A 41-year-old man with human immunodeficiency virus (HIV) (CD4 count, 446/mm 3 ) developed a protracted course of abdominal pain, weight loss, and increasing liver function tests after undergoing a metronidazole treatment regimen for Giardia enteritis. Three months later, endoscopic retrograde cholangiography (ERCP) showed dilated common and intrahepatic bile ducts and luminal irregularities of the common bile duct. Seven months after the onset of his acute diarrhea, a repeat ERCP with aspiration demonstrated many Giardia trophozoites and cysts in the bile and continued structural abnormalities consistent with cholangiopathy. A 10-day course of high-dose intravenous metronidazole did not resolve these signs or symptoms. A gallbladder ultrasound showed a thickened wall. Laparoscopic cholecystectomy led to resolution of abdominal pain and normalization of serum alkaline phosphatase over an 8-month period. Gallbladder histopathology revealed chronic cholecystitis, but no parasites were seen on hematoxylin and eosin staining or with Giardia antigen enzyme immunoassay testing of the gallbladder. The patient refused to undergo a follow-up ERCP, but a right upper quadrant ultrasound and computed tomography of the abdomen were normal.
From the Infectious Disease Service (N.E.A.), the Gastroenterology Service (C.C.), and the Departments of Pathology (V.R.) and Surgery (N.H.), Walter Reed Army Medical Center, Washington D.C., U.S.A.; and the Infectious Disease Division (N.E.A.), Department of Surgery (D.B.), Uniformed Services University of the Health Sciences, Bethesda, Maryland, U.S.A.
Submitted January 26, 2000.
Accepted April 26, 2000.
The views and assertions contained herein are those of the authors and do not reflect the official policy or positions of the U.S. Army or the U.S. Department of Defense.
Address correspondence and reprint requests to Dr. Naomi Aronson, Infectious Diseases, Ward 63, Walter Reed Army Medical Center, 6900 Georgia Avenue NW, Washington, DC 20307-5001, U.S.A.