WHEN TO PERFORM ENDOSCOPY ON CASES OF SUSPECTED MAC
demonstrated a large 10 x 10 cm medial pleural based tumor mass with invasion into the pericardium and displacement of the heart to the left. This represented a growth of approximately 4 cm from the previous 6 cm mass over the course of a few weeks. A clinical dilemma arose with concern for pseudoprogression versus progression of the disease in spite of olaparib therapy. With continued therapy, repeat CT chest demonstrated near complete resolution of the large right apical tumor mass, resolution of the right pleural effusion and no new identifiable masses. To the best of our knowledge, this is the first reported case of pseudoprogression of metastatic breast cancer with the use of olaparib. Discussion:
stool testing for pathogens as the first- line evaluation followed by endoscopy when the diarrheal illness is persistent and stool tests fail to reveal a cause in immunocompromised patients. MAC can affect several parts of the gastrointestinal system. In one review of 55 previously reportedcasesofMACwithGIinvolvement, endoscopy demonstrated involvement of the duodenum (76%), rectum (24%), ileum (6%), colon (4%), esophagus (4%), jejunum (2%), and stomach (2%). MAC colonization of the gastrointestinal tract is important because it increases the risk of disseminated MAC with the risk of MAC bacteremia approaching 60% within 1 year. Our approach to this patient was to perform endoscopy only when her symptoms persisted despite treatment. This case was interesting in that duodenum, ileum, and colon were all affected. Lastly, this case was an excellent example of several classic MAC findings including the findings of profound anemia, elevated alkaline phosphatase, splenomegaly, mesenteric and abdominal lymphadenopathy.
K. Boland; T. Tollivoro; Y. Nakanishi Department of Internal Medicine, Tulane Health Sciences Center, New Orleans Case: A 43 year old woman with a past medical history of AIDS (CD4 of 5) and non-adherence with HAART presented with a 3 month history of nonbloody diarrhea, abdominal pain, and an 80 pound weight loss. She was cachectic with mild tenderness throughout the abdomen and was noted to have pancytopenia with a profound anemia. Alkaline phosphatase was elevated with normal AST and ALT. Stool culture, O&P, C diff, shiga toxin, and stool cryptosporidium Ag were negative. Stool Acid Fast Stain was positive. Mediastinal, axillary, retroperitoneal, and inguinal lymphadenopathy were noted on CT scan with mild wall thickening of the proximal jejunum and splenomegaly. ID and GI were consulted who recommended initiation of azithromycin, rifabutin, and ethambutol given the high suspicion for disseminated MAC. After 12 days of hospitalization, her diarrhea had not improved, and it was decided to proceed with both an EGD and colonoscopy. EGD demonstrated atrophic appearing mucosa diffusely in the 2nd and 3rd portions of duodenum. Colonoscopy showed moderately severe colitis in the ileocecal valvewith themucosa appearing edematous, erythematous, and friable. The TI had multiple small erythematous, hypervascular appearing lesions with the appearance of angioectasias. A perianal fistula was also noted. The pathology of the duodenal, terminal ileum, IC valve, and random colon biopsies all showed acid-fast bacilli bacteria within the macrophages. Given the endoscopy findings with blood cultures which were previously positive and eventually grew MAC, the diagnosis of disseminated MAC was confirmed. Her diarrhea gradually improved and she was restarted on HAART before discharge. Discussion: In the post-HAART era, the incidence of diarrhea attributed to opportunistic infections has decreased; however, the workup and evaluation for infectious diarrhea continues to be paramount. The American Society for Gastrointestinal Endoscopy recommends
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28 J LA MED SOC | VOL 171 | NO. 1
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