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Winning Abstracts from the 2010 Medical Student Abstract Competition: A Benign Cause of Neck Swelling In The HIV Patient

Authors: Priti Dangayach, Baylor College of Medicine, Class of 2011
Monisha Arya, MD, MPH, Assistant Professor of Medicine, Baylor College of Medicine

Introduction: The combination of multiple parotid cysts with diffuse cervical lymphadenopathy suggests the diagnosis of benign lymphoepithelial cysts of the parotid gland, a condition that may herald the diagnosis of HIV. Antiretroviral therapy for this condition may be curative.

Case Presentation: A 36-year-old HIV-positive woman with a CD4 count of 609 cells/ÁL developed acute rightsided neck pain, which progressed to swelling above the mandible within two weeks. She denied constitutional symptoms. Physical examination revealed bilateral neck swelling and tenderness, greater on the right side. Her neck ultrasound showed bilateral, anechoic, and primarily cystic lesions in the parotid glands. The cytopathology report after fine needle aspiration was negative for malignancy. Subsequent computed tomography detected a 3-cm well-circumscribed homogenously hypodense cystic lesion in the right parotid gland and a similar 1.2-cm lesion in the left. Multiple small lymph nodes were present in the cervical and supraclavicular chains bilaterally. Based on these characteristic imaging findings of bilateral parotid cysts with associated lymphadenopathy, these lesions were characterized as benign lymphoepithelial cysts of the parotid gland, a condition predominantly found among HIV-positive individuals. Our patient underwent needle aspiration of the right cyst, with immediate complete relief of her symptoms. However, within 3 weeks, the neck pain and swelling reappeared prompting repeat aspiration. Ultimately, twelve aspiration procedures were performed over four years. The patient began highly active antiretroviral therapy for her CD4 count of 264 cells/ÁL in July 2009. Now in December 2009, her CD4 count has increased, her viral load has become undetectable, and her swelling has not reappeared. She has remained symptom-free for five months, the longest duration of relief that she has experienced in four years.

Discussion: In HIV-positive individuals, lymphoepithelial cysts of the parotid gland are typically benign, bilateral, multiple, and associated with lymphadenopathy. Several approaches have been tried to manage lymphoepithelial cysts including aspiration, surgery, steroids, and antiretroviral treatment. Conservative management includes repeated aspirations. Surgical resection leads to resolution of cysts, but is associated with considerable risks. Antiretroviral therapy may be curative. This case highlights the importance of suspecting benign lymphoepithelial cysts of the parotid gland in HIV-positive patients who present with neck swelling. Characteristic imaging findings support this diagnosis. Limited published research suggests that antiretroviral therapy may be curative. Notably, benign lymphoepithelial cysts of the parotid gland can be the presenting manifestation of HIV infection, and HIV testing should be performed in patients who present with neck swelling and characteristic imaging findings.

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