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A 51-year-old woman was referred for evaluation of chronic diarrhea. She had spent a 14 day vacation in Sri Lanka three years ago. The clinical examination of the patient was unremarkable. Values for protein, iron, zinc, copper and folic acid were decreased and the Shilling- and D-xylose tests revealed pathological results. Gliadin and Endomysium antibodies were not detectable. Histologic examination of the duodenum displayed chronic duodenitis with increased epithelial regeneration and villous atrophy. In the MRI a segment of the mid small bowel with increased thickness of the intestinal wall was described. Abdominal CT-scans demonstrated multiple, enlarged mesenteric lymph nodes. Laparoscopy with biopsies of the ileum and mesenteric lymph nodes excluded a malignant lymphoma, mycobacteriosis or Whipple's disease. Oral therapy with tetracyclines (250 mg q. i. d.) and substitution of folic acid and iron led to rapid improvement of the clinical symptoms which persisted after cessation of the antibiotic therapy. In view of the clinical course tropical sprue has to be assumed despite the short duration of the journey to a tropical region.

History and Findings: A 30-year-old man with a known HIV infection for 7 years presented for treatment with antiretroviral drugs. He was known to have had herpes zoster, oral hairy leukoplakia and recurrent Candida stomatitis, but was otherwise without symptoms., Investigations: The CD4 lymphocyte count was 19 cells/mm3 and there were 41,000 HIV-RNA copies/ml., Diagnosis, Treatment and Course: The HIV infection was in CDC stage B3, indicating the need for combined antiretroviral treatment. A week after starting stavudine, saquinavir and ritonavir he had to be admitted because of nausea and vomiting, colicky abdominal pain, diarrhea, fever up to 39 degrees C and a rise of C-reactive protein to 207 mg/dl. Bacteriological examination of feces and biopsy of an enlarged retroperitoneal lymph node revealed atypical mycobacteria. Antituberculosis treatment was started. The CD4 cell count rose to 56/mm3 and the viral count fell to 11,000/ml. Each time after initiating a different antiviral regimen the symptoms recurred., Conclusions: This case illustrates an atypical manifestation of on opportunistic infection: during combined antiviral treatment the CD4 cell count rose and thus precipitated an heretofore subclinical mycobacterial infection with focal lymphadenitis. If, on starting antiretroviral treatment at a late HIV stage, new symptoms develop within 1-3 weeks, one should consider drug-induced side effects or the onset of an opportunistic infection that has become manifest as the result of an improved immunological state.

We report on a 30-year old patient suffering from acute abdomen. X-ray examinations (abdomen photograph, passage of contrast medium) showed an obstructive ileus of the small bowel. Exploratory laparatomy revealed an obstruction of the small bowel by means of masses of lymphatic nodes as part of a mesenteric lymphadenopathy. M. tuberculosis was identified as growing in cultures of peritoneal smears and material of lymphatic nodes. The retrospective examination of the pre-operative x-ray photographs of the chest showed an old primary complex of the lung. A combination of four antituberculotic drugs: Rifampicin, ethambutol, isoniazid and pyrazinamid was administered following the concept of a 6-month regimen. This treatment was successful: CT-scans of the abdomen showed a reduction of the mesenterial lymphadenopathy and the disappearance of the duodenal impression in the follow-up after 4 weeks of therapy. The abdominal TBC represents a severe disease requiring a differential diagnostic distinction from other abdominal diseases such as ileitis terminalis, Crohn's disease, neoplass as especially gastrointestinal lymphomas, giardiasis, amoebiasis and yersinia enterocolitis. The disease has a special importance among immigrant populations.

In 23 years the mesenteric lymphadenitis syndrome has been observed more closely in 4974 appendectomies. Examination of the fine structure of the lymph nodes removed showed a non-specific catarrhal inflammation, while a tubercular disease of the lymph nodes could not be demonstrated in any case. After removal of the appendix, complete freedom from complaint was obtained in almost all cases.