AIDS-Associated Cryptosporidial and Cytomegalovirus Cholangiopathy

Acquired immune deficiency syndrome (AIDS)-associated cholangiopathy is a biliary tract condition seen in AIDS patients who are severely immunosuppressed, contributing to significant mortality in this population, even in developed countries with access to highly active antiretroviral therapy (HAART).  We discuss a thirty-six-year-old human immunodeficiency virus (HIV)-positive male, non-compliant with HAART therapy, who presented with a one-year history of weight loss, persistent fatigue, and chronic diarrhea, which had worsened significantly in the past few weeks. Routine laboratory studies on presentation indicated elevated liver enzymes and alkaline phosphatase, a CD4 count of 2 cells/mm³, and a high HIV RNA count of 8.8 million. Imaging via CT of the abdomen and pelvis and ultrasound of the abdomen both displayed thickening and edema in the gallbladder without evidence of gallstones, raising concerns of acalculous cholecystitis. The patient subsequently decompensated, requiring intravenous vasopressors to maintain hemodynamic stability, broad-spectrum antibiotics, and resumption of antiretroviral therapy. Biliary fluid drainage was performed, and Cryptosporidium and cytomegalovirus (CMV) were detected via polymerase chain reaction (PCR) testing. The diagnosis of AIDS cholangiopathy was established; however, the patient's diarrhea worsened upon the introduction of tube feeds. Despite ongoing antimicrobial treatment, the patient developed a fever of 101.4°F, became asystolic and subsequently passed away. This case highlights the diagnostic, management, and therapeutic challenges of AIDS cholangiopathy. Also, it underscores the importance of thorough investigation into even mild or intermittent diarrhea and abnormal liver function tests in all HIV-infected patients, particularly in severely immunosuppressed patients. AIDS cholangiopathy should be considered in AIDS patients with diarrhea and abnormal liver function tests, irrespective of age, due to its associated morbidity across all age groups. Laboratory investigations often reveal markedly elevated alkaline phosphatase, gamma-glutamyltransferase, and mild to moderate liver enzyme elevations as hallmark findings of AIDS cholangiopathy. Ultrasonography is the first-line screening modality of AIDS cholangiopathy. Cryptosporidium parvum is the most common infectious etiology of AIDS cholangiopathy and can be identified by DNA-based polymerase chain reaction (PCR) testing of the stool or biliary fluid or acid-fast staining of stool specimens. Early detection of HIV infection and the prompt initiation and adherence to highly active antiretroviral therapy (HAART), which helps with maintaining a normal CD4 count and a low HIV viral load through HAART therapy, thereby significantly reducing the risk of developing AIDS cholangiopathy in HIV patients.