S5090 A Ghost of the Past: Devastating Gastrointestinal Pathologies in a Fulminant Acquired Immunodeficiency Syndrome (AIDS) Patient in the Modern Antiretroviral Therapy Era

Introduction: Acquired immunodeficiency syndrome (AIDS) is the most advanced stage of human immunodeficiency virus (HIV) infection, defined by a CD4+ T-cell count <200 cells/μL or the presence of specific AIDS-defining opportunistic infections or malignancies. The gastrointestinal (GI) tract is a major site of pathology in AIDS, and opportunistic infections - such as Cytomegalovirus (CMV), Mycobacterium avium complex (MAC), or Cryptosporidium - can affect any segment of the GI tract, leading to severe morbidity. Case Description/Methods: A 42-year-old man with a history of AIDS, latent syphilis, and Kaposi sarcoma (KS) with prior cycles of liposomal doxorubicin presented with progressive dyspnea over 2 weeks as well as months of profuse watery diarrhea every 3-4 hours. He denied abdominal pain, fevers, hematochezia/melena and reports compliance with antiretroviral therapy (ART). He was initially diagnosed with AIDS in 2018 after receiving a contaminated blood transfusion in Mexico and has been intermittently adherent to his ART, only being transiently undetectable in 2020 and 2021. His CD4+ count on admission was 2 and exam revealed extensive KS lesions across his trunk, extremities, face, and mucosal surfaces. An upper endoscopy showed scattered large violaceous, ulcerated nodules in the duodenum and multiple such plaques in the esophagus. Diffusely congested and granular mucosa with reduced vascularity and surface pattern as well as shallow rounded ulcers/erosions were found in the entire colon, and a localized area of granular patchy-white mucosa was noted at the anorectal junction. Pathology revealed spindle cell proliferation with HHV8 staining positivity consistent with KS in the duodenum as well as focal viral inclusions positive for CMV colitis in the duodenum and colon. The patient was initiated on ganciclovir and planned for reinitiating of chemotherapy, but this was temporarily held due to the development of exudative non-malignant pleural effusions requiring recurrent thoracenteses. Discussion: Encountering fulminant AIDS in the modern era is uncommon with widespread use of highly effective ART. However, poor compliance and instances of rare virologic and immunologic failure in the setting of ART can result in HIV-infected individuals progressing to AIDS. Being a once-in-a-generation encounter, gastroenterologists working up AIDS patients for GI symptoms should be cognizant that the differential remains broad and that each segment of the GI tract should be carefully examined and biopsied.