P3062 - Hepatic Lesions Secondary to Disseminated Mycobacterium avium Complex: A Diagnostic Challenge in a Patient With Advanced HIV Complicated by Kaposi Sarcoma Inflammatory Cytokine Syndrome

Kathryn Thompson, MD¹, Emily Evans, MD¹, Vanessa Van Doren, MD¹, Matthew Collins, MD, PhD¹, William Blake, MD¹, Jason Brown, MD^2
1Emory University, Atlanta, GA; ²Emory University School of Medicine, Atlanta, GA

Introduction: The differential diagnosis for hepatic lesions in a patient with advanced HIV disease (AHD) is complex and requires work-up for malignancy and opportunistic infections. Disseminated Mycobacterium avium complex (DMAC) can cause granulomatous hepatic lesions but the diagnosis may be delayed due to slow growth on acid-fast bacilli (AFB) cultures and anchoring on other diagnoses in AHD.

Case Description/Methods: A 30-year-old man with AHD (CD4 count 18 cells/uL) that started anti-retroviral (ARV) therapy two weeks prior to admission presented with shortness of breath (SOB), diarrhea, abdominal distention, violaceous skin lesions, hepatosplenomegaly, retroperitoneal lymphadenopathy, and bilateral pleural effusions on CT imaging (Figure 1A). A skin biopsy confirmed Kaposi sarcoma (KS) (Figure 1B). MRI abdomen/pelvis showed hepatosplenomegaly with multifocal scattered T2 hyperintense lesions noted to be consistent with hepatic KS (Figure 1C/1D). He had a persistent ALP elevation to 200-500s U/L, isolated AST elevation to the 40s-120s U/L, and total bilirubin elevation to 4.2 mg/dL. He had high levels of HHV-8 DNA (8,040,000 copies/mL) and IL-6 (55.8 pg/mL), and a lymph node biopsy showed plasmacytosis with HHV8+ plasma cells, suggestive of KS inflammatory cytokine syndrome (KICS). He received paclitaxel with improvement in SOB, diarrhea, and abdominal distention. Work-up for other etiologies of hepatic lesions was negative (Table 1). After four weeks, one AFB sputum culture and one blood culture grew Mycobacterium avium complex. He presented one week after discharge with elevated liver enzymes and kidney injury, and ultimately died from multiorgan failure likely from immune reconstitution inflammatory syndrome (IRIS) given recent ARV initiation and untreated DMAC.

Discussion: DMAC should be considered in a patient with AHD that presents with granulomatous hepatic lesions, hepatosplenomegaly, and diffuse lymphadenopathy. It was initially thought that KS explained the clinical picture, including his hepatic lesions, given improvement with KICS treatment and initial negative AFB blood cultures. However, his abdominal imaging, cholestatic pattern of liver injury, and delayed clinical decline after initial improvement with KICS treatment was more characteristic of granulomatous hepatitis due to untreated DMAC. This case highlights the diagnostic complexity of characterizing hepatic lesions in a patient with AHD and the high mortality associated with IRIS and untreated opportunistic infections.



Disclosures:


Kathryn Thompson, MD¹, Emily Evans, MD¹, Vanessa Van Doren, MD¹, Matthew Collins, MD, PhD¹, William Blake, MD¹, Jason Brown, MD². P3062 - Hepatic Lesions Secondary to Disseminated Mycobacterium avium Complex: A Diagnostic Challenge in a Patient With Advanced HIV Complicated by Kaposi Sarcoma Inflammatory Cytokine Syndrome, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.