Abstract Introduction Human immunodeficiency virus (HIV), particularly when progressing to acquired immunodeficiency syndrome (AIDS), renders individuals highly susceptible to opportunistic infections. Tuberculosis (TB) remains a leading cause of morbidity and mortality in HIV patients, often presenting atypically with extrapulmonary involvement in advanced immunosuppression. Drug-resistant Mycobacterium tuberculosis (DR-mTB) further complicates management and worsens prognosis. We present a rare and challenging case of disseminated DR-mTB in a patient with newly diagnosed AIDS, complicated by refractory septic shock requiring methylene blue as rescue therapy. Description A 43-year-old male with diabetes presented with acute abdominal pain. Computed tomography imaging suggested appendicitis but revealed multifocal necrotic masses in the liver, pancreas, and right retroperitoneum, including the psoas. He was admitted with sepsis of unknown origin. HIV testing confirmed a new diagnosis, with a CD4 count of 14, confirming AIDS. Antiretroviral therapy (ART) was promptly initiated. He developed persistent fevers, generalized lymphadenopathy, and a right supraclavicular abscess. Magnetic resonance cholangiopancreatography confirmed pancreatic and hepatic masses; esophagogastroduodenoscopy revealed severe Candida esophagitis and cystic pancreatic and duodenal masses; however, biopsies were technically challenging. Supraclavicular lymph node biopsy yielded grossly purulent drainage. Subsequent image-guided bone marrow and lymph node biopsies detected acid-fast bacilli, prompting a four-drug regimen for TB; polymerase chain reaction analysis confirmed DR-mTB. The patient rapidly deteriorated, requiring high-flow nasal cannula and high-dose vasopressors for septic shock; impending respiratory failure necessitated intubation. He developed new-onset atrial fibrillation, acute renal failure, and acute liver injury with persistent lactic acidosis (lactate 15 mmol/L). A trial of methylene blue was administered to counter nitric oxide-mediated vasodilation, providing transient hemodynamic improvement. He developed hypoglycemia from hepatic failure. Despite maximal support, he remained anuric; progressive multi-organ failure led to palliative extubation per family wishes. Discussion This case highlights the complexity of diagnosing disseminated DR-mTB in advanced AIDS. Atypical abdominal presentations may delay diagnosis. Despite early ART and anti-TB therapy, our patient experienced a rapid and fulminant course within weeks of presentation. Methylene blue, by inhibiting nitric oxide-mediated vasodilation and increasing systemic vascular resistance, serves as a temporizing measure in refractory shock unresponsive to conventional vasopressors. While it provided transient hemodynamic support, our patient’s outcome was ultimately determined by overwhelming infection and multi-organ dysfunction. While rescue therapies like methylene blue may support blood pressure, definitive management of underlying infection remains critical. This case underscores the potential role and limitations of methylene blue in refractory septic shock in severely immunocompromised patients. This abstract is funded by: None
Shahab et al. (Fri,) studied this question.