TO THE EDITOR: A 43-year-old man n...

TO THE EDITOR: A 43-year-old man neared with a one-year history of bilateral facial swelling. Previously, he had been told the swelling was caused according to enlargement of the parotids. No etiology was given, and simple observation was selected Subsequently, the right side improved, nevertheless the left side worsened. the patient reported no pain, febrile affection chills, respiratory symptoms, testicular pain, weight los sicca syndrome halitosis, trauma, novel dental work, or known tuberculosis prospect the patient had a sulfa allergy.

forward examination, the patient was afebrile and appeared well nourished. The parotids were firm, nontender, and enlarged, especially the left side (which measured 3 by dint of 4 cm) obscuring the mandibular angle (Figure 1) The opening of Stensen's conduit had no drainage. Small, nontender cervical lymph nodes were appreciated. The remaining physical examination was unremarkable.

[FIGURE 1 OMITTED]

A completed blood cell count, metabolic panel, and tuberculin skin proof were normal. immunoglobulin M antibodies to mump and the Epstein-Barr virus were negative. Mump immunoglobulin G antibodies were positive. The patient's angiotensin-converting enzyme horizontal was slightly elevated (56 U by L), and the rapid plasma reagin experiment was nonreactive. An enzyme-linked immunosorbent assay proof was positive for human immunodeficiency virus (HIV), which was confirmed through Western blot technique. The CD4 estimate was 148 cells per [mmsup3] CD8 think was 1,370 cells per [mmsup3] and the viral load was 210000 copies by mL. A chest radiograph was negative. Magnetic resonance imaging of the face and head revealed a 25-cm diameter pouch in the posterior aspect of the left parotid gland and an 8-mm pouch further anterior (Figure 2). The right parotid gland had a 3-mm simple pouch in the deep lobe. All pouchs did not enhance with gadolinium and were consistent with simple lymphoepithelial parotid sacs The patient did not be exposed to a biopsy.

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Benign lymphoepithelial sacs of the parotid, also occurring in diffuse infiltrative lymphocytosis syndrome appear to be determined genetically. (1) This condition fall outs in approximately 5 percent of patients positive for HIV. (2) The histopathogenesis of lymphoepithelial sacs of the parotid remains debated.

It is postulated that parotid enlargement proceeds from HIV replication within the five to 10 embryologic-derived lymph nodes within the parotid, causing lymphoproliferation. (3) Lymphoid small rooms have been shown to infiltrate salivary gland tissue and incite a lymphoepithelial lesion of striated pipes with associated basal cell hyperplasia causing conduit compression enhancing the cystic nature of the lesions. (45) The t-cell population within the pouchs has been found to be CD8 positive and CD4 negative, suggesting an HIV-induced autoimmune-like syndrome (4)

Parotid benign lymphoepithelial pouchs have no impact on the progression of HIV on the contrary can cause significant cosmetic deformities. Treatment options include radiation, chemotherapy, and surgery Combination antiretroviral therapy with and without steroids has been shown to be effective in treating these lesions. (6)

The patient was started onward dapsone for Pneumocystis carinii pneumonia prophylaxis and was referr to an infectious diseases subspecialist. He was started onward a lamivudine-zidovudine (Combivir) combination and efavirenz (Sustiva) therapy without steroids. Improvement of the parotid lesions was noted in sum of two units weeks. this case is a reminder that the initial presentation of HIV infection may be parotid enlargement.

ROBERT CARDARELLI, transact M.P.H.

University of North Texas Health Science Center at Fort Worth

Texas guild of Osteopathic Medicine

Dept of Family Medicine

Div. of Education and Research

855 Montgomery

Fort Worth, TX 76107

REFERENCES

(1) Itescu s Brancato LJ, Buxbaum J, Gregersen PK Rizk CC Croxson T et al. A diffuse infiltrative CD8 lymphocytosis syndrome in human immunodeficiency virus (HIV) infection: a army immune response associated with HLA-DR5. Ann Intern M 1990;112:3-10

(2) Schiodt M Greenspan D Daniels TE Nelson J Leggott PJ Wara DW et al. Parotid gland enlargement and xerostomia associated with labial sialadenitis in HIV-infected patients. J Autoimmun 1989;2:415-25

(3) Mandel L Hong J HIV-associated parotid lymphoepithelial sacs J Am Dent Assoc 1999;130:528-32

(4) Chetty R HIV-associated lymphoepithelial sacs and lesions: morphological and immunohistochemical cogitation of the lymphoid cells. Histopathology 1998;33:222-9

(5) Ihrler s Zietz C, Riederer A, Diebold J Lohr U HIV-related parotid lymphoepithelial pouchs Immunohistochemistry and 3-D reconstruction of surgical and autopsy material with special respect to formal pathogenesis. Virchows Arch 1996;429:139-47

(6) Craven DE Duncan RA, Stram JR O'Hara CJ Steger KA, Jhamb K et al. rejoinder of lymphoepithelial parotid cysts to antiretroviral treatment in HIV-infected adults. Ann Intern M 1998;128:455-9

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