Appendicitis in HIV-infected patients during the era of highly active antiretroviral therapy

Subtype C HIV-1 reservoirs throughout the body in ART-suppressed individuals

Subtype B HIV-1 reservoirs have been intensively investigated, but reservoirs in other subtypes and how they respond to antiretroviral therapy (ART) is substantially less established. To characterize subtype C HIV-1 reservoirs, we implemented postmortem frozen, as well as formalin fixed paraffin embedded (FFPE) tissue sampling of central nervous system (CNS) and peripheral tissues. HIV-1 LTR, gag, envelope (env) DNA and RNA was quantified using genomic DNA and RNA extracted from frozen tissues. RNAscope was used to localize subtype C HIV-1 DNA and RNA in FFPE tissue. Despite uniform viral load suppression in our cohort, PCR results showed that subtype C HIV-1 proviral copies vary both in magnitude and tissue distribution, with detection primarily in secondary lymphoid tissues. Interestingly, the appendix harbored proviruses in all subjects. Unlike subtype B, subtype C provirus was rarely detectable in the CNS, and there was no detectable HIV-1 RNA. HIV-1 RNA was detected in peripheral lymphoid tissues of 6 out of 8 ART-suppressed cases. In addition to active HIV-1 expression in lymphoid tissues, RNAscope revealed HIV RNA detection in CD4-expressing cells in the appendix, suggesting that this tissue was a previously unreported potential treatment-resistant reservoir for subtype C HIV-1.

Acute appendicitis in people living with HIV: What does the emergency surgeon needs to know?

Acute appendicitis is among the commonest surgical emergencies seen in an acute setting. Individuals living with the Human Immunodeficiency Virus (HIV) and/or the Acquired Immunodeficiency Syndrome (AIDS) have an increased risk of encountering complications with acute appendicitis. We conducted a literature search using the words appendicitis and HIV in google scholar, Medline, Scopus and PubMed. The search also extended to cover HIV presented with acute appendicitis, their outcome during and following the management of acute appendicitis. Several studies showed that HIV is associated with a higher rate of acute appendicitis than the general population. HIV can directly affect the appendix, through opportunistic infections, immune reconstitution inflammatory syndrome associated with start of antiretroviral medication. High index of suspicion is needed to exclude conditions that mimic acute appendicitis (abdominal tuberculosis, pyelonephritis, cytomegalovirus, cryptosporidium, pneumococcus, Amoebic appendicitis and pill impaction). The clinical presentation may not be typical of acute appendicitis and can be associated with low white cell count and variable fever. The Alvarado score for predicting acute appendicitis can be used and more research is needed to establish cut-off point value. Computed tomography scan and ultrasound are widely used in clinical diagnosis. Importantly, acute appendicitis with HIV/AIDS can be associated with high rate of post-surgical complications like infections, delay of healing, perforation, peritonitis, intra-abdominal abscess and longer hospital stay. HIV/AIDS with acute appendicitis is complex condition. Therefore, we conclude that patients with known HIV and acute appendicitis should also be managed in close liaison with HIV physicians during, before and after surgical treatment.

Leucocyte count and C-reactive protein cannot be relied upon in the diagnosis of acute appendicitis in HIV-infected patients

BACKGROUND

South Africa has the highest prevalence of human immunodeficiency virus (HIV) infection in the world, and is commonly found in association with appendicitis. Atypical presentation of appendicitis in the presence of HIV infection makes clinical diagnosis of appendicitis unreliable, and inflammatory markers are commonly used as adjuncts. The aim of this study was ascertain the value of inflammatory markers in the diagnosis of appendicitis in patients with and without HIV infection.

METHODS

Patients with acute appendicitis were studied and divided into HIV-infected and HIV-uninfected groups. Symptoms, and systemic and local signs were recorded. Appendiceal pathology was classified as simple or as complicated by abscess, phlegmon or perforation. Total white cell count (WCC) and C-reactive protein (CRP) were chosen as inflammatory markers. Findings were compared between the two groups.

RESULTS

The study population consisted of 125 patients, of whom 26 (20.8 per cent) had HIV infection. Clinical manifestations did not differ statistically, and there was no difference in the incidence of simple or complicated appendicitis between the two groups. The mean CRP level was significantly higher in HIV-infected patients (194.9 mg/l versus 138.9 mg/l in HIV-uninfected patients; P = 0.049), and mean WCC (x109/L) was significantly lower (11.07 versus 14.17×109/l respectively; P = 0.010).

CONCLUSION

Clinical manifestations and pathology did not differ between HIV-infected and HIV-uninfected patients with appendicitis, except that the WCC response was significantly attenuated and CRP levels were generally higher in the presence of HIV infection.

HIV Infection: Its Impact on Patients with Appendicitis in Botswana

BACKGROUND

To compare the presentation, management, and outcome of HIV-positive patients with appendicitis to those of HIV-negative patients with appendicitis.

SUMMARY BACKGROUND DATA

The literature is limited regarding the impact of HIV infection on patients with appendicitis.

METHODS

A retrospective review of patients with appendicitis and known HIV status admitted to Princess Marina Hospital, Gaborone, Botswana, aged 13 years and greater was performed from January 2013 to December 2015. Data on patient demographics, presentation, laboratory findings, management, and outcomes were analyzed.

RESULTS

A total of 295 patients with appendicitis and known HIV status were identified, of which 119 (40.3%) were HIV positive. The median [IQR] ages for HIV-positive and HIV-negative patients were 34 [29-42] and 26 [20-33] years, respectively. The male-to-female ratio for the same two groups was 0.8:1 and 1.4:1, respectively. Presenting symptoms, signs, and white blood cell count were similar in both groups. HIV-positive patients had significantly higher overall (4.2 vs. 0.0%, p = 0.010) and postoperative (4.4 vs. 0.0%, p = 0.024) mortality rates. There was no significant difference in the total complication rate between HIV-positive and HIV-negative patients (13.2 vs. 7.9%, p = 0.192). Compared to HIV-positive patients with a CD4 count ≥200, patients with a CD4 count <200 have a significantly higher postoperative mortality rate (17.6 vs. 1.4%, p = 0.023) and a trend toward a higher total postoperative complication rate (31.3 vs. 10.8%, p = 0.054).

CONCLUSION

Within our setting, HIV infection, particularly with a CD4 <200, was correlated with significantly higher mortality in patients with acute appendicitis.

Acute Appendicitis as the Initial Clinical Presentation of Primary HIV-1 Infection

We report a case of an adolescent who presented at our emergency department with acute abdominal pain. While the initial diagnosis was acute appendicitis, a secondary and coincidental diagnosis of primary HIV-1 infection was made. Concurrent and subsequent clinical and molecular biology findings form the basis of our argument that primary HIV-1 infection was the cause of acute appendicitis in this individual.

A retrospective evaluation of the Modified Alvarado Score for the diagnosis of acute appendicitis in HIV-infected patients

BACKGROUND

The aim of this study was to evaluate and compare the diagnostic value of a Modified Alvarado Score (MAS) ≥7 for acute appendicitis in both Human Immunodeficiency Virus (HIV)-negative (HIVneg) and positive (HIVpos) patientcohorts.

METHODS

This retrospective study included all HIV-tested patients undergoing appendectomy at a regional hospital from March 2010 to March 2011. The MAS was calculated for all patients, as well as for the HIVneg and HIVpos groups separately. Two subgroups were considered for each of these: MAS ≥7 (high likelihood of appendicitis) and MAS <7 (low likelihood of appendicitis). These subgroups were then analysed against histopathological findings of the resected appendix. MAS specificities and sensitivities were determined by comparing Receiver Operator Characteristic (ROC) curves for the various scores.

RESULTS

The study comprised 133 patients. Eighty-six (65%) were men and the median age was 20 years (range 4-64); 18 patients (14%) were HIVpos. Appendicitis was confirmed histologically in 113 patients, 100 in the HIVneg group and 13 in the HIVpos group. Specificity and sensitivity of a MAS ≥7 for HIVneg patients was 73 and 85% respectively. Based on the ROC curves, HIVpos patients only showed similar sensitivities (69%) and specificities (80%) at a MAS ≥8.

CONCLUSION

A MAS ≥7 is a reliable predictor of acute appendicitis in HIVneg patients. In HIVpos patients, the MAS threshold required to accurately predict appendicitis is 8. The use of a MAS ≥7 in this group of patients will result in unnecessary surgical intervention.

The Association Between Barium Examination and Subsequent Appendicitis: A Nationwide Population-Based Study

OBJECTIVE

The incidence and association between appendicitis and barium examination (BE) remain unclear. Such potential risk may be omitted. We conducted a longitudinal, nationwide, population-based cohort study to investigate the association between BE and appendicitis risk.

METHODS

From the Taiwan National Health Insurance Research Database, a total of 24,885 patients who underwent BE between January 1, 2000 and December 31, 2010 were enrolled in a BE cohort; an additional 98,384 subjects without BE exposure were selected as a non-BE cohort, matched by age, sex, and index date. The cumulative incidences of subsequent appendicitis in the BE and non-BE cohorts were assessed using the Kaplan-Meier curves and log-rank test. Cox proportional hazards regression analyses were employed to calculate the appendicitis risk between the groups.

RESULTS

The cumulative incidence of appendicitis was higher in the BE cohort than in the non-BE cohort (P = .001). The overall incidence rates of appendicitis for the BE and non-BE cohorts were 1.19 and 0.80 per 1000 person-years, respectively. After adjustment for sex, age, and comorbidities, the risk of appendicitis was higher in the BE cohort (adjusted hazard ratio = 1.46, 95% confidence interval = 1.23-1.73) compared with the non-BE cohort, especially in the first 2 months (adjusted hazard ratio = 9.72, 95% confidence interval = 4.65-20.3).

CONCLUSIONS

BE was associated with an increased, time-dependent appendicitis risk. Clinicians should be aware of this potential risk to avoid delayed diagnoses.

Appendicitis in the HIV Era: a South African perspective

The relationship between HIV infection and the clinical spectrum of appendicitis has not been fully elucidated in the South African context. The aim of this study is to compare the surgical management, histopathology, and outcomes between HIV-positive and HIV-negative patients undergoing surgery for appendicitis. A retrospective chart analysis was performed of 50 patients who underwent surgery for appendicitis at King Edward VIII Hospital, Durban, South Africa between January 2012 and December 2012. Patients were stratified by HIV serostatus into HIV-positive and HIV-negative groups. Fifty patients underwent surgery for appendicitis during the study period. Of the 50 patients, 14 were HIV-positive (28 %) and 36 were HIV-negative (72 %). Perforated appendicitis was more frequent in the HIV-positive group (50 vs. 25 %, p > 0.05). There was a significantly higher laparotomy rate in HIV-positive patients (71 vs. 33 %, p < 0.05). Granulomatous inflammation of the appendix was only noted in HIV-positive patients (n = 3). There was no significant difference in the complication rate between the two groups (p > 0.05) and no difference in the mean length of hospital stay (7.8 ± 4.89 vs. 5.8 ± 3.94 days, p > 0.05). In this retrospective study, perforated appendicitis was seen to be more common in HIV-positive patients resulting in a higher laparotomy rate in this group. Granulomatous inflammation was only found in HIV-positive patients. There was no difference seen in the complication rate, length of hospital stay, and mortality between HIV-positive and HIV-negative patients.

Cytomegalovirus immune reconstitution inflammatory syndrome manifesting as acute appendicitis in an HIV-infected patient

Background

Appendicitis occurs with increased frequency in HIV infected compared to HIV uninfected persons. CMV-related appendicitis specifically presents with typical appendicitis symptoms including surgical abdomen, fever and leukocytosis and may have a more severe course with higher mortality than other types of infective appendicitis. We report the first case of CMV appendicitis as a manifestation of Immune Reconstitution Inflammatory Syndrome (IRIS).

Case presentation

The patient was a 38 year old woman with a recent diagnosis of HIV infection who complained of right lower quadrant pain, anorexia, nausea and fevers two weeks after initiating antiretroviral therapy. Acute appendicitis was suspected and the patient underwent an appendectomy. Pathologic examination of the resected appendiceal tissue demonstrated inflammation with perforation and cytopathic changes typical of CMV that were positive for CMV by immunostain. This presentation of CMV abruptly after antiretroviral therapy initiation with a pronounced cellular infiltration of the tissue, is consistent with CMV-IRIS presenting as appendicitis.

Conclusions

Appendicitis can be a rare manifestation of CMV-IRIS in HIV-infected patients who start antiretroviral therapy. Evaluation of appendiceal tissue for cytopathic changes and CMV should be considered in acute appendicitis in HIV infected persons.

Bilateral facial nerve palsy and appendicitis occurring during acute retroviral syndrome

We herein report the case of 41-year-old homosexual man who presented to our hospital with typical acute retroviral syndrome. Complications of bilateral facial nerve palsy and appendicitis appeared eight days after admission. The bilateral facial nerve palsy spontaneously recovered one month later; however, the appendicitis required surgical intervention. To our knowledge, this is the first reported case of appendicitis related to acute retroviral syndrome.

Outcomes of Laparoscopic and Open Appendectomy for Acute Appendicitis in Patients with Acquired Immunodeficiency Syndrome

The aims of this study were to compare outcomes of appendectomy between acquired immunodeficiency syndrome (AIDS) and nonAIDS patients and laparoscopic appendectomy (LA) versus open appendectomy (OA) in AIDS patients. Using the Nationwide Inpatient Sample database, from 2006 to 2008, clinical data of patients with AIDS who underwent LA and OA were evaluated. A total of 800 patients with AIDS underwent appendectomy during these years. Patients with AIDS had a significantly higher postoperative complication rate (22.56% vs 10.36%), longer length of stay [(LOS) 4.9 vs 2.9 days], and higher mortality (0.61% vs 0.16%) compared with non-AIDS patients. In nonperforated cases in patients with AIDS, LA was associated with a significantly lower complication rate (11.25% vs 21.61%), lower mortality (0.0% vs 2.78%), and shorter mean LOS (3.22 days vs 4.82 days) compared with OA. In perforated cases in patients with AIDS, LA had a significantly lower complication rate (27.52% vs 57.50%), and shorter mean LOS (5.92 days vs 9.67 days) compared with OA. No mortality was reported in either group. In patients with AIDS, LA has a lower morbidity, lower mortality, and shorter LOS compared with OA. Laparoscopic appendectomy should be considered as a preferred operative option for acute appendicitis in patients with AIDS.