Case report: a rare case of chylous ascites from Mycobacterium avium intracellulare in a patient with AIDS: review of the literature

Cytomorphology of Mycobacterium avium intracellulare-associated ascites

Ascites due to Mycobacterium avium intracellulare (MAI) infection is extremely rare and associated with a poor outcome. The cytomorphology of this condition has not been previously reported. We present a unique case of a 45-year-old woman with iatrogenic immunodeficiency who developed MAI-associated chylous ascites. The ascitic fluid cytology showed numerous lymphocytes and foamy histiocytes with abundant intracytoplasmic MAI organisms. The diagnosis was confirmed by tissue biopsy showing MAI mesenteritis. It is important to consider MAI-associated ascites in the differential diagnosis whenever ascitic fluid shows a predominant population of lymphocytes and macrophages, especially in immunocompromised patients.

High mortality in peritonitis due to Mycobacterium avium complex: retrospective study and systematic literature review

BACKGROUND

Mycobacterium avium complex (MAC) infection is often disseminated and mainly involves lymph nodes, spleen, liver or bone marrow. Peritonitis due to MAC infection (PMAC) is a very uncommon manifestation.

METHODS

In this report, after describing the case of the only PMAC infection in our 10-year retrospective study, which occurred in an AIDS patient who was non-adherent to highly active antiretroviral therapy (HAART), we performed a systematic literature review of documented bacteriological PMAC.

RESULTS

Including our patient, 51 cases of PMAC have been reported. Patients were most often male (sex ratio 2.14), with a median age of 41 years (2.8-72) and an immunodeficiency in all cases, most often AIDS (57%), cirrhosis (20%) and continuous ambulatory peritoneal dialysis (CAPD) (18%). Ascites was more often chylous (54%) than exudative (46%) and, in this case, lymphocytic (60%), with an inconstantly positive acid-fast bacilli smear (54%). Non-disseminated PMAC patients were more likely to have peritoneal dialysis (39% versus 6.5%, p < .01) or cancer with immunosuppressive therapy (39% versus 0%, p < .0001), while AIDS was the leading underlying disease in disseminated-PMAC patients (83% versus 11%, p < .001). Mortality was high (50%), with no difference between disseminated and non-disseminated PMAC.

CONCLUSIONS

This report highlights the need to be aware of an atypical presentation of PMAC infection, which is associated with a high rate of mortality even for non-disseminated infection.

Mycobacterial chylous ascites: report of three cases and systematic review

Background

Chylous ascites is an uncommon presentation of mycobacterial infection.

Methods

We report three cases of tubercular chylous ascites, and in addition, we performed a systematic review of the published literature for the clinical presentation, treatment, and outcomes of mycobacterial chylous ascites. We followed the PRISMA guidelines for the systematic review.

Results

A total of 33 cases (including three of ours) were included. The mean age of the reported cases was 32.54 ± 17.56 years, and a male predominance (76%) was noted. The predominant clinical features were abdominal distension, abdominal pain, fever and loss of appetite and weight. Mycobacterium tuberculosis (MTB) and Mycobacterium avium-intracellulare (MAC) infection were responsible for 16 and 15 cases, respectively. All patients with MAC related chylous ascites had HIV infection. The mechanisms were related to lymph nodal enlargement, constrictive pericarditis and remote scrofuloderma. Overall, there was 29% mortality. Use of anti-mycobacterial therapy with use of total parenteral nutrition, octreotide and medium chain triglyceride-based diet resulted in improvement in the rest of the cases. The cause of death in our case was anti-tubercular therapy-induced hepatitis; three deaths were due to disseminated mycobacterial infection, one due to cardiopulmonary failure and unknown in four patients.

Conclusion

Chylous ascites due to mycobacterial infection is uncommon and associated with poor outcome. However, early diagnosis and nutritional management along with antimycobacterial therapy can improve outcome.

Mycobacterium avium complex peritonitis in the setting of cirrhosis: Case report and review of the literature

Mycobacterium avium complex is a rare cause of peritonitis. We report here the fourth case in the literature of MAC peritonitis associated with cirrhosis in the absence of AIDS, and discuss the possibility of different etiologies in persons with and without AIDS.

Chylous ascites: a late complication of intra-abdominal Mycobacterium avium complex immune reconstitution syndrome in HIV-infected patients

Chylous ascites related to Mycobacterium avium complex (MAC) in HIV-infected patients is rare, with only six cases reported in the English literature. We report a series of six cases from a single institution. During the past six years, chylous ascites was diagnosed in six (35%) of 17 AIDS patients, all of whom had previously been diagnosed with intra-abdominal MAC immune reconstitution syndrome (MAC-IRS). A review of medical records identified no other cases of chylous ascites among HIV-positive patients over the past 13 years (1994–2007), and the incidence was estimated at one in 2248 HIV-positive admissions. The ascitic fluid had a milky appearance and a median triglyceride level of 4.07 mmol/L (range 3.19–29.6 mmol/L) (360 mg/dL, range 282–2620 mg/dL). After a median follow-up of 20 months, five (83%) of six patients survived. Chylous ascites is a late complication of intra-abdominal MAC-IRS, and is usually associated with a favourable prognosis.

Chylous ascites secondary to B-cell non Hodgkin's lymphoma in a patient with the acquired immune deficiency syndrome (AIDS)

In the present article we describe a patient with AIDS and chylous ascites secondary to B-cell non Hodgkin's lymphoma. A 43 years old homosexual HIV-positive man. Complained of abdominal fullness, diarrhea and a rapidly increase in abdominal girth of 1 week duration. A diagnostic paracentesis was performed and revealed a milky fluid with high triglyceride levels. All blood tests and analysis of the peritoneal fluid with polymerase chain reaction for DNA sequence of broad-range bacterial Post Voiding Residual volume, Mycobacterium tuberculosis, Kaposi Sarcoma associated Herpes virus and Epstein Barr Virus were negative. CT scan did not demonstrate any evidence for cancer. An exploratory laparotomy was thus performed. A mass spreading along the mesenteric route to the omentum was found and a debulking resection was performed. The final pathology report was of diffuse, CD20-positive, CD3-negative, Epstein Barr Virus-negative, large B-Cell non Hodgkin's lymphoma. Subsequently, he underwent five cycles of CHOP (cyclofosfamide, doxorubicin, vincristin, prednison) chemotherapy with further partial regression of the abdominal tumour. Five months after the initial diagnosis of lymphoma, the patient relapsed and was treated with high-dose BEAM (carmustine, etoposide, cytosine, arabinoside, melphalan) chemotherapy followed by CD34 stem-cell transplantations salvage therapy. This notwithstanding, the patient died due to intestinal secondary to tumor relapse 2 months later.

Mycobacterium avium complex peritonitis in an AIDS patient

Mycobacterium avium complex (MAC) frequently disseminates in AIDS patients, where the gastrointestinal tract is a major target organ. While ascites in AIDS patients is common, peritonitis secondary to MAC is rare. We describe the first case of MAC peritonitis in an AIDS patient without underlying cirrhosis, portal hypertension, chylous ascites or peritoneal dialysis. This case highlights the need to be aware of atypical presentations of MAC disease in AIDS patients with a history of disseminated MAC, even those who compliantly take highly active antiretroviral therapy.

Chylous Ascites Revisited - old Disease, new Management

Extravasation of chyle from the intestinal lymphatics into the peritoneal cavity results in chylous ascites, identified by its characteristic milky appearance. Chylous ascites is rare, but it has been suggested that its incidence may be increasing in the adult population. Successful management depends on identifying the underlying cause of the lymphatic disruption. The spectrum of causative pathologies seen in adult and paediatric practices are vastly different: congenital lymphatic problems predominate in the latter, while occult malignancy often causes adult chylous ascites. This review looks at the various aetiologies, diagnosis and the recent advances in the management of this condition. gynaecological malignancies, while in the paediatric population, both sexes are affected equally. It has been suggested that the incidence of chylous ascites may be increasing in line with higher incidence of malignant disease and complications of HIV infection. The reason for this may simply reflect increased reporting of the disorder, or it may be due to increasing diagnostic capability.

The majority of early reports of chylous ascites describe anecdotal cases, and there are very few series describing the causes and management of the condition. This again reflects the rarity of chylous ascites.

There is a need for a review of this rare cause of ascites to highlight changing aetiology and new therapeutic options.

Acute transient chylous ascites associated with acute biliary pancreatitis

We report a case of acute chylous ascites secondary to acute biliary pancreatitis, the first such case reported in the literature. Surprisingly, chylous ascites was detected during elective cholecystectomy. The pathogenesis and management of this problem is discussed.

Successful treatment of chylous ascites secondary to Mycobacterium avium complex in a patient with the acquired immune deficiency syndrome

Chylous ascites is a rare form of ascites, the presence of which generally denotes a very poor long term prognosis. We report the case of a patient with acquired immune deficiency syndrome (AIDS) and massive chylous ascites secondary to Mycobacterium avium complex (MAC) infection, identified in the ascitic fluid by a DNA probe assay. With multidrug anti-MAC therapy the ascites resolved completely, and the patient has survived for >21 months. Diagnosis and treatment of MAC-related chylous ascites are reviewed.