A 46-year-old man, HIV positive for 8 years, presented to the emergency department (ED) with increasing left-sided neck pain and swelling during the past 2 months. The patient denied any other symptoms. In the ED, his vital signs were normal. Physical examination result was notable for a 3-cm, firm, nontender, mobile mass on the superior lateral aspect of the left side of the neck (Figure 1). Bedside ultrasonography was initially performed to determine the cause of the mass (Figure 2). Computed tomography (CT) with intravenous contrast and fine-needle aspiration was then performed to confirm this finding (Figure 3).
Figure 3. CT of neck with intravenous contrast; left-sided lymphadenopathy. Used with permission of Brita E. Zaia, MD, Alameda County Medical Center, Highland General Hospital, Oakland, CA.
Diagnosis
Neck lymphadenopathy
The differential diagnosis for head and neck lymphadenopathy in HIV-positive adults is broad and includes primary head and neck malignancy, lymphoma, Kaposi's sarcoma, and infectious causes such as abscess, primary HIV infection, infectious mononucleosis caused by Epstein-Barr virus, cytomegalovirus infection, toxoplasmosis, and tuberculosis.1 In this case, bedside ultrasonography was used initially to help determine the cause of the neck mass. On ultrasonography, lymph nodes appear hypoechoic, with high vascular signal on color Doppler, which was observed in this patient (Figure 2).2, 3 In contrast, abscess cavities and cysts lack the presence of vascularity and color flow.3 The CT scan of the neck confirmed multiple enlarged lymph nodes in the left side of the neck, and fine-needle aspiration performed in the ED was highly suggestive of Hodgkin's lymphoma. Treatment for Hodgkin's lymphoma in HIV-positive patients includes chemotherapy and antiretroviral therapy. Overall survival rates are well below that of non-HIV-associated Hodgkin's lymphoma.4
References
1. 1Shores CG. Infections and disorders of the neck and upper airway. In: Tintinalli JE, Kelen GD, Stapczynski JS, et al. editor. Emergency Medicine: A Comprehensive Study Guide. 6th ed.. New York, NY: McGraw-Hill; 2004;p. 1498–1499.
2. 2Fox JC, McDonough J. Lower extremity venous studies. In: Cosby K, Kendall J editor. Practical Guide to Emergency Ultrasound. Philadelphia, PA: Lippincott Williams & Wilkins; 2006;p. 264.
3. 3Frazee BW, White DAE. Soft tissue. In: Cosby K, Kendall J editor. Practical Guide to Emergency Ultrasound. Philadelphia, PA: Lippincott Williams & Wilkins; 2006;p. 331–335.
4. 4Pletcher SD, Goldberg AN. Head and neck manifestations of human immunodeficiency virus infection. In: Cummings CW editors. Otolaryngology: Head and Neck Surgery. 4th ed.. Philadelphia, PA: Mosby, Inc; 2005;.
Alameda County Medical Center, Highland General Hospital, Oakland, CA
For the diagnosis and teaching points, see page 146.
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