|
Prepared
by....
Virat
Sirisanthana,
M.D.
|
| Patient:
A
12-
year-old
HIV-infected
boy |
Address:
Chiang
Mai |
|
|
CC:
neck
mass
for
4
weeks |
Present
Illness:
| |
A
12-year-old
boy
presented
with
subacute
onset
of
neck
mass.
He
has
been
known
to
be
an
HIV-infected
child
and
has
been
on
2
antiretroviral
drugs
(ART)
for
2-3
years.
Because
of
his
poor
response
to
the
dual
regimen
his
antiretroviral
drugs
were
switched
to
3TC
+
d4T
+
idinavir
+
ritronavir
(HAART)
3
weeks
prior
to
this
occurrence
of
the
neck
mass
.
Prior
to
the
switching
his
CD4
was
2%
(40
cells/mm3)
and
his
viral
load
(VL)
was
250,205/ml.
The
mass
slowly
enlarged
and
turned
inflammed
(Fig
1,
Fig
2)
in
4
weeks.
|
Past
Medical
History:
>
The
patient
had
been
diagnosed
with
perinatally
acquired
HIV
infection
since
7
years
of
age.
>
He
started
taking
2
antiretroviral
drugs
when
he
was
about
10
year
old.
>
He
had
been
having
multiple
illnesses
due
to
his
immune
deficiency
syndrome....
including
pneumonia,
otitis
media,
oral
thrush. |
| Family
History:
He
is
the
only
child.
|
Physical
examination:
| |
Vital
signs:
T
37.8
C,
PR
100/min,
RR
24/min,
BP
120/60
mmHg
GA:
A
cachetic
boy,
good
consciousness,
active
W/A
94.74%,
H/A
102.73%
HEENT:
>
enlarged
and
inflammed
Lt
submandibular
node
2
cm
in
diameter
(Figure
2).
>
other
cervical
lymph
nodes
also
enlarged,
0.7-1cm
in
diameter
bilaterally,
>
no
injected
pharynx
and
tonsils,
>
normal
tympanic
membranes
bilaterally
Heart:
no
murmur,
normal
S1,S2
Lungs:
clear,
no
adventitious
sounds
Abdomen:
soft,
normal
bowel
sounds,
liver
and
spleen
were
not
palpable
Extremities:
no
edema
Skin:
no
rash |
|
|
Problems:
neck
mass
in
an
HIV-infected
boy
who
has
been
on
HAART
for
3
weeks.
|
Laboratoy
investigations:
| |
>
CBC:
Hb
10.7
g/dL
Hct
33.7%
WBC
7,700/mm3
(N
22%,
E
5%,
L
59%,
M
14%)
Platelet
292,000/mm3
>
U/A:
brown
color,
clear,
no
WBC,
no
RBC
>
Aspiration
of
the
mass
obtained
serious
fluid.
There
was
no
organism
seen
in
the
staining
>
Fine
needle
aspiration
(FNA)
obtained
bloody
fluid.
Histology
revealed
epitheloid
cells,
giant
cells....
compatible
with
"granulomatous
lymphadinitis.
Few
acid
fast
bacilli
(AFB)
was
also
seen
(Figure
3).
>
FNA
fluid
was
sent
for
bacterial
and
mycobacterial
cultures.
>
Hemoculture
for
mycobacterium
was
sent.
>
CD4
12%
540
cells/mm3,
VL
8,453/ml. |
| |
|
|
|
Figure
3
Smear
and
stained
aspirated
fluid
|
|
Diagnosis:
| |
Mycobacterial
lymphadinitis
in
HIV-infeced
boy
(Immune
reconstitution
inflammatory
syndrome) |
Treatment:
| > |
Anti-tuberculous
and
anti-Mycobacterium
avium
complex
(INH,
rifampin,
ethambutol,pyrazinamide
and
carithromycin)
were
started. |
| > |
HAART
was
continued. |
| > |
Prophylaxis
for
Pneumocystis
carinii
(co-trimoxazole)
was
continued. |
|
Course
of
illness:
| >. |
6
weeks
after
the
fine
needle
aspiration
the
aspirated
fluid
was
reported
as
"no
growth",
but
hemoculture
was
reported
as
growing
Mycobacterium
avium
complex
(MAC).
Anti
-mycobacterial
drugs
were
adjusted.
He
had
been
on
only
carithromycin
and
ethambutol
since
then.
The
lymphadinitis
gradually
reduced
in
size
and
finally
was
incised
and
drained.
The
lesion
healed
slowly
in
4
months |
| > |
HAART
was
continued.
His
CD4
cells
had
been
above
200
cells/mm3
since
then
and
his
last
VL
was
<400/ml. |
| > |
Prophylaxis
for
Pneumocystis
carinii
(co-trimoxazole)
was
discontinued
after
his
CD4
count
was
>200
cells/mm3
for
3
months. |
|
Discussion:
|
>.
|
After
the
use
of
highly
active
antiretroviral
therapy
(HAART),
there
has
been
a
decrease
in
the
incidence
of
opportunistic
infections
among
HIVinfected
patients.
However,
experience
during
the
past
several
years
has
disclosed
the
emergence,
in
a
small
proportion
of
cases,
of
a
unique
set
of
complications.
This
phenomenon
is
now
labeled
as
immune
reconstitution
in.ammatory
syndrome
(IRIS).
It
is
a
paradoxical
deterioration
in
clinical
status
attributable
to
the
recovery
of
the
immune
system
during
HAART.
|
|
>
|
The
manifestations
of
this
syndrome
are
diverse
and
depend
on
the
particular
infectious
agent
involved.
MAC
has
been
described
as
one
of
the
most
common
infectious
agents
associated
with
IRIS. |
|
>
|
The
most
common
presentation
of
MAC-induced
IRIS
is
localized
lymph
node
enlargement
(lymphadinitis)
which
commonly
occurs
1-3
weeks
after
starting
HAART.
All
of
these
patients
had
significant
increases
in
CD4
cells
with
a
marked
decreasing
in
VL.
The
biopsies
of
the
affected
nodes
showed
granulomatous
inflammation,
which
usually
are
not
seen
in
AIDS,
suggests
that
the
clinical
presentation
is
due
to
a
restored
inflammatory
response.
|
Suggested
reading:
|
>
|
1.
Shelburne
SA
3rd,
Hamill
RJ,
Rodriguez-Barradas
MC,
et
al.
Immune
reconstitution
inflammatory
syndrome:
Emergence
of
a
unique
syndrome
during
highly
active
antiretroviral
therapy.
MEDICINE
81:213-27,2002 |
|
>
|
2.
Jenny-Avital
ER,
Abadi
M.
Immune
reconstitution
cryptococcosis
after
initiation
of
successful
highly
active
antiretroviral
therapy.
Clin
Infect
Dis.
2002
Dec
15;e128-33.
|
|
|
An
HIV-infected
boy
with
neck
mass
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to
Interesting
Case
List
|
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