HIV-associated parotid lymphoepithelial cysts

Navigating Parotid Lymphoepithelial Cysts in HIV Patients: A Tale of Two Distinct Scenarios

A rare occurrence in HIV-infected individuals is the development of diffuse infiltrative lymphocytic syndrome (DILS), which is marked by a widespread infiltration of CD8+ lymphocytes in body tissues, persistent elevation of CD8+ lymphocyte levels, as well as bilateral parotid swellings and cervical lymphadenopathy. It is distinct due to its suspected autoimmune origin and is found in about 5-10% of people living with HIV. This retrospective analysis involves two patients admitted to our tertiary care rural hospital with complaints of bilateral parotid swellings, a provisional diagnosis of DILS associated with HIV-positive status and lymphoepithelial cysts, their subsequent management, including conservative treatment and surgical excision of one of our patients. Our goal is to contribute to and advance the knowledge of this rare condition.

Recurrent lymphoepithelial cysts after parotidectomy in an undiagnosed HIV-positive patient

A benign lymphoepithelial cyst (BLEC) is defined as a rare, benign lesion composed of single or multiple cysts found within salivary glands or the lateral cervical area. Increasing reports suggest an association between BLEC and human immunodeficiency virus (HIV), although its pathogenesis remains unclear. We report a 51-year-old male who presented with recurrent bilateral BLECs after initial parotidectomy of cyst. An HIV panel was then performed with a positive result. We review the surgical and medical managements of BLEC while also discussing further treatment recommendations. Clinicians should be aware that BLEC recurrence postparotidectomy may be the initial presenting symptom of HIV in a patient with no risk factors.

Human immunodeficiency virus and salivary gland pathology: an update

Salivary gland disease is a common manifestation of human immunodeficiency virus (HIV) infection, with a significant increase in prevalence over the last two decades. This review summarizes contemporary knowledge of non-neoplastic salivary gland disease in HIV infection. The aim is to update information on and bring attention to those lesions, which are almost exclusive to the salivary glands in the HIV setting. The associated conditions include xerostomia or salivary gland hypofunction; Sjögren syndrome-like illness; salivary gland enlargements, including benign lymphoepithelial cysts (cystic lymphoid hyperplasia); diffuse infiltrative CD8+ lymphocytosis syndrome; and mucous extravasation phenomena, especially ranula. Many of these conditions show considerable overlap, and thus, the term HIV-associated salivary gland disease is used to designate HIV infection with xerostomia or salivary gland hypofunction, enlargement of one or more of the major salivary glands, or both. These manifestations may be related to HIV infection, and therefore, prompt recognition is invaluable in the diagnosis and treatment of both the salivary gland disease and HIV infection.

HIV-associated salivary gland disease--clinical or imaging diagnosis?

OBJECTIVES

This work aimed at studying the salivary gland disease (SGD) as it relates to associated factors, such as persistent generalised lymphadenopathy (PGL), lymphocytic interstitial pneumonia (LIP), clinical and immunological features of AIDS, and salivary flow rate and pH, as well as at exploring the relationship between the clinical diagnosis and the imaging diagnosis by ultrasound (US) examination of the parotid glands.

METHODS

Information regarding the observation of parotid gland enlargement, PGL, LIP, and clinical and immunological features of AIDS was gathered from medical records, and a saliva sample for unstimulated salivary flow rate and pH measurement was collected from 142 children aged 3 through 10 years treated at the Department of Infectious Diseases of Joana de Gusmão Children's Hospital, Florianópolis, SC, Brazil. High-resolution ultrasonography was performed in 58 children. Pearson's chi-square test and t-test were used to evaluate the association between the variables.

RESULTS

A significant association was found between SGD and LIP. Ultrasound revealed a 50% higher incidence of SGD that was not reported in the patients' records.

CONCLUSION

US examination proved to be essential for the correct diagnosis and monitoring of the progression of HIV/SGD.

Benign lymphoepithelial cysts of parotid and submandibular glands in a HIV-positive patient

Patients with human immunodeficiency virus (HIV) infection have been reported to have parotid swellings of various types such as diffuse infiltrative lymphocytosis syndrome, parotitis, intraparotid lymphadenopathy, benign lymphoepithelial cyst (BLEC), as well as salivary gland neoplasms such as adenoid cystic carcinoma, Kaposi sarcoma and lymphoma. LECs in the parotid gland are uncommon benign entities with increased incidence associated with HIV infection. We are presenting a case of 28-year-old HIV-positive patient with BLECs in the parotid and submandibular glands.

HIV-associated salivary gland disease

The authors review the clinical presentation, diagnostic evaluation, and treatment modalities for salivary gland enlargement in an HIV-infected population. Because this can occasionally be the presenting clinical symptom of HIV infection, it is important for the oral/maxillofacial surgeon to diagnose and manage HIV salivary gland enlargement.

Effect of HAART on salivary gland function in the Women's Interagency HIV Study (WIHS)

OBJECTIVE

To determine the impact of highly active antiretroviral therapy (HAART) on salivary gland function in human immunodeficiency virus (HIV) positive women from the Women's Interagency HIV Study (WIHS).

DESIGN

Longitudinal cohort study.

SUBJECTS AND METHODS

A total of 668 HIV positive women from the WIHS cohort with an initial and at least one follow-up oral sub-study visit contributed 5358 visits. Salivary gland function was assessed based on a dry mouth questionnaire, whole unstimulated and stimulated salivary flow rates, salivary gland enlargement or tenderness and lack of saliva on palpation of the major salivary glands.

MAIN OUTCOME MEASURES

Changes in unstimulated and stimulated flow rates at any given visit from that of the immediate prior visit (continuous variables). The development of self-reported dry mouth (present/absent), enlargement or tenderness of salivary glands (present/absent), and absence of secretion on palpation of the salivary glands were binary outcomes (yes/no).

RESULTS

Protease Inhibitor (PI) based HAART was a significant risk factor for developing decreased unstimulated (P = 0.01) and stimulated (P = 0.0004) salivary flow rates as well as salivary gland enlargement (P = 0.006) as compared with non-PI based HAART.

CONCLUSIONS

PI-based HAART therapy is a significant risk factor for developing reduced salivary flow rates and salivary gland enlargement in HIV positive patients.

The Benign Lymphoepithelial Cyst and a Classification System for Lymphocytic Parotid Gland Enlargement in the Pediatric HIV Population

OBJECTIVES/HYPOTHESIS

The objectives of this study are to present a series of parotid gland benign lymphoepithelial cysts (BLEC) in HIV-positive children and to propose a three-tiered classification system for HIV-associated lymphocytic parotid gland enlargement.

STUDY DESIGN

The authors conducted a retrospective case series and literature review.

METHODS

The authors conducted a retrospective chart review of four pediatric patients with HIV-associated parotid gland BLEC who presented to a tertiary care university medical center.

RESULTS

Four pediatric HIV-positive patients (four girls; age range, 7-17 years [mean age, 12.8 years]) were diagnosed with parotid gland BLEC. Two patients presented with acute parotitis and the others presented with asymptomatic enlargement of the parotid glands. Three patients had bilateral parotid gland BLEC. The other patient demonstrated persistent generalized lymphadenopathy (PGL) of the intraparotid and cervical lymph nodes and early BLEC limited to the left parotid gland. One patient also displayed parotid gland microcalcifications and cystic changes in the adenoids, neither of which have been described previously in the setting of HIV-associated BLEC. Computed tomography was performed on all patients, and one patient underwent fine needle aspiration to confirm the diagnosis. All patients opted for observation and antiretroviral medication therapy as long-term treatment. Based on these findings and a review of the literature, we propose a three-tiered classification system for lymphocytic parotid gland enlargement in the HIV population: 1) PGL, 2) benign lymphoepithelial lesions (BLEL), and 3) BLEC.

CONCLUSIONS

This series equals the largest pediatric series of HIV-associated parotid gland BLEC in the English literature. One patient in our series also demonstrated PGL; there were no cases of BLEL. A classification system based on morphology is proposed to help resolve the confusion in terminology used to describe this entity. Most pediatric HIV-infected patients with parotid gland BLEC can be treated with observation and antiretroviral medication therapy. For others, who are symptomatic or more concerned about their cosmetic appearance, sclerotherapy may offer a reasonable option. Radiation therapy and surgery should be reserved for select cases.

Bilateral parotid voluminous masses: a case report

The case of a 75-year-old woman with voluminous bilateral symmetrical masses of the parotid glands is reported, and the literature relevant to the differential diagnosis in bilateral neoplastic and nonneoplastic parotid masses is reviewed. The presurgical workup was based on clinical evaluations, nuclear magnetic resonance imaging findings, and cytologic examination to obtain the differential diagnosis. Benign or malignant tumors were excluded. Surgery was performed for esthetic reasons and in consideration of progressive enlargement of lesions. Histopathologic examination of resected masses revealed benign lymphoepithelial cysts with polyclonal infiltration of lymphoid cells. Serological testing for tuberculosis, cytomegalovirus, human immunodeficiency virus, and Epstein-Barr virus (EBV) and testing using the in situ hybridization technique for the presence of cytomegalovirus and EBV were negative for productive infection or viral replication. A diagnosis of retention cysts was suspected on the basis of presurgical evaluation, histopathological examination, and serologic analysis. In this case, bilateral obstruction of the parotid ducts by a mobile denture probably played the main role in the pathogenesis and development of bilateral parotid retention cysts, because any other specific cause for the pathogenesis was not found with diagnostic tools.

Histopathological analysis and demonstration of EBV and HIV p-24 antigen but not CMV expression in labial minor salivary glands of HIV patients affected by diffuse infiltrative lymphocytosis syndrome

BACKGROUND

The diffuse infiltrative lymphocytosis syndrome (DILS) in HIV patients is characterized by the persistence of CD8-circulating lymphocytes and lymphocytic infiltration, predominantly in salivary glands.

METHODS

We examined seven HIV-positive patients with bilateral parotid enlargement and sicca symptoms. Minor labial salivary gland biopsies were performed in all patients and submitted for histopathological analysis and immunohistochemistry for CD4, CD8, cytomegalovirus (CMV), LMP-EBV protein, and HIV p-24 protein.

RESULTS

In all cases, lymphocytic infiltration of the minor salivary glands, mainly periductal, was found. Acinar atrophy, ductal ectasia, and mild to moderate fibrosis were also observed. We noticed strong immunohistochemical reaction for LMP-EBV and p-24 proteins in ductal cells in all cases, while staining for CMV was consistently negative. The lymphocytes were positive for CD8, but consistently negative for CD4.

CONCLUSIONS

A role of Epstein-Barr virus (EBV) and HIV, but not CMV, in the pathogenesis of DILS, is suggested by our immunohistochemical findings.

Parotid gland involvement in advanced AIDS

OBJECTIVE

This study describes the involvement and the histological alterations found in the parotid glands of 100 patients who died with AIDS.

MATERIALS AND METHODS

Sex, age, CD4 cell count and clinical history were obtained from the files of 100 patients who died with AIDS. Histological analysis of the parotid glands was performed using H&E, Gomori-Grocott, Ziehl-Neelsen and Mucicarmine. Histological findings were grouped in reactive, infectious, cystic, neoplastic and concomitant lesions.

RESULTS

None of the patients presented complaints or symptoms related to salivary gland alterations prior to death. The mean age of the patients and CD4 cell count were 36.4 years and 76.07 cells microliter-1, respectively. Histological alterations of the parotid glands were found in 51% of the patients. The most common alteration was non-specific chronic sialadenitis (29 cases), followed by infectious conditions (22 cases). Mycobacteriosis was the most common infectious disease (10 cases), followed by cytomegalovirus (nine cases), cryptococcosis (three cases) and histoplasmosis (two cases). Lymphoepithelial cysts occurred in six cases, Warthin's tumor and non-Hodgkin Lymphoma in one case each.

CONCLUSIONS

These results indicate that infection and other lesions in the parotid glands are more frequent than hitherto described in the specialized literature in AIDS patients. Clinicians should consider parotid gland involvement, when evaluating disease extension in advanced AIDS patients.

Pondering parotid masses

A49-year-old, human immunodeficiency virus (HIV)- infected, Haitian-born woman presented with a left facial mass that she had noticed for the previous eight weeks. She was known to have been HIV-seropositive for the previous 11 years and had been on multiple antiretroviral therapies. Her past medical history was also significant for hypertension, disseminated varicella zoster virus and recurrent oral and buttock Herpes simplex episodes. She was taking the following medications at the time of her presentation with the facial mass: stavudine, lamivudine, didanosine, nelfinavir mesylate, famciclovir, hydrochlorothiazide and cotrimoxazole. She had no complaints of fever, chills, sweats, weight loss or anorexia. She denied any pain, redness or warmth at the site of the facial swelling. Her most recent CD4 lymphocyte count was 336 cells/µL, with an HIV viral load of log102.6 copies/mL. Physical examination revealed a 4 cm fluid-filled mass in the left parotid gland. There was no detectable induration, redness, warmth or tenderness, and no associated adenopathy. The rest of the examination was unremarkable. An aspirate of the mass was performed under sterile conditions and yielded 30 mL of turbid, yellow liquid. A Gram stain revealed no neutrophils, scant mononuclear cells and no visible organisms. An acid-fast stain was negative as well. Routine, mycobacterial and fungal cultures showed no growth. Cytological analysis showed scant reactive lymphocytes and no malignant cells. The patient was not given therapy and was observed for another two months. The fluid reaccumulated in the left parotid gland, and the patient?s only complaint concerned the unsightly appearance of the mass. The lesion was again aspirated for 30 mL of fluid and this time, the fluid had a turbid, brown appearance. All laboratory results were identical to the results from the first aspirate. What is your diagnosis, and how would you treat this patient?