S4908 Mycobacterium Avium Complex Duodenitis: An Unusual Case of Malabsorption

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Introduction: Anemia is often seen in patients with human immunodeficiency virus (HIV) infection and the cause is usually multifactorial, for example, anemia of chronic disease, impaired erythropoietin production, direct infection within bone marrow cells, or antiretroviral therapy. Mycobacterium avium complex (MAC) infection frequently develops in patients with acquired immunodeficiency syndrome (AIDS), and anemia occurs in individuals either due to primary bone marrow infection or in the setting of chronic inflammation. Here, we present the case of severe nutritional deficiency anemia as a manifestation of MAC duodenitis in patient with AIDS. Case Description/Methods: A 36-year-old man with a past medical history of AIDS presented to the emergency room with 2 months of chronic diarrhea with associated fatigue and intermittent dark stools. On exam, patient’s vital signs were within normal limits. Pertinent laboratory results included: hemoglobin 6.5 g/dL, mean corpuscular volume 77.1 fL, ferritin 30 mg/ml, serum iron 17 mcg/dl, direct total iron binding capacity 205 mcg/dl, folate 2.0 ng/ml, albumin 1.9 g/dl, CD4 40 cells/uL, and HIV viral load 80,600 copies/ml. Given his low CD4 counts, chronic diarrhea with melena and iron/folate deficiency, patient underwent a complete endoscopic evaluation. Upper endoscopy revealed congestion, erythema, and blunting of the duodenal villi. Colonoscopy was unremarkable. The pathology of duodenal biopsy revealed shortened, broad villi with AFB and PAS-positive bacilli. These findings are consistent with Mycobacterium avium complex duodenitis. He was subsequently started on treatment with azithromycin, ethambutol, and rifabutin prior to discharge. At his 4-week follow-up, the patient reported the resolution of his symptoms. Discussion: In summary, this case demonstrates the unusual cause of anemia in patient with MAC infection, with iron and folate deficiency anemia, led to an emergency blood transfusion. The classic clinical manifestation of MAC infection includes fever and anemia in which usually associated with primary bone marrow infection or inhibitory effects on hematopoiesis. Nutritional deficit should always be considered as a differential diagnosis when patients present with chronic diarrhea, especially in patients with AIDS where providers often focus more on opportunistic infections (see Figure 1).Figure 1.: A) Upper endoscopy revealed congestion, erythema and blunting of the duodenal villi. B and C) Duodenal mucosa with AFB and PAS-positive bacilli.

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