A 9-year-old HIV-infected girl with fever and abdominal distension

Prepared by...................Nuthapong Ukarapol, M.D.
Virat Sirisanthana M.D
CC : A 9-year-old HIV-infected girl presented with prolonged fever for 6 weeks before admission.
PI: She is a known case of HIV-infected child. She was diagnosed as HIV-category A when she was 4 year old. Since then she had been in good health until within the past year when she deveolped several episodes of "pneumonia". She was not on PCP prophylaxis. Six week prior to this admission she started having fever. First, the fever occurred only at night, then it turned to be intermittent ferver. Three weeks prior to admission, she came to a pediatric clinic and had basic investigations done, including Hb 7.7 gm/dl, wbc 8,600/cumm , N 74.4 %, L 17%, M 7.9% ,E 0.3%, Plt 522,000/cumm, and normal urine analysis. She was supportively treated. One week prior to admission, the patient developed a neck mass just below the right mandible.
Significant PH: She had a history of contacting a tuberculosis case 4-5 years ago.
Significant PE:

VS: T 39-40 C, P 115 /min, RR 30/min, BP 120/80 mmHg, body weight 20 kg (she lost a few kilograms this illness)
GA: A girl, normal consciousness, not cachexia
HEENT: moderately pale, no jaundice, no oral thrush
A mass at right mandibular angle, sized 2.5 x 2.5 cm, was noted. It was firm, not tender, and movable.
LN: multiple lymph nodes at supraclavicular and cervical both sides, approximately 1 cm in diameter.
Heart: regular ,no murmur
Lung: clear
Abdomen: mild distension, liver 5 cm below right costal margin, spleen 3 cm below left costal margin
There was a large matted intra-abdominal mass noted during examination.
Skin : no lesion
Investigations:
CBC : Hb 7 gm/dl, Hct 23%, WBC 9,600/cumm, N 76% E 14% L 9%, Platelet 407,000/cumm
PBS: Hypochromic microcytic red cells, toxic granulation 1+ , no vacuolization
U/A: normal
CXR: miliary pattern with enlargement of the hilar nodes (figure 1, 2)
Tuberculin test and gastric washing for AFB x 3 days were negative
H/C 2 spp: negative
Widal test: O =1:20 , H = 1:20
Weil-Felix test: OX-2 =1:20, OX-K=1:20, OX-19=1:40
Thick film for malaria: negative
Cold agglutinin: negative
Melioidosis titer: 1:16 (negative)
Figue 1
Figure 2
Clinical course:
The patient developed abdominal pain and diarrhea on the second day of hospitalization, while being investigated. Stool examination revealed WBC 15-20/HPF. Stool modified AFB and culture were negative. She was emprically treated with cefotaxime intravenously and co-trimoxazole for PCP prophylaxis. Two days later, she developed vomiting, abdominal distention with ascites. On physical examination, mild generalized tenderness was noted.

Further investigations included:
Abdominal ultrasound showed generalized bowel dilatation, ascites, and massive retroperitoneal and mesenteric lymphadenopathy.
CT abdomen (Figure 3-4) was also requested. The study revealed numerous rim enhancing hypodense lymphadenopathy at perigastric, gastrohepatic, portal hepatic, celiac, peripancreatic, retrocaval aortocaval, para-aortic and mesenteric region. Some of mesenteric lymph nodes were calcified. Thickening of wall of the cecum and terminal ileum was noted. Hepatosplenomegaly, collapsed small bowel, ascites, find nodular infiltration, and atelectasis in both basal lungs with bilateral pleural effusion were also seen.
Right mandibular lymph node biopsy: positive acid-fast bacilli
Figure 3
Figure 4
Clinical course (continue):
The patient was supportively treated. Anti-tuberculosis drugs (INH, Rifampicin, PZA, and streptomycin) were started after the report of lymph node biopsy. Metronidazole was added. The patient deteriorated and developed respiratory failure. She subsequently died as a result of severe ARDS (figure 5)
Figure 5
Lung and liver necropsy were carried out:

Lung pathology: There was evidence of thick hyaline membrane lining the alveolar spaces (Figure 6-7). Multiple granulomas were noted. On a special stains, AFB-positive microorganisms were detected (Figure 8) .
Figure 6-7: show lung histopathology. G: granuloma, H: hyaline membrane
Figure 8: An AFB-positive organism seen in this section.
Liver pathology: Macrovesicular steatosis was noted throughout the liver. There were multiple granulomas noted (Figure 9-10). Langhan's giant cells were also seen in the granulomas (Figure 10).
Figure 9 (10X)
Figure 10 (40X)
Final diagnosis: Disseminated tuberculosis in HIV-infected child
Diagnosis : Disseminated tuberculosis in HIV-infected child

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