A 14 year-old boy, who has history of multiple transfusions during neo-natal period, was referred to my outpatient department from a corporate hospital with all investigation reports for the management of HIV in August 2013.
The boy reported to the hospital with complaints of pain over right thigh since1-week in July 2013. After seeing multiple osteolytic lesions in the bones during investigations, he was referred to a higher center by the local orthopedic surgeon.
On examination, the boy was well nourished and appeared healthy. Multiple enlarged lymph nodes and scars of Herpes Zoster over right costal area and scars of Chicken pox over abdomen, chest and back were found. He gave a history of steroid inhalation since his childhood (for more than 12 years) as he was an asthmatic since childhood. However, during examination, the respiratory system had no abnormal findings.
Computed tomography of the whole body revealed osteolytic lesions on skull, mandible, right scapula, head of both humeri, L1 and L4 Vertebrae, 5th and 10th ribs, both acetabulum and ala of sacrum and enlargement of cervical, axillary, mesenteric, iliac and inguinal nodes (Figures 1 and 2). Magnetic resonance imaging of pelvis revealed multiple osteolytic lesions over both acetabulum and a larger one over the ala of Sacrum. Enhancing hyperintense bone marrow lesions of iliac bones, right acetabulum and lumbar vertebral bodies were noticed along with enlarged para-aortic, iliac and inguinal lymph nodes [Figure 3].
HIV ELISA was positive. HIV Viral load was 141,700 copies/ml. His CD4 count was 226 cells/mm. TB PCR was negative. Both parents were nonreactive for HIV and appeared healthy.
Biopsy of lymph nodes revealed reactive lymphadenitis, and there was no evidence of lymphoma or any other malignancy. Trephine biopsy of bone marrow and biopsy from sacral ala also revealed no evidence of malignancy.
The boy was put on antiretroviral therapy (ART) (ZDV + 3TC + EFV) since August 2013 and he is doing well. Osteolytic changes improved with ART [Figure 4]. On March 2014, his viral load was reduced to undetectable level and his CD4 Count was 518 cells/cubic mm. He also gained 4 kg in 5 months.