The recent epidemic of acquired immunodeficiency syndrome (AIDS) and the increasingly

widespread use of immunosuppressive agents to prevent rejection after transplantation

and to treat other diseases have led to the recognition that these groups of patients are
peculiarly sus- ceptible to certain diseases not frequently encountered in the general
population. While the history of an organ transplant or chemotherapy for malignancy is
not easily overlooked, the same cannot be said for the possibility that a patient might
have acquired AIDS. Those at high risk for AIDS include homosexual or bisexual men,
prostitutes, intrave- nous drug users, recipients of blood products including hemophiliacs.
The presence of unexplained lymphadenopathy, especially if found in two or more
extrainguinal sites, or a history of pneumonia caused by Pneumocystis should heighten
the suspicion of the clinician caring for the patient. Anorectal pathology including
anorectal abscess or fistula, or gonorrheal proctitis, is common in individuals with AIDS. It
is not within the purview of this chapter to discuss separately each of the acute
abdominal emergencies that may be encountered in the immunocom- promised patient,
since these conditions have been described in previ- ous chapters. Rather, the reader’s
attention is drawn to the wide variety of conditions that are encountered in this
population of patients.

Only a small percentage of HIV-positive patients or those with clinical AIDS will require a
laparotomy, but abdominal pain and diarrhea are extremely common among these
patients. Because of this frequency and because the mortality for operation is high, albeit
lower in recent years, an accurate diagnosis is especially vital in this group of patients.

Suppression of signs and symptoms

As in individuals on steroids (see Chap. 25), signs and symptoms are often minimal, even
in the presence of severe peritonitis. Nowhere is clinical judgment tested to a greater
degree than in this group of patients. The slightest degree of pain, tenderness, or
abdominal disten- tion must be carefully evaluated and regarded very seriously.
Elevations in body temperature tend also to be of lesser degree in immunocompro-
mised than in nonimmunosuppressed individuals. In many instances, it will only be the
slight but definite worsening of subtle signs and symptoms, adduced over a period of
hours of evaluation and reevalu- ation, that will direct the surgeon to an urgently needed
laparotomy. Leukopenia is common.