Abstract
Gastrointestinal (GI) infections can arise in patients with human immunodeficiency virus (HIV). Opportunistic infections typically occur with low CD4 counts. Biliary cholangiopathy is a syndrome of biliary obstruction due to infection-induced stricturing. Cases have been reported in patients with AIDS. Patients commonly present with right upper quadrant (RUQ) or epigastric pain while fever and jaundice are less common. Here, we describe a case of cytomegalovirus (CMV) cholangiopathy in an HIV patient with a CD4 count of 402 on antiretroviral therapy (ART). A 47-year-old male with HIV who presented to the GI clinic for evaluation of RUQ pain with CT findings of biliary dilation in the right hepatic lobe. The patient had history of prior cholecystectomy. Physical exam was normal without jaundice. Liver function tests were normal except for an elevated alkaline phosphatase of 153; CD4 count was 402. Complete blood count and comprehensive metabolic panel were normal. Magnetic resonance cholangiopancreatography (MRCP) revealed a large filling defect in the right intrahepatic duct with biliary dilatation. An endoscopic retrograde cholangiopancreatography (ERCP) performed revealed a large stone in the proximal CBD extending into the right intrahepatic duct. A sphincterotomy was performed and a plastic stent was placed to break the stone. The stone was completely fragmented and removed during a second ERCP performed a month later. Spyglass cholangioscopy was performed to visualize the biliary tree. Edematous and erythematous mucosa was noted in the proximal common bile duct. Biopsies were taken which revealed CMV inclusions in the epithelium without signs of malignancy. CMV serology revealed elevated IgG with normal IgM. CMV viral load was undetectable. Patient was treated with 30 days of valgancyclovir and currently doing is well.AIDS cholangiopathy is diagnosed by ERCP but typically MRCP and ultrasound are ordered beforehand. A patient might present with RUQ pain and cholestatic labs. Our case is highly unusual as AIDS cholangiopathy is typically seen in patients with low CD4 counts while our patient presented with a near normal CD4 count. Medical treatment for CMV cholangiopathy is valganciclovir and the duration of treatment is determined by whether CMV viremia is present. If biliary strictures are noted on CT or MRCP, endoscopic dilation using ERCP could be performed to decompress the bile duct.