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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
 
 
Figure 1
Figure 2

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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