A 35-year-old woman from Morocco with a history of cholecystectomy, without toxic habits or sexual risk factors.
He was admitted in May 2011 due to fever peaks up to 38.5oC, along with colic pain in the right hypochondrium and epigastrium, pruritus and dysphagia.
Physical examination revealed abdominal tenderness, focalized right hypochondrium with no signs of peritoneal irritation, jaundice, and oral muguet.
The rest of the anamnesis and physical examination were normal.
Blood tests revealed hemoglobin 10.9 g/dl, neutrophil count 8220, lyophil count 2,300 cells/μl, 58.3% neutrophil count, C-reactive protein 0.1 mg/dl, IgG125 IgG positive IgG/dl
Autoantibodies antineutrophil cytoplasmic cytoplasmic (ANCA-antinuclear), antimitochondrial (AMA), antimicrosomal (LKM-1) antibodies, and
Positive HIV serology with viral load greater than 10 million copies/ml, positive IgG CMV with viral load 2 to 5 million copies/ml, positive rubella IgG and Toxoplasma gondii IgG higher than 250 IU/ml.
Serology HBV, HCV, HAV, LUES, Brucella, Cryptococcus, Leishmania, CMV IgM negative; EBV IgM result indeterminate.
Ankylosing Cryptosporidium in faeces, Legionella antigen and pneumococcus in urine, sputum smear and urine for three, negative blood cultures
Development of Candida albicans in sputum culture.
Mantoux negative.
Lymphocyte populations were 177 CD4/μl, 534 CD3/μl, 346 CD8/μl and a CD4/CD8 ratio of 0.51.
Normal eye fund.
Abdominal ultrasound showed a dilated common bile duct with a fusiform appearance, and upper endoscopy showed whitish plaques throughout the esophagus suggesting esophageal candidiasis.
A magnetic resonance cholangiography showed intrahepatic bile duct ectasia with some stenotic segment and slight dilation of the hepatocholedochus duct without stenosis or lithiasis.
During admission, the patient received medical treatment with ganciclovir at a dose of 500 mg every 12 hours intravenous for two weeks, followed by valganciclovir 900 mg every 24 hours.
From the second week on, antiretroviral treatment (emtricitabine/tenofovir, darunavir and ritonavir) was started with good tolerance.
In addition, 100 mg of oral plug was administered every 24 hours for 7 days, 300 mg of medicated oxycholic acid every 12 hours and 800 mg of fluconazole and midazolam administered every 12 hours, 8chlorphen
In spite of the medical treatment, the patient continued to be treated conservatively with cytolysis (total bilirubin 10.26 mg/dl, AF 544 U/l, GGT 175 U/l, GOT 448 170 U/ganl).
ERCP confirmed the presence of fusiform dilatation of the extrahepatic bile duct, with normal intrahepatic dilation, and allowed treatment with sphincterotomy, placing a plastic extrahepatic stent in the bile duct.
Four days after ERCP the patient improved clinically and analytically (FA 310 U/l, GGT 94 U/l, GOT 212 U/l, GPT 84 U/l, HIV viral load negative and CMV negative).
In subsequent reviews it has remained stable with persistent elevation of alkaline phosphatase in ranges of 400-600 U/l, negative HIV viral load and CMV.
