Lymph Node Co-Infection of Mycobacterium Avium Complex and Cytomegalovirus in an Acquired Immunodeficiency Syndrome Patient
A 31-year-old homeless man with severe cachexia presented with abdominal pain for 2 hours prior to admission. During the preceding 3 years, he had several sexual contacts in addition to a history of IV drug addiction. He had previously been in good health. He was unaware of any family history of immunodeficiency disorder or infectious disease. He had a history of night sweats and a 12 kg weight loss in a period of three months. For the preceding 3 weeks, he had suffered from mild dyspnea. He was afebrile (Temperature: 36.5°C) and his pulse and respiratory rates were 88 and 26 per minute, respectively.\nA physical examination showed diffuse abdominal tenderness. Neither peripheral lymphadenopathy nor hepatosplenomegaly was detected. Auscultation of the heart revealed normal sounds. Diffuse rales were heard in a chest examination. An examination of the oral cavity, pharynx, larynx, salivary glands and skin was unremarkable. A neurological examination showed bilateral normal ankle-tendon reflexes, and sensory and motor exams were normal.\nA chest X-ray showed a diffuse miliary pattern. Sonography revealed several para-aortic lesions of varying size, which were consistent with lymphoma. Laboratory data showed leukopenia [white blood cells: 1200/mL, lymphocytes: 26%; polymorphonuclear leukocytes (PMN): 68%], normocytic anemia [Hemoglubin (Hb): 115 g/L], first hour erythrocyte sedimentation rate (ESR) was 76 mm/h, C-reactive protein (CRP) was 40 mg/L (normal, <5 mg/L), lactate dehydrogenase (LDH) and alkaline phosphatase were not high (400 IU/L; and 250 IU/L, respectively), and alanine amino-transferase (ALT) and aspartate amino-transferase (AST) levels were in the normal range (45 and 40 IU/L, respectively). Blood cultures remained sterile. Several other workups were all unremarkable.\nThe patient continued to have abdominal pain and tenderness after admission, while no source of acute abdominal pain was identified. Diagnostic laparotomy was performed for the multiple para-aortic lymph nodes and they were removed for histopathological examination. Unfortunately, the patient developed respiratory arrest and died in the operating room. The cadaver was shifted to Legal Medicine Organization of Fars and an autopsy was performed 24 hours after death to determine the exact cause of death.\nMultiple para-aortic lymphadenopathy was identified, and the diameter of the largest lymph node was 25 mm. Gross examination of the lungs showed diffuse congestion and patches of consolidation. The liver and spleen were grossly unremarkable with a normal size. The central nervous system, heart, gastrointestinal tract, kidneys, bladder and all other organs showed no significant changes. Microscopic examination of the lungs showed a predominantly mononuclear inflammatory infiltrate in conjunction with edema and hyperplasia of the alveolar epithelium. A characteristic intra-nuclear CMV inclusion body was detected (). The immunoperoxidase technique using monoclonal antibody (Clone DDG9 + CCH2, Dako, Denmark) confirmed the diagnosis of CMV infection. Examination of the enlarged lymph nodes showed diffuse replacement of nodal architecture by foamy, large and plump macrophages.\nThe cytoplasm of these macrophages contained large amounts of a diastase resistant Periodic Acid Schiff (PAS) positive material due to the presence of bacilliform bodies. Acid fast stain showed macrophages containing innumerable organisms (). CMV intra-nuclear inclusions were also detected in these lymph nodes (). No fungi or bacteria were identified with Gram, PAS, metenamin silver or Warthin-Starry stains. Serological studies for HIV antibody on peripheral blood (preserved in the hospital blood bank) were positive for enzyme immunoassay, which confirmed a western blot assay. Serological tests for hepatitis A, B, C and syphilis showed negative results. Examination of other organs showed no specific changes, either grossly or microscopically.