Bloody Diarrhea in a 17-year-old Male......infection with HIV-1

Bloody Diarrhea in a 17-year-old Male:

A 17-year-old African American male presented to the emergency department complaining of 5 days of diarrhea, which was watery and intermittently bloody. He had engaged in his first act of condomless receptive anal intercourse 2 months prior. Additionally, he reported a diagnosis of “strep throat” 1 week before this presentation but did not receive antimicrobial treatment. Vital signs were within normal limits, and the patient was afebrile upon presentation, although developed fever to 38.1° Fahrenheit the following day. Pertinent physical findings included submandibular and posterior cervical lymphadenopathy with white oropharyngeal lesions along the buccal mucosa and lateral aspects of the tongue. There was no posterior pharyngeal erythema, exudate, or ulcerations. Abnormal laboratory findings included white blood cell count of 31 000 K/mcL, platelet count of 54 000 K/mcL, aspartate aminotransferase of 185 U/L, alanine aminotransferase of 65 U/L, and a positive fecal occult blood test. A fourth generation human immunodeficiency virus (HIV) antigen/antibody test was positive and differentiation assay confirmed infection with HIV-1; CD4 cell count was 346 cell/μL, and HIV-1 RNA was detected at 2.6 million copies/mL. Abdominal ultrasound showed only gallbladder sludge. Patient was started on amoxicillin for untreated streptococcal pharyngitis and oral nystatin for thrush. Serum rapid plasma reagin, urine, and rectal nucleic acid amplification tests for Neisseria gonorrhea and Chlamydia, evaluation for stool ova and parasites, including microscopic examination for Cyclospora, Isospora, Entamoeba, Cryptosporidium, and Giardia were negative. Rapid heterophile antibody test, hepatitis B surface antigen, hepatitis C RNA, treponemal antibody test, and blood cultures were also negative. Colonoscopy was notable for scattered erythematous mucosa with nodular lesions in the cecum and rectum. Colonic biopsy specimens were stained with hematoxylin-eosin stain (H&E; Figure 1) as well as Warthin-Starry stain (Figure 2).