A 6-year-old HIV-infected girl with neck mass (page 1/3)

Prepared by.... Thanyawee Puthanakit, M.D
Virat Sirisanthana, M.D.
Patient: A 6-year-old girl, Address: Lamphun province
CC : Left cervical mass for 4 weeks
Present Illness:
1 year PTA : She presented with thrombocytopenic purpura and wasting. Further investigations revealed that she was an HIV-infected child (CDC clinical category C). Prednisolone was prescribed for the thrombocytopenia which gradually subsided. Since then, she was put on co-trimoxazole for primary PCP prophylaxis.
6 wk PTA: Because of her immunological suppression (CD4 cell percentage was 4% and CD4 cell count was 97 cells/ mm3) and the high viral load (359,000 copies/ml or 5.56 log10), she was started on highly active antiretroviral therapy (GPOvirS-30, which is a combination of stavudine 30 mg + lamivudine 150 mg + nevirapine 200 mg). She was on half a tablet, orally every 12 hours.
4 wk PTA: After 2 weeks of GPOvirS-30 , she developed left cervical node lymphadenopathy 2x3 cms in diameter, firm consistency, mild tender (figure 1) with low grade fever. She was treated as bacterial infection with cloxacillin syrup for 2 weeks with no response. The mass gradually enlarged in size to 4x6 cm. in diameter (as in figure 2), and she developed daily moderate grade intermittent fever.
Figure 1
Figure 2

Physical examination:

 

GA: A girl, febrile, mild pale
V/S: BT (highest peak) 39.5 C (see temperature chart in figure 3), PR 130/min, BP 100/70 mmHg, RR 36/min, BW: 10.5 kg (< 3rd percentile) Ht: 88 cm (< 3rd percentile). Her weight curve has been passing 2 major percentile lines.
HEENT: mild pale conjuntivae, no icteric sclera, TMs: normal, no dental caries
Lt. supraclavicular node enlargement 4X 6 cms, firm, irregular surface, fix to underlying soft tissue and tender (fig 2)
Heart: regular rhythm, normal S1 S2, no murmur
Lungs: normal breath sound, no adventitious sound
Abdomen: soft liver 4 cm below RCM, spleen 3 cm below LCM
Ext: no skin lesions
Figure 3 Body temperature

What is your differential diagnosis?

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