Her past surgery history included hysterectomy for a 10 × 15 cm uterine myoma and ascending colonic abscess about 7 cm in diameter manifested from diverticulitis requiring surgical decompression of abscess with diverting colostomy for 2 years and fluoroscopy-guided drainage of a 7-cm diverticular abscess 3 months prior to admission.
She was managed with broad-spectrum antibiotics that were tailored to a specific antibiotic according to culture and sensitivity of the abscess until full remission was attained. Regarding her HIV, her viral load had persistently been undetectable. CD4 counts had been sustained between 600 and 1,000/mm3 with Truvada, Prezista, and Norvir combination. She had never been given prophylaxis or got treatment for HIV-associated opportunistic infections or malignancy. Her systemic review was insignificant for fever, night sweat, diarrhea, blood in stool, loss of weight, and poor appetite.
During admission, her vital signs were unremarkable except for low-grade fever of 100.7°F and physical examination was significant for diverting colostomy at the left lower quadrant of the abdomen with tenderness on the left side of the abdomen on palpation and rebound tenderness as well. Bowel sound was normal.
Admission labs including lipase, lactic acid, and liver function test were unrevealing for a source. Blood cultures, urine cultures, and fungal cultures showed no growth. ESR 122 and CRP 99.19 and fluid abscess for AFB showed no growth and cultures of fluid abscess showed gram-positive cocci in pairs and in clusters, E. coli, Bacteroides fragilis, and rare A. meyeri.
Later, blood cultures and sensitivity showed she is resistant to ampicillin, levofloxacin, Doxycycline, and intermediately susceptible to Unasyn (Ampicillin and sulbactam).
X-ray (abdomen) showed no evidence of small bowel obstruction. Presence of bowel outside of the abdominal cavity lateral to the iliac crests was consistent with parastomal hernia.
CT scan (abdomen and pelvis) on admission showed status post left lower quadrant colostomy. Large parastomal hernia containing fat and nondilated small bowel loops with long segment mural thickening involving descending and sigmoid colon was seen. Left lower quadrant colostomy and large peristomal hernia containing fat and small bowel lobes were seen.
Moderate inflammatory changes were again seen surrounding the sigmoid colon suggestive of diverticulitis. Interval increase in the size of the fluid collection or abscess formation at or adjacent to the sigmoid colon since the previous exam measured approximately 5.5 × 4.3 cm.
Either extension or additional collection was also seen to the left of the colon measuring 3.6 × 3.2 cm. Mildly enlarged mesenteric lymph nodes were seen at the left lower abdomen.
CT scan (after 6 weeks of completion of antibiotics) showed near complete resolution of diverticular abscess. Persistent left lower quadrant phlegmonous stranding and hazy opacification was noticed. ESR was trending down to 50 and so was CRP (10.01) on recent follow-up.