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Revista Española de Cirugía Oral y Maxilofacial

On-line version ISSN 2173-9161Print version ISSN 1130-0558

Rev Esp Cirug Oral y Maxilofac vol.31 n.3 Barcelona May./Jun. 2009

 

PÁGINA DEL RESIDENTE

 

What would your diagnosis be?

¿Cuál es su diagnóstico?

 

 

Woman age 44 that goes to an Oral and Maxillofacial consult through her family doctor. In the region that corresponds to the end of the parotid tubercle we find it in bilateral form, of elastic consistency, unattached at adjacent surfaces, asymptomatic and 3 months developed. Among the preexisting conditions we would like to highlight that the patient is HIV positive. In the cervico-facial CT we observed lesions that looked like cysts in both parotid glands (Figs. 1-4).


Lesion of benign lymphoepithileal cyst of the parotid gland in a patient infected with HIV

Lesión linfoepitelial quística benigna de glándula parótida en paciente con infección por VIH

 

 

C. Moreno García1, M.A. Pons García2, R. González García2, L. Ruiz Laza2, F. Monje Gil3

1 Médico Residente.
2 Médico Adjunto.
3 Jefe de Servicio.
Servicio de Cirugía Oral y Maxilofacial. Hospital Infanta Cristina. Complejo Hospitalario Universitario de Badajoz. España.

Correspondence

 

 


 

Introduction

Lesion of Benign Lymphoepithelial Cyst (LBLC) is an uncommon condition that affects the salivary glands, mainly the parotid gland, and has been associated with HIV infection.

From a clinical perspective, regarding parotid and cervical, they form because of the presence of an unpainful elastic tubercle growing progressively and associated with the cervical adenopathy. The LBLC is something to take into account during the differential diagnosis of cervical masses in patients infected with the HIV virus.

 

Discussion

HIV infection is associated with many entities that affect the salivary glands, for example lymphoma, Sjögren syndrome, Kaposi sarcoma and lesion of benign lymphoepithelial cyst.1-6 Before the 80's LBLC's of the parotid made up less than 3% of the benign tumors reported in this gland. Later and due to the increased incidence of HIV infection the number of such cases increased.1,2

LBLC of the salivary glands affects the parotid more frequently than the sub maxillas6-8. Histologically the lesion is made up of one or various cysts filled with a clear gelatinlike liquid, covered by a scaly metaplastic epithelium or columnar, and surrounded by an infiltrated lymphoid that has myoepithelial islet cells. The lymphoid component has the same characteristics as those seen in the adenopathys of the less advanced HIV infection, that is to say hyperplasia or follicle fragmentation with enlarged germinating centers.

The etiology of the LBLC is unknown; indicators of active replication of HIV-1 like the p24 protein or viral RNA, in the sinus of reticular dendrictic cells of lymphoid follicles. Their histology is similar to that of the adenopathys of persistent poly adenopathic syndrome. As a result of this knowledge it occurred to some authors that these lesions are caused by HIV9. Another etiopathogenic hypothesis is based on the fact that the parotid capsule would remain lumped together in various lymphatic ganglion nodes with parts of acinic glands on the inside. The hyperplasia reactivates the lymphatic tissue, secondary to the HIV infection, obstructing the excretion duct of the remaining glands, allowing for cystic retention.

The usual appearance consists of a slow growing unpainful cervical tubercle, without signs of inflammation, with bilateral symmetry. It usually occurs in patients with persistent polyadenopathic syndrome, with a slight or fair decrease in CD4 lymphocytes and a relative increase in CD8 cells in the blood.6-9,13,16-8,23,25

Within the complimentary studies when performing the CT, MRI and ecograph we find multiple bilateral parotid cysts associated with cervical adenopathys. According to different doctors the CT and MRI images of HIV patients are patognomonical and don't need more complimentary studies. In any case we could finish the diagnosis using FNAB.

Clinical manifestations usually respond to treatment with anti-retrovirals.11,19 Many cases have been described where LBLC was treated with Zidovudine, although it wasn't done constantly.7 In the absence of an answer if the patients reports local discomfort r esthetic motives periodic percutaneous drainage is the suggested treatment of these cysts. Another option is surgical abscission (normally using superficial parotidectomy).

Treatment using low doses of radiotherapy adds morbidity to the benign pathology especially in pediatric cases. The results with this treatment have been partial.22 As a minimally invasive treatment sclerotherapy with doxycycline has been suggested, but the series that were carried out are small and long term follow up with these patients is necessary in order to compare results.21

 

Conclusions

The LBLC is a topic that should be taken into account when diagnosing cervical masses found in HIV patients. This lesion's benignancy allows us to treat it in a conservative manner especially in patients with advanced immunodepression.

 

 

Correspondence:
Carlos Moreno García
Hospital Infanta Cristina
Avenida de Elvas / Carretera de Portugal s/n
06080 Badajoz. España
Email: carlosmorenogar@gmail.com
Email: carlosmorenogarcia@wanadoo.es

 

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