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A 29-year-old man infected with the human immunodeficiency virus (HIV) presented with right-sided abdominal pain and diarrhea. His CD4 cell count was 24 per cubic millimeter, and his HIV viral load was greater than 200,000 RNA copies per milliliter. He had recently been discharged from the hospital after an episode of Pneumocystis carinii pneumonia, which had been treated with trimethoprim–sulfamethoxazole and prednisone. Four days later, he reported crampy abdominal pain and six to eight loose stools per day. His medications included lopinavir–ritonavir, combivir, trimethoprim–sulfamethoxazole, and azithromycin. The lopinavir–ritonavir and combivir were stopped, and his diarrhea responded to a 10-day course of metronidazole (500 mg given orally every eight hours) for a presumptive diagnosis of Clostridium difficile colitis. The patient continued to report severe right-sided abdominal pain but had some improvement in the diarrhea. A colonoscopy revealed inflamed and edematous mucosa (Panel A) with multiple discrete, nodular and polypoid lesions covered with yellowish exudates (Panel B). A cytotoxic assay of a stool specimen for C. difficile toxin B was positive. The findings on histopathological examination of rectosigmoid-biopsy specimens were consistent with a diagnosis of pseudomembranous colitis. The patient was treated with a four-week course of metronidazole, which resulted in complete resolution of his symptoms. The discrete nodular and polypoid lesions, in contrast to the more common finding of diffuse inflammation on colonoscopy, may be related to the patient's HIV-induced state of severe immunodepression.
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