Atypical presentation of Ogilvie syndrome in an ambulatory HIV-positive adult with concurrent nutcracker anatomy: a case report

Introduction and importance: Ogilvie syndrome (OS) is characterized by marked colonic dilation without mechanical obstruction, typically seen in hospitalized patients. Its occurrence in ambulatory individuals without classic risk factors is uncommon and may create diagnostic uncertainty. Case presentation: A 37-year-old ambulatory man with well-suppressed HIV presented with progressive abdominal distention, dull pain, and urinary retention over 3 weeks. Computed tomography (CT) imaging revealed marked colonic dilation without evidence of mechanical obstruction, ischemia, or perforation, and incidentally demonstrated nutcracker anatomy. Flexible sigmoidoscopy excluded distal obstruction. The patient was managed conservatively with bowel rest, laxatives, and decompression, with complete resolution of symptoms by day 7 without neostigmine or invasive intervention. Clinical discussion: This case highlights OS occurring in an atypical ambulatory patient without typical risk factors. HIV-associated autonomic dysfunction may represent a possible contributing mechanism despite viral suppression. The incidental finding of nutcracker anatomy did not influence management, underscoring the importance of correlating imaging findings with clinical presentation and avoiding diagnostic distraction. Conclusion: OS should be considered in patients with unexplained colonic dilatation, even in atypical ambulatory settings. A structured diagnostic approach and careful interpretation of incidental findings are essential, and conservative management may be effective in uncomplicated cases, avoiding unnecessary invasive interventions.