Difficulties in Diagnosing of Pancreatic Cancer in HIV Infection with Generalised Lymphadenopathy: Tuberculosis, Non-Tuberculosis Mycobacterial Infection or Metastases (Clinical Case)

Abstract

Our observation of the pancreatic cancer diagnosing difficulties in a patient with HIV infection with generalised lymphadenopathy is presented. The patient’s HIV infection was diagnosed 8 months before hospitalisation, he did not receive antiretroviral therapy. He came to the doctor already in a serious condition, when severe intoxication syndrome, weight loss, abdominal pain radiating to the lower back and diarrhea were noted. The patient was hospitalised in a serious condition, where he spent 42 days. The patient had severe immunosuppression since hospitalisation time (CD4+ lymphocyte count was 20 cells, viral load was more than 3,000,000 RNA copies/mL). He did not suffer from tuberculosis before. Considering the severe immunosuppression and doubtful lipoarabinomannan test (LF-LAM), it was impossible to exclude a tuberculous etiology of lymphadenopathy. Mycobacterium tuberculosis was not detected either in the sputum or in the pleural fluid. However, non-tuberculosis mycobacteria were found in the sputum. The patient underwent two contrast-enhanced computed tomography scans of the abdominal cavity, which revealed increasing generalised lymphadenopathy and hepatosplenomegaly, with no signs of neoplastic lesions of the pancreas. Therefore, the diagnosis of oncopathology was confirmed only pathohistologically. Despite massive complex therapy during inpatient treatment the general condition progressively worsened, intoxica tion syndrome, multiple organ failure and polyserositis increased. The cause of death was the progression of multiple organ failure on the background of an HIV-related disease with manifestations of malignant neoplasms (undifferentiated pancreatic cancer with foci of necrosis and destruction of tumor tissue with metastases in the lymph nodes and liver, along with a non-tuberculous mycobacterial infection affecting the intra-thoracic lymphatic nodes. Thus, timely intravital diagnosis of pancreatic cancer in HIV-infected patient with generalised lymphadenopathy and those with severe immunosuppression may cause difficulties, because CT signs and other manifestations of pancreatic lesions may not be detected. Severe immunosuppression and a doubtful LF-LAM test made it impossible to rule out the tubercular etiology of lymphadenopathy. At the same time, generalised lymphadenopathy was a manifestation of metastases and non-tuberculosis mycobacterial infection.