h a d e n itis , a s c ite s S u p u ra tio n o f Iy m p h o n o d u s , g ra n u lo m a to u s p e rito n itis S e v e ra l p e rfo ra tio n s a t th e te rm in a l ile u m , b lo c k e d flu id S u p u ra tio n o f Iy m p h o n o d u s , g ra n u lo m a to u s p e rito n itis
H y p e rp la s tic ile itis w ith fis tu la , g ra n u lo m a to u s p e rito n itis , a s c ite s G ra n u lo m a to u s h e p a titis , m e s e n te ric ly m p h a d e n itis , a s c is tis V o lu m o u s m e s e n te ric a n d re tro p e rito n e a l ly m p h a d e n itis , a s c ite s G ra n u lo m a to u s p e rito n itis , g ra n u lo m a to u s h e p a titis , a s c ite s , ly m p h a d e n itis
G ra n u lo m a to u s p e rito n itis , p e rih y la r ly m p h a d e n itis , c h ro n ic c o le c is titis w ith s to n e s , a s c ite s
H e m o p e rito n e u m , g ra n u lo m a to u s h e p a titis
p e rito n e u m , sm a ll in te stin e a n d liv e r (F ig u re s 3 a n d 3 A ).
P o sitiv e a lc o h o l-a c id -re sista n t b a c illi w e re fo u n d in 8 c a se s
(6 7 % ). In th e ly m p h o n o d i o f 3 p a tie n ts (2 5 % ), ly m p h o id
tissu e w a s re p la c e d b y g ra n u lo m a s fo rm e d b y
x a n th o m a to u s m a c ro p h a g e s fu ll o f b a c illi, w ith o u t c a se o u s
n e c ro sis (F ig u re 4 ). T h is re sp o n se p a tte rn , a sso c ia te d w ith
th e c lin ic a l p ic tu re su g g e sts a ty p ic m y c o b a c te rio sis (1 3 ).
Evolution in the post-op period
O n e p a tie n t d ie d d u rin g th e p e rio d im m e d ia te ly a fte r
su rg e ry , a s a c o n se q u e n c e o f p o o r g e n e ra l sta te .
F o u r p a tie n ts d ie d a fte r a n a v e ra g e p e rio d o f 5 5 d a y s
in th e h o sp ita l. T h e d e a th w a s m u c h m o re a c o n se q u e n c e
o f o th e r c o m p lic a tio n s, re su ltin g fro m th e sy n d ro m e , th a n
th e a b d o m in a l m y c o b a c te rio sis itse lf.
O n e p a tie n t h a d a ste rc o ra l fistu la a n d a sk e d to b e
d isc h a rg e d fro m th e h o sp ita l.
S ix p a tie n ts w e re d isc h a rg e d a fte r a lo n g
h o sp ita liz a tio n p e rio d (2 7 d a y s in a v e ra g e ) (T a b le V I).
D IS C U S S IO N
A b d o m in a l tu b e rc u lo sis w a s in itia lly d e sc rib e d in
1 8 4 3 (1 7 ) a n d h a s a lw a y s b e e n c h a ra c te riz e d b y o c c u rrin g
in re g io n s w h e re e n v iro n m e n ta l sa n ita tio n is d e ffic ie n t (1 1 ).
In th e la st d e c a d e , e v e n th e m o re d e v e lo p e d c o u n trie s
w h e re it w a s a b o u t to d isa p p e a r; a re su rg e n c e o f th is
in fe c tio n w a s o b se rv e d , c a u se d n o t o n ly b y th e im m ig ra tio n
o f A sia n p o p u la tio n s, b u t a lso b y th e A ID S e p id e m ic s
(6 ,7 ,1 1 ,1 3 ).
L ite ra tu re h a s re fe rre d th e p re se n c e o f a ty p ic b a c illi
fo rm s, n a m e ly
Mycobacterium avium intracellulare
in p a tie n ts w ith th e A ID S sy n d ro m e . T h is b a c te riu m is a no p p o rtu n ist w ith lo w p a th o g e n ic ity , b u t in p a tie n ts w ith
im m u n o su p p re ssio n c a u se s se v e re a n d d isse m in a te d
p ro b le m s, o fte n in v o lv in g th e a b d o m e n (2 4 ).
F o r th is re a so n , in th e se p a tie n ts it is m o re a d e q u a te
to re fe r to th e d ise a se a s a b d o m in a l m y c o b a c te rio sis, a s
th e re a re se v e ra l sp e c ie s o f a lc o h o l-a c id -re sista n t b a c illi
th a t c a n a c t a s in fe c tio u s a g e n ts.
T h e im m u n o su p p re ssio n sta tu s is a lso re sp o n sib le
fo r th e m a ssiv e d isse m in a tio n o f th e b a c illu s to a b d o m in a l
o rg a n s, e v o lv in g v e ry ra p id ly w ith c o m p lic a tio n s su c h a s
p e rfo ra tio n s a n d ste n o sis in h o llo w v isc e ra , p ro d u c in g a n
e x tre m e ly se v e re p ic tu re th a t is d iffic u lt to re v e rt.
In th e b e g in n in g , sig n s a n d sy m p to m s c a n b e v e ry
n o n -sp e c ific , a s o th e r m a n ife sta tio n s o f A ID S c o u ld
in te rfe re w ith th e c lin ic p ic tu re .
A b d o m in a l p a in , fe v e r, w e ig h t lo ss, a n e m ia ,
v o m itin g , h e p a to e sp le n o m e g a ly , c o u ld a lso b e c a u se d b y
o th e r p a th o g e n s th a t c h a ra c te riz e th e sy n d ro m e .
T h e c o n c o m ita n t p u lm o n a ry d ise a se c o n firm e d b y
fin d in g th e a lc o h o l-a c id -re sista n t b a c illu s in th e sp u tu m
FIGURE 3 - P eritoneal m ycobacteriosis (100x). E pithelioid granulom as in Langhans-type giant cells on peritoneum
FIGURE 4 -A bdom inal m ycobacteriosis. X antogranulom atous reaction in Iym phnode (200x). S trongly positive S A A R
can su g g est th e p resen ce o f th is' sam e ag en t in th e ab d o m en ,
b u t th is asso ciatio n is n o t alw ay s o b serv ed , as w e co u ld
co rro b o rate in o u r stu d y .
Im ag in g d iag n o sis o f th e ab d o m en co u ld su g g est th e
p resen ce o f liq u id co llectio n s, n o d e m asses an d flu id /air
lev els.
FIGURE 3A - P eritoneal m ycobacteriosis (200x). E pithelioid granulom as in Langhans-type giant cells on peritoneum
C h an g es o b serv ed in th e ch em ical p ro file an d in th e
h em o g ram are also n o n -sp ecific.
C o n stan tly seen in o u r p atien ts, an em ia an d
leu co p en ia are also o b serv ed in o th er A ID S p atien ts th at
d o n o t h av e m y co b acterio sis.
L ap aro to m y is im p erativ e if th e early m an ifestatio n
is an acu te ab d o m en , as a co n seq u en ce o f its fast sp read in g .
A d iag n o stic lap aro to m y is im p erativ e in a p atien t
th at h as p ro g ressiv e ab d o m in al p ain w ith sig n s o f
p erito n eal in fectio n o r ab d o m in al d isten sio n , an d is u n d er
th e su sp icio n o f h av in g m y co b acterio sis.
T h e su rg ical in terv en tio n sh o u ld b e as little
ag g ressiv e as p o ssib le.
R essectio n s o r w id e an asto m o sis are n o t in d icated
in d ealin g w ith ed em ato u s tissu e, in filtrated b y g ran u lo m as,
w ith fistu la an d p erfo ratio n .
In sp ite o f th e satisfacto ry resp o n se to th e sp ecific
treatm en t, th e ad v an ce o f o th er ag en ts o f th e sy n d ro m e
w ill fo llo w .
A s a co n seq u en ce, a lo n g p erio d o f h o sp italizatio n
an d ev en late d eath cau sed b y o th er co m p licatio n s can b e
o b serv ed .
T h u s, asso ciatio n w ith ab d o m in al m y co b acterio sis
an d A ID S lead s to h ig h m o rb id ity an d h ig h m o rtality .
In o u r situ atio n , d u e to th e h ig h in cid en ce o f
tu b ercu lo sis an d p o o r san itatio n , an A ID S p atien t w ith
acu te o r in sid io u s ab d o m en sh o u ld alw ay s lead to th e
h y p o th esis o f m y co b acterio sis.
9 0 1
T a b le V
P a t ie n t s w it h A ID S a n d a b d o m in a l m y c o b a c t e r io s is t h a t u n d e r w e n t s u r g e r y in H o s p it a llp ir a n g a , J u ly 1 9 8 9 t o J a n u a r y 1 9 9 2
A b d o m in a l p a tte rn o f d is e a s e a n d p re s e n c e o f h e p a to e s p le n o m e g a ly
+ +
+ +
+ +
+ +
+ +
+
+ +
+ +
+ P a tie n t Ile o c e c a l
1 +
2 +
3
4
5 +
6
7 +
8 9 1 0 1 1 1 2
G a n g lio n ic H e p a tic P e rito n e a l H e p a to e s p le n o m e g a ly +
+ + + + + + + +
+
+ +
T a b le V I
P a t ie n t s w it h A ID S a n d a b d o m in a l m y c o b a c t e r io s is t h a t u n d e r w e n t s u r g e r y in H o s p it a l Ip ir a n g a , J u ly 1 9 8 9 t o J a n u a r y 1 9 9 2
A s s o c ia te d P a th o lo g ie s , M o rb id ity A n d M o rta lity
P a tie n t S u rg e ry A s s o c ia te d p a th o lo g y E v o l u tio n /c o m p i ic a tio n s E le c tiv e /E m e rg e n c y
1 E m e rg e n c y E s o p h a g e a l c a n d id ia s is S e p s is /S A R A - D e a th a fte r 1 8 h o u rs 2 E m e rg e n c y C a n d id ia s is /d ia rrh e a D is c h a rg e d a fte r 2 0 d a y s
3 E le c tiv e C a n d id ia s is /p n e u m o c is to s is S e p s is /S A R A - D e a th a fte r 2 5 d a y s
4
E m e rg e n c y N o n -s p e c ific c e rv ic a l D is c h a rg e d a fte r 1 9 d a y s ly m p h a d e n itis5 E m e rg e n c y C a n d id ia s is /s c ro fu lo s is S te rc o ra l fis tu la , a s k e d to b e d is c h a rg e d a fte r 2 5 d a y s
6 E m e rg e n c y K a p o s i's s a rc o m a D is c h a rg e d a fte r 1 8 d a y s
7 E m e rg e n c y D ia h rre a /n o n -s p e c ific S e p s is , d e a th a fte r 6 m o n th s a n d a h a lf re c titis
8 E le c tiv e O ra l c a n d id ia s is D is c h a rg e d a fte r 2 2 d a y s
9 E le c tiv e P n e u m o c is to s is / S e p s is /S A R A - D e a th a fte r 6 2 d a y s c a n d id ia s is
1 0 E m e rg e n c y S c ro fu lo s is /p u lm o n a ry D is c h a rg e d a fte r 3 5 d a y s tu b e rc u lo s is
1 1 E m e rg e n c y O ra l c a n d id ia s is /b ra in D e a th a fte r 5 2 d a y s to x o p la s m o s is
1 2 E m e rg e n c y N o n -s p e c ific e n c e p h a lo p a th y D is c h a rg e d a fte r 2 0 d a y s
RESUMO
O b je tiv o : e s tu d a r a in fe c 9 a o m ic o b a c te ria n a a b d o m in a l e m p o rta d o re s d a S fn d ro m e d e Im u n o d e fic ie n c ia A d q u irid a . M a te ria l e M e to d o s : o s a u to re s e s tu d a ra m 1 2 p a c ie n te s p o rta d o re s d e A l O S e d e m ic o b a c te rio s e a b d o m in a l, in te rn a d o s n o H o s p ita llp ira n g a (S a o P a u lo - B ra s il) d e ju n h o d e 1 9 8 9 a ja n e iro d e 1 9 9 2 . 0 d ia g n 6 s tic o d e to d o s e le s fo i c o n firm a d o a tra v e s d e e x a m e h is to p a to l6 g ic o d e fra g m e n to s d e 6 rg a o s c o lh id o s d u ra n te a la p a ro to m ia re a liz a d a , e m s u a m a io ria , p o r m o tiv o s e m e rg e n c ia is . R e s u lta d o s : fo ra m o b s e rv a d a s p e rfu ra 9 0 e s d e a l9 a s fle a s , c o le 9 0 e s s e ro p u ru le n ta s e n v o lta s e b lo q u e a d a s p o r v fs c e ra s , e p fp lo o n e fib rin a .
A
h e p a to e s p le n o m e g a lia s e fa z ia p re s e n te e m to d o s o s p a c ie n te s e u m a p e rito n ite g ra n u lo m a to s a g e n e ra liz a d a fo i o b s e rv a d a e m m a is d a m e ta d e . U m d o e n te fa le c e u n o p 6 s -o p e ra t6 rio im e d ia to ; 4 a p 6 s 5 5 d ia s e m m e d ia d e in te rn a 9 a o . U m p a c ie n te e v o lu iu c o m ffs tu la e s te rc o ra l e te v e a lta a p e d id o ; 6 tiv e ra m a lta a p 6 s u m p e rfo d o d e in te rn a 9 a o d e 2 7 d ia s e m m e d ia . C o n c lu s o e s : o s a u to re s re a l9 a m q u e e m re g io e s e m d e s e n v o lv im e n to o n d e a in c id e n c ia d e tu b e rc u lo s e a in d a e e le v a d a , n u m d o e n te c o m A I O S q u e a p re s e n te u m q u a d ro a b d o m in a l d o lo ro s o e irrita tiv o , a h ip 6 te s e d e m ic o b a c te rio s e d e v e ra s e m p re s e r c o g ita d a .REFERENCES
1 . B A R N E S , P .; L E E D O M , J.M .; R A V E L IN , D .R .; C H A N D R A S O M A , P . - A n u n u su a l c a se o f tu b e rc u lo sis p e rito n itis in a m a n w ith A ID S . E st J M e d 1 4 4 :4 6 7 -9 , 1 9 8 6 . 2 . B A R O N E , J.E .; G IL G O L D , B .S .; A R V A N T IS , M .L .;
N E A L O N , T .E - A b d o m in a l p a in in p a tie n ts w ith a d q u ire d im m u n e d e fic ie n c y sy n d ro m e . A n n S u rg 2 0 4 :6 1 9 -2 3 , 1 9 8 6 . 3 . B A S T A N I, B .;L S A H R IA T Z A D E H , M .R ; D E H D A S H T I,
E - T u b e rc u lo u s p e rito n itis. R e p o rt o f 3 0 c a se s a n d re v ie w o f th e lite ra tu re . Q J M e d 5 6 :2 4 9 -5 7 ,1 9 8 5 .
4 . C .D .C . - U p d a te . A c q u ire d im m u n e d e fic ie n c y sy n d ro m e (A ID S ) - M M W R 3 1 :5 0 7 -1 4 , 1 9 8 2 .
5 . C .D .C . - T u b e rc u lo sis a n d a c q u ire d im m u n o d e fic ie n c y sy n d ro m e . M M W R 3 6 :7 8 5 -9 4 , 1 9 8 7 .
6 . C .D .C . - T u b e rc u lo sis a n d h u m a n im m u n o d e fic ie n c y v iru s in fe c tio n : re c o m m e n d a to n fo r th e A d v iso ry C o u n c il fo r th e E lim in a tio n o f T u b e rc u lo sis. M M W R 3 8 :2 3 6 -8 , 1 9 8 9 . 7 . C .D .C . - P re v e n tio n a n d c o n tro l o f tu b e rc u lo sis in U S .
C o m m u n itie s w ith a t risk m in o rity p o p u la tio n . M M W R 4 1 : 1 -2 -2 , 1 9 9 2 .
8 . D A S , P .; S H U L K A , H .S . - C lin ic a l d ia g n o sis o f a b d o m in a l tu b e rc u lo sis. B r J S u rg 6 3 :9 4 1 -6 , 1 9 7 6 .
9 . D IN N E N , P .; H O M A N , W .P .; G R A F E , W .R - T u b e rc u lo u s p e rito n itis. A n n S u rg 1 8 4 :7 1 7 -2 2 , 1 9 7 6 .
1 0 . E P S T E IN , B .M .; M A N N , J.H . - C T o f a b d o m in a l tu b e rc u lo sis. A JR 1 3 9 :8 9 1 -6 , 1 9 8 2 .
1 1 . H A D D A D , E S .; G H R O S S IA N , A .; S A W A Y A , E .; N E L S O N , A .R - A b d o m in a l tu b e rc u lo sis. D is C o l R e c tu m 3 0 :7 2 4 -3 5 , 1 9 8 7 .
1 2 . K A P O O R , Y .K ; S H A R M A , L .K - A b d o m in a l tu b e rc u lo sis. B r J S u rg 7 5 :2 -3 , 1 9 8 8 .
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1 4 . M IN IS T E R IO D A S A U D E - P ro g ra m a N a c io n a l d e C o m b a te
a
T u b e rc u lo se - R e u n ia o d a A v a lia 9 a o O p e ra c io n a l d a D e c a d a d e 8 0 - B ra sflia , 1 9 9 2 .1 5 . O L C O T T , c .T .; P A C C H IN E , D . - T u b e rc u lo u s p e rito n itis. A m R e v T h b e rc 2 8 :2 7 -3 3 , 1 9 3 3 .
1 6 .P A L M E R , K R ; P A T IL , D .H .; B A S R A N , G .S .; R IO R D A N , 1 .E ; S IL K , D .B .A . - A b d o m in a l tu b e rc u lo sis in u rb a n B rita in - a c o m m o n d ise a se . G u t 2 6 : 1 2 9 6 -1 3 0 5 , 1 9 8 5 .
1 7 . R O S E N G A R T , T .K ; C O P P A , G .E - A b d o m in a l m y c o b a te ria l in fe c tio n s in im m u n o c o m p ro m ite d p a tie n ts. A m J S u rg 1 5 9 : 1 2 5 -3 1 , 1 9 9 0 .
1 8 . S E N IS E , J.E ; H A N R IC K , P .A .; G U ID U G L I, R G .; R IB E R A , J.M .; S IQ U E IR A , S .A .C . - P e rfu ra 9 a o d e a l9 a ile a l p o r tu b e rc u lo se e m p o rta d o re s d a sfn d ro m e d a im u n o d e fic ie n c ia a d q u irid a . R e v P a u l M e d 1 0 9 :6 1 -4 ,
i
9 9 1 .1 9 . S O R IA N O , Y .; T O R , J.; D O M E N E C H , E .; G A B A R R E , E .; M U G A , R ; C L O T E T , B . - T u b e rc u lo sis a b d o m in a l in lo s p a c ie n te s c o m A ID S . M e d C lin (B a re ) 9 7 (4 ):1 2 1 -4 , 1 9 9 1 . 2 0 . S O U B A N I, A .O . &G L A T T , A .E . - T u b e rc u lo sis p e rito n itis
a s a in itia l m a n ife sta tio n o f H I V in fe c tio n . N .Y . S ta te J. M e d . 9 2 :2 6 9 -7 0 , 1 9 9 2 .
2 1 . S T U B E N B O R D , 1 .G .; S P E S , J. - T u b e rc u lo u s p e rito n itis, a n a n a lisis o f 2 5 7 c a se s. S u rg G y n e c O b st 2 6 9 :6 7 -9 , 1 9 3 8 . 2 2 . S U N D E R M A N , G .; M c D O N A L D , R .J.; M A N IA T IS , T .; O L E S K E , 1 .; K A P IL A , R ; R E IC H M A N , R B . - T u b e rc u lo sis a s a m a n ife sta tio n o f th e a c q u ire d im m u n o d e fic ie n c y sy n d ro m e (A ID S ). JA M A 2 7 6 :3 6 2 -6 , 1 9 8 6 .
2 3 . V A N D E R P O O L , D .M .; O 'L E A R Y , J.P . - P rim a ry tu b e rb u lo u s e n te ritis. S u rg G y n e c . O b st 1 6 7 :1 6 7 -7 3 , 1 9 8 8 .
2 4 . Z A K O W S K I, E ; F L IG IE L , S .; B E R L IN , G .W .; JO H N S O N , L . - D isse m in a te d M y c o b a c te riu m a v iu m -in tra c e llu la re in fe c tio n in h o m o sse x u a l m a n d y in g o f A ID S . JA M A 2 4 8 :2 9 8 0 -8 2 , 1 9 8 2 .
2 5 . Z E N D E R , H .O .; A R R IG O N I, E .; E C K E R T , J.; K A P A N C I, Y . - A c a se o f e n c e p h a lito z o o n p a tie n t w ith A ID S . A m J
C lin P a th o l 9 2 : 3 5 2 -6 , 1 9 8 9 .
