Extrapulmonary manifestations of tuberculosis in the neck of HIV positive patient: a case report
D Krasic1, M Trajkovic1, D Mihailovic2, M Stojanovic1, S Arandjelovic1
1 Department of Maxillofacial surgery, University Dental Clinic of Nis, Nis, Serbia.  2 Department fo Pathology, Faculty of Medicine, University of Nis, Nis, Serbia
DOI
http://dx.doi.org/10.13070/rs.en.1.842
Date
2014-05-29
Cite as
Research 2014;1:842
License
Abstract

Coinfection of tuberculosis and HIV is often characterized by atypical radiographic findings, extrapulmonary form of tuberculosis, and multidrug-resistant tuberculosis and extremely drug-resistant tuberculosis. An HIV-positive 25-year-old female patient was admitted for biopsy and histopathological examination of a tumor on the right side of her neck. Extrapulmonary manifestations of tuberculosis in the neck in the form of massive soft tissue conglomerate is a rare pathological entity. The regression of tuberculosis processes of the neck shows the efficiency of the combined surgical and tuberculostatic therapy in the treatment of tuberculosis among HIV-positive patients without compromising the immune system.

Introduction

HIV causes a progressive loss of immunity at the cellular level which leads to a significant increase in the risk of tuberculosis among HIV-positive patients [1]. Despite the effective treatment of tuberculosis co-infected with HIV, the tuberculosis infection rates continue to rise in sub-Saharan Africa [2]. According to the World Health Organization, one third of the world population is infected by Mycobacterium Tuberculosis [3]. Tuberculosis is the most common opportunistic infection that occurs among HIV-seropositive patients and the most common cause of death among patients infected by HIV [4]. The World Health Organization’s data show that one in every three AIDS patients dies from tuberculosis [5]. The coinfection of HIV and tuberculosis is characterized by the appearance of multidrug-resistant tuberculosis (MDRTB) and extremely drug-resistant tuberculosis (XDRTB) [6] [7]. The most frequent forms of tuberculosis affect lymph nodes predominantly in the neck region [8]. Intrathoracic lymphadenopathy is not a feature of primary HIV syndrome and should raise suspicion of tuberculosis or limfom [9]. Other forms of extrapulmonary tuberculosis have pleural or pericardial effusion, abdominal tuberculosis or tuberculosis meningitis [10]. Independently of HIV status, current guidelines recommend that tuberculosis requires at least six-month treatment with four drugs in the intensive care unit and two drugs in the following phase. The therapy involves the use of Isoniazid, Rifampicin, Etambutol and Piranizamid [11]. Antiretroviral therapy is administered after HIV infection is ascertained [13] [14].

Extrapulmonary manifestations of tuberculosis in the neck of HIV positive patient: a case report figure 1
Figure 1. Preoperative CT.
Case presentation

A 25-year-old female patient was admitted into the Department of Maxillofacial Surgery in Niš for a biopsy and histopathological examination of the tumor on the right side of the neck. She had been hospitalized a month before in the Department of Infectious and Tropical Diseases of Clinical Center Niš because of headaches, difficulty in movement and of suspected acute meningitis, and was diagnosed as HIV positive through western blot analysis. CD4 cell number at the time of HIV diagnosis was 21mm3. She was treated with Amfotericin B, Fluconazole, antiretroviral therapy and polysymptomatic therapy. The number of CD4 cells was 150mm3 after the treatment. During the ten-day hospitalization a tumor formation in the lateral triangle neck area sized 10x20mm was observed. Tumefaction painlessly enlarged, so that upon admission into the Department of Maxillofacial Surgery it had very firm consistency. Tumefaction was located in the lateral neck triangle area, in the right thyroid region and paratraheal region expanding to the opposite side. The patient underwent multi-slice computer tomography (MSCT) of the neck, 80x40 mm sized tumefact was observed on the level IV with extension to the opposite side, which showed a striking contrast material capture at the periphery and large zones of necrosis in the middle (figure 1). Tumefact was in close contact with internal jugular vein (IJV) and arteria carotis communis (ACC).

Extrapulmonary manifestations of tuberculosis in the neck of HIV positive patient: a case report figure 2
Figure 2. Preoperative and postoperative picture of the patients.

The patient underwent the extirpation of tumefact and a lymphadenectomy of the neck at the level III and IV with general endotracheal anesthesia. The extirpated content is grey-yellowish tissue of multilobular material, and was identified histopathologically as Inflamatio chronic caseosa granulomatosa (figure 3). The patient was sent to the Clinic for Pulmonary Diseases and Tuberculosis of Clinical Center Niš, where tuberculostatic therapy was administrated: 750 mg Tbl. Etambutol 1x1, Tbl. Isoniasid 250 mg 1x1. 1200 mg Tbl. Pyrasinamid 1x1, Tbl. Rifampicin 1x1.

Extrapulmonary manifestations of tuberculosis in the neck of HIV positive patient: a case report figure 3
Figure 3. Lymph node biopsy: caseous necrosis and epitheloid cells. HE, a-obj.x10, b-obj.x20.

Two weeks after the removal of the stitches there were signs of necrosis in the lateral triangle neck area. The patient underwent a tissue necrectomy and the area in question epithelized in full after daily toilet and wound dressing. The patient underwent regular tests of blood, biochemistry and CD4 cells which were within the normal range. Three months after the start of therapy, the patient underwent tuberculostatic nuclear magnetic resonance (NMR) control, which showed a homogenous oval formation size 22x13 mm in the lateral triangle neck area, which extensively postcontrastly increased on the edges. The NMR control and examination of the patient showed regression of tuberculosis focus on the neck upon the performed surgical intervention and tuberculostatic therapy. The patient continued with regular control by an infectious disease specialist and maxillofacial surgeon and with a regular control of CD4 cells, tuberculostatic and antiretroviral therapy.

Discussion and Conclusion

Extrapulmonary manifestations of tuberculosis in the neck in the form of massive soft tissue conglomerate is a rare pathological entity. The initial diagnosis is difficult because of clinical manifestations that raise suspicion of other changes of genesis. According to the localization of change, its extensive expansion in relation to vital neck structures and the presence of HIV infection, we decided to go for extirpation biopsy and antiretroviral therapy with regular monitoring and maintenance of CD4 cell number. Tuberculostatic therapy was administered after histopathologoical findings by pulmonologists. The regression of tuberculosis processes of the neck shows the efficiency of the combined surgical and tuberculostatic therapy in the treatment of tuberculosis among HIV-positive patients without compromising the immune system.

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