Non-traumatic perforation of the jejunum in a human immunodeficiency virus-infected patient receiving combination antiretroviral therapy A case report
Non-traumatic perforation of the jejunum in a human immunodeficiency virus-infected patient receiving combination antiretroviral therapy A case report
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DOI：
10.1097/md.0000000000018163
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发表时间：
2019-12-01
期刊：
影响因子：
1.6
通讯作者：
Hsieh, Szu-Min
中科院分区：
文献类型：
--
作者：
Lee, Yi-Chien;Chiou, Chien-Chun;Hsieh, Szu-Min
理由：在联合抗逆转录病毒治疗（cART）时代，由巨细胞病毒（CMV）和鸟分枝杆菌复合体（MAC）感染引起的非创伤性肠穿孔在获得性免疫缺陷综合征（AIDS）患者中已变得罕见；然而，由于广泛使用基于整合酶抑制剂的治疗方案，随后出现了 CMV 相关和 MAC 相关的免疫重建炎症综合征 (IRIS)。在此，我们报告一例人类免疫缺陷病毒 (HIV) 感染患者自发性空肠穿孔的病例，该患者对 cART 的依从性良好。患者关注的问题：一名 32 岁的 HIV 感染者在开始 cART 后 3 天出现 CMV 疾病和 DMAC 感染，暴露了 IRIS。在对机会性感染进行适当治疗后，出现间歇性发热并伴有腹部淋巴结肿大，表现为矛盾的 IRIS。患者给予泼尼松龙治疗，随后根据临床情况逐渐减量。诊断：在类固醇剂量滴定过程中，中空器官意外穿孔，并通过胸片诊断出严重腹痛的临床表现。干预措施：患者接受手术修复，腹膜如厕顺利。结果：术后第10天，患者顺利出院，手术伤口干净。教训： 在cART时代，肠穿孔可能是IRIS危及生命的表现。如果可能，应避免使用类固醇，以降低肠穿孔的风险，特别是在涉及胃肠道的机会性疾病后发生 IRIS 时。
Rationale: Non-traumatic bowel perforation caused by cytomegalovirus (CMV) and Mycobacterium avium complex (MAC) infections has become rare among patients with acquired immunodeficiency syndrome (AIDS) in the era of combination antiretroviral therapy (cART); however, CMV-associated and MAC-related immune reconstitution inflammatory syndrome (IRIS) has subsequently emerged owing to the wide use of integrase inhibitor-based regimens. Here we report a case of spontaneous perforation of the jejunum in a patient with human immunodeficiency virus (HIV) infection with good compliance to cART.Patient concerns: A 32-year-old HIV-infected man developed CMV disease and DMAC infection, as unmasking IRIS, 3 days after the initiation of cART. After appropriate treatment for opportunistic infections, intermittent fever with enlarged lymph nodes in the abdomen occurred as paradoxical IRIS. The patient was administered prednisolone with subsequent tapering according to his clinical condition.Diagnoses: Unexpected perforation of hollow organ during the titration of steroid dose with clinical presentations of severe abdominal pain was diagnosed by chest radiography.Interventions: He underwent surgical repair with peritoneal toileting smoothly.Outcomes: He was discharged well with a clean surgical wound on post-operative day 10.Lessons: Bowel perforation may be a life-threatening manifestation of IRIS in the era of cART. Steroids should be avoided, if possible, to decrease the risk of bowel perforation, especially in IRIS occurred after opportunistic diseases involving the gastrointestinal tract.