Cytomegalovirus immune reconstitution inflammatory syndrome

28 Background: Appendicitis occurs with increased frequency in HIV infected compared to 29 HIV uninfected persons. CMV-related appendicitis specifically presents with typical 30 appendicitis symptoms including surgical abdomen, fever and leukocytosis and may have 31 a more severe course with higher mortality than other types of infective appendicitis. We 32 report the first case of CMV appendicitis as a manifestation of Immune Reconstitution 33 Inflammatory Syndrome (IRIS). 34 Case: The patient was a 38 year old woman with a recent diagnosis of HIV infection who 35 complained of right lower quadrant pain, anorexia, nausea and fevers two weeks after 36 initiating antiretroviral therapy. Acute appendicitis was suspected and the patient 37 underwent an appendectomy. Pathologic examination of the resected appendiceal tissue 38 demonstrated inflammation with perforation and cytopathic changes typical of CMV 39 that were positive for CMV by immunostain. This presentation of CMV abruptly after 40 antiretroviral therapy initiation with a pronounced cellular infiltration of the tissue, is 41 consistent with CMV-IRIS presenting as appendicitis. 42 Conclusions: Appendicitis can be a rare manifestation of CMV-IRIS in HIV-infected 43 patients who start antiretroviral therapy. Evaluation of appendiceal tissue for cytopathic 44 changes and CMV should be considered in acute appendicitis in HIV infected persons. 45 46