A 35-year-old male presented to us with acute increase in bilateral neck swelling since 5-6 days, neck pain, fever, and weight loss.
Patient had first noticed the swelling 2 months ago. It started as multiple neck swellings which were initially small. He did not take any treatment for it. Later on he was admitted for altered sensorium. His serology for HIV was positive andfine needle aspiration cytology of swelling was suggestive of tuberculosis. CD4 count was 48 cells/mm. Magnetic resonance imaging of brain was normal. He was given category 1(2HREZ+4HR) under RNTCP and Anti Retroviral antiretroviral therapy (3TC+d4T+EFV), with septran and fluconazole for prophylaxis against pneumocystis carinii and fungal infections. He improved symptomatically after the drugs were started, even though there was no appreciable change in the number and size of swelling.
After about 2 months of treatment there was acute aggravation of complaints for which the patient presented to us. There was a history of increase in size of swelling during the past 1 week. On examination of the neck swellings, there were multiple, discrete, firm, mobile, tender, nonwarm, nonreducible, nonpulsatile swellings on both sides of the neck involving all lymph node groups [Figure 1, 2]. The swellings were of different sizes ranging from 2 to 12 cm in maximum dimension. There was no enlargement of any other lymph node groups in the body. Ultrasonography of the neck revealed multiple bilateral enlarged conglomerated nodes in levels 2, 3, 4, and 5. Chest X ray was normal. Sputum examinations of two morning samples were negative for acid fast bacilli. CD4 count was 100 cells per cubic millimeter of blood.
At this stage considering the fact that in spite of treatment with ATT+ART, the patient had presented with increase in size of neck swelling, we were considering a differential diagnosis of infection with drug-resistant bacilli, infection by MOTT, and IRD.
Tablet prednisolone 25 mg once daily was added to his treatment and it was tapered over a period of 3 weeks. The swelling gradually became soft; skin over swelling became tense and red. About 100 cc pus was aspirated from neck swelling and sent for mycobacterial culture and sensitivity. AFB culture report (BACTEC/L-J) was suggestive of M. avium complex (MAC) on the basis of NAP (rho-nitro-alpha-acetyl amino-beta-hydroxy-propiophenone) and morphology. AFB culture and sensitivity report showed sensitive to all first line drugs. The patient had a diagnosis of AIDS, he was on antiretroviral therapy with increase in CD4 count and worsening of preexisting disease; hence, the diagnosis was IRD.
Along with category-1 ATT and ART, azithromycin and ciprofloxacin were added for MOTT. Patient was kept on fortnightly follow-up. At the time of sending this publication the patient had completed 4 months of treatment and the patient is symptomatically better with marked reduction in size of the swelling [Figure 3].