A 6-year-old HIV-infected girl with neck mass (page 2/3)
Prepared by.... Thanyawee Puthanakit, M.D
Virat Sirisanthana, M.D.
Differential diagnosis of cervical lymphadenitis

What is a proper management?
1. The fine needle aspiration (FNA) of the mass was performed.
> The FNA reveals several foamy histiocytes within reactive lymphoid and necrotic background. Acid fast stain reveals acid fast bacilli 3+ clustering within macrophages, few extracellular acid fast bacilli are occasionally observed (Fig 4). Imp. Mycobacterium lymphadenitis, most likely mycobacterium avium complex.
Figure 4
> Pus culture was also done and Mycobacterium spp . was reported 2 months later.
2. Hemoculture for mycobacterium was performed.
> Four weeks later, hemoculture was reported as Mycobacterim avium.
About Mycobacterium culture:
There are 2 methods:
1. Standard culture methods: using a combination of broth and solid media, such as Lowenstein-Jensen or Middlebrook 7H10 or 7H11. Inoculated media are incubated at 37 C for 6-8 weeks in 10% carbon dioxide and 90% air. Traditionally it takes 2-4 weeks for the growth of mycobacteria. and another 4-6 weeks for biochemical tests for species identification.
2. The BACTEC radiometric system: specimen from the patient is inoculated into culture media containing a radiolabled substrate that is metabolized in the presence of mycobacteria to carbon dioxide and detected by radiorepirometirc methods, a growth signal usually can be detected within average of 2 weeks, however it may require up to 4 weeks for specimen with low colony counts.
For the "species" identification:
1. Biochemical tests: 4-6 weeks
2. Polymerase chain reaction method: 2 days (not always available)
3. Chest X-ray was performed.
The cardiac outline is normal and the lung fields are clear. There is prominent right paratracheal soft tissue on right side compatible with enlarged nodes
(Fig 5).
Figure 5
4. Other Laboratory investigations:
CBC: Hb 9 gm/dl Hct 28% Wbc 5,800 cell/mm3 (PMN 67 %, Band 6% Lymp 22% Mono 5%), Plt 346,000 /mm3
LFT: TB/DB 0.49/0.25 mg/dl, AST/ALT 21/4 U/L, Alk 145 U/L, Alb/Glo 3.6/4.5 gm/dl
Diagnosis: HIV-infected child with Disseminated Mycobacterium avium complex (DMAC)
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