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Question of the Day

A 38-year-old male, known to be HIV-positive with a CD4 count of 50 cells/µL, presents with a 2-week history of progressive right upper quadrant abdominal pain and intermittent fever. Imaging reveals diffuse dilatation of the intrahepatic and extrahepatic bile ducts without evidence of calculi. What is the most probable diagnosis?
Answer Details
✅ Correct Answer: C. AIDS cholangiopathy, secondary to opportunistic infection in a severely immunocompromised patient.
📝 Explanation:

AIDS cholangiopathy is a recognized opportunistic complication in severely immunocompromised HIV-positive individuals, typically those with CD4 counts below 100 cells/µL. It is characterized by right upper quadrant pain, fever, and imaging findings of diffuse biliary tree dilatation, often due to infections like Cryptosporidium, Cytomegalovirus (CMV), or Microsporidium. This diagnosis aligns with the clinical presentation and imaging findings in a patient with advanced HIV disease, as per the National Consolidated Guidelines for the Prevention, Care and Treatment of HIV, STIs and TB, 2023/24.

🔤 Memory spark:

AC-CD4: AIDS Cholangiopathy, CD4 <100

❌ Why Wrong:
A    Cholangiocarcinoma less likely in young HIV patient.
B    PSC has different demographics.
D    Stones would show filling defects.
E    Cholecystitis affects gallbladder, not ducts.
🏥 Setting:

Emergency Department

⏰ Urgency:

Urgent

🎯 Learning Objective:

Accurately diagnose AIDS cholangiopathy in an HIV-positive patient with advanced immunosuppression presenting with biliary symptoms.

🗝️ Key Teaching:

AIDS cholangiopathy is an important differential in HIV-positive patients with CD4 counts <100 cells/µL presenting with right upper quadrant pain, fever, and imaging evidence of biliary tree dilatation, often caused by opportunistic pathogens like Cryptosporidium or CMV.

💎 Clinical Pearls:

In advanced HIV (CD4 <100), RUQ pain with dilated bile ducts strongly suggests AIDS cholangiopathy, requiring investigation for opportunistic infections.

📖 Reference:

National Consolidated Guidelines for the Prevention, Care and Treatment of HIV, STIs and TB, 2023/24, Section on Opportunistic Infections

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