Strongyloides stercoralis infection as a cause of acute granulomatous appendicitis in an HIV-positive patient in Athens, Greece

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

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.

Eosinophilic acute appendicitis caused by Strongyloides stercoralis and Enterobius vermicularis in an HIV-positive patient

A 29 year old female HIV-positive patient presented in emergency with acute right lower quadrant abdominal pain, fever, tenderness and positive Blumberg sign. Laboratorial tests revealed eosinophilia, anaemia and leukocytosis. She underwent exploratory laparotomy followed by appendectomy. The pathological analysis of the appendix revealed acute appendicitis, accentuated eosinophilia and infestation by Strongyloides stercoralis and Enterobius vermicularis. She did well after surgery and adequate treatment. To the authors' knowledge, this is the first case of eosinophilic acute appendicitis caused by these two parasitic worms reported in the medical literature.

Unusual histopathological findings in appendectomy specimens: A retrospective analysis and literature review

AIM: To document unusual findings in appendectomy specimens.

METHODS: The clinicopathological data of 5262 patients who underwent appendectomies for presumed acute appendicitis from January 2006 to October 2010 were reviewed retrospectively. Appendectomies performed as incidental procedures during some other operation were excluded. We focused on 54 patients who had unusual findings in their appendectomy specimens. We conducted a literature review via the PubMed and Google Scholar databases of English language studies published between 2000 and 2010 on unusual findings in appendectomy specimens.

RESULTS: Unusual findings were determined in 54 (1%) cases by histopathology. Thirty were male and 24 were female with ages ranging from 15 to 84 years (median, 32.2 ± 15.1 years). Final pathology revealed 37 cases of enterobiasis, five cases of carcinoids, four mucinous cystadenomas, two eosinophilic infiltrations, two mucoceles, two tuberculosis, one goblet-cell carcinoid, and one neurogenic hyperplasia. While 52 patients underwent a standard appendectomy, two patients who were diagnosed with tuberculous appendicitis underwent a right hemicolectomy. All tumors were located at the distal part of the appendix with a mean diameter of 6.8 mm (range, 4-10 mm). All patients with tumors were alive and disease-free during a mean follow-up of 17.8 mo. A review of 1366 cases reported in the English literature is also discussed.

CONCLUSION: Although unusual pathological findings are seldom seen during an appendectomy, all appendectomy specimens should be sent for routine histopathological examination.

Appendicitis in HIV-infected patients during the era of highly active antiretroviral therapy

BACKGROUND

Limited studies have suggested increased incidence rates and unusual clinical presentations of appendicitis among HIV-infected patients during the pre-highly active antiretroviral therapy (HAART) era. Data in the HAART era are sparse, and no study has evaluated potential HIV-related risk factors for the development of appendicitis.

METHODS

We retrospectively studied 449 HIV-infected patients receiving care at a US Naval hospital involving 4750 person-years (PY) of follow-up. We also evaluated the rates of appendicitis among HIV-negative persons at our medical facility. We compared demographics, HIV-specific data, and HAART use in HIV-infected patients with and without appendicitis.

RESULTS

Sixteen (3.6%) of 449 patients developed appendicitis after HIV seroconversion. The incidence rate was 337 cases/100 000 PY, more than fourfold higher than among HIV-negative persons. Eighty-eight per cent of cases among HIV-infected patients had an elevated white blood count at presentation, 39% were complicated, and 64% required hospitalization. HIV-infected patients with appendicitis compared with those who did not develop appendicitis were less likely to be receiving HAART (25 vs. 71%, P<0.001), had higher viral loads (3.5 vs. 1.7 log(10) HIV-1 RNA copies/mL, P=0.005), and were younger (median age of 30 vs. 41 years, P<0.002). In the multivariate model, receipt of HAART remained protective [odds ratio (OR) 0.21, P=0.012] for appendicitis, while younger age was positively associated (OR 1.08, P=0.048) with appendicitis.

CONCLUSION

Acute appendicitis occurs at higher incidence rates among HIV-infected patients compared with the general population. Our study demonstrates that the lack of HAART may be a risk factor for appendicitis among HIV-infected patients; further studies are needed.