Maintaining a high index of suspicion for such conditions facilitates prompt diagnosis and treatment, potentially improving clinical outcome. Lymphoma is one condition that defines a patient with HIV as having AIDS.3 Lymphomas frequently ( 95%) arise from B cells and are categorised as shown in box 1.4 A key difference between lymphomas associated with HIV and those in the general Rabbit Polyclonal to RPS2 population is that they are often more aggressive, with frequent spread to the bone marrow and extra-nodal tissues and organs. in the groin, neck or axilla would be strongly suspected of having an AIDS-defining illness, and the appropriate management would be commenced without delay. HAART has revolutionised the treatment of HIV in many ways. Typically consisting of two nucleoside reverse transcriptase inhibitors and either a non-nucleoside reverse transcriptase inhibitor (NNRTI), protease inhibitor or integrase inhibitor, combination therapy helps to minimise drug resistance, reduce viral burden and preserve immune system function. As a result, mortality from AIDS-defining illnesses, including opportunistic infections and AIDS-related malignancies, has decreased, with a corresponding increase in mortality from non-AIDS-defining illnesses such as colorectal and anal cancers, and hepatic, cardiovascular and pulmonary disease.1 2 In light of these advances, it is possible that this clinical suspicion for an AIDS-defining illness is not as high in the present day as it was prior to the era of antiretrovirals and HAART. This case report demonstrates that this suspicion for an AIDS-defining illness must remain high in patients who clinically and objectively demonstrate a good response to HAART. Moreover, it encourages clinicians to consider an AIDS-defining illness as the primary diagnosis in individuals on HAART who present with innocuous symptoms. This will minimise diagnostic delay and permit treatment to be initiated quickly. Case presentation A 30-year-old man attended the emergency department with a slowly expanding mass in the left groin. Five months prior to his presentation he had sought guidance from his primary care physicians, who felt it was a haematoma caused by a minor injury sustained at the gym. When the mass did Isochlorogenic acid C not resolve, another general practitioner referred him to the general surgical emergency support for evacuation of the suspected haematoma. The man was a fit, athletic individual with HIV who was otherwise well, with no constitutional symptoms such as weight loss, fevers or night sweats. He had been taking HAART for 9?months following a CD4 count that had fallen to 340?cells/mm3. On admission, his CD4 count was 560?cells/mm3 and his viral load was undetectable, indicating that HAART was producing a good biological response. On clinical examination, the mass measured 1510?cm. It was tender and firm with induration of the overlying skin. The left leg and thigh was enlarged with non-pitting oedema and suggested lymphoedema. Chest and abdominal examination, including digital rectal examination, was unremarkable. Investigations On admission, the serum lactate dehydrogenase (LDH) was elevated; all other routine blood haematological and biochemical analysis was unremarkable (Table 1). A CT scan revealed an isolated, irregular mass in the left groin, measuring 1411?cm, with associated fat stranding and invasion of the adjacent musculature (physique 1). The mass also encased the femoral vessels and a Doppler ultrasound confirmed thrombosis of the common femoral and long saphenous veins. The CT scan of the chest, abdomen and pelvis was otherwise unremarkable. MRI showed the mass to be multi-septate, made up of patchy areas of enhancement with an avid rim (physique 2). Table?1 Blood test results on admission, with laboratory reference ranges indicated in brackets deletion. Similarly, there were no apparent rearrangements of Isochlorogenic acid C or em IGH/BCL2 /em . The detailed histological assessment favoured a diagnosis of Burkitt’s lymphoma. A positron emission tomogram indicated the groin mass to be intensely fluorodeoxyglucose (FDG)-avid, with diffuse subcutaneous extension in the left thigh (physique 3). FDG-avid lymph nodes were present adjacent to the mass, in the left external iliac chain Isochlorogenic acid C and bilaterally in the axillary and deep upper cervical regions (not detectable clinically). Open in a separate window Physique?3 Positron emission tomogram demonstrating fluorodeoxyglucose uptake. Treatment The time from admission to formal diagnosis was 12?days. The patient was referred to the appropriate specialist team and commenced on chemotherapy. Outcome and follow-up The patient had a complete metabolic response to the chemotherapy. At 8?months follow-up, he remains in clinical and radiological remission and continues with his usual activities of daily living. Discussion This case report reiterates the importance of suspecting an AIDS-defining illness in patients on HAART who are otherwise clinically well, with preserved CD4 counts and undetectable viral loads. Maintaining a high index of suspicion for such conditions facilitates prompt diagnosis and treatment, potentially improving clinical outcome. Lymphoma is usually one condition that defines.