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Journal List > Ulster Med J > v.75(2); May 2006

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Ulster Med J. 2006 May; 75(2): 160–161.
PMCID: PMC1891733
Copyright © The Ulster Medical Society, 2006
Atypical presentation of HIV in a pregnant patient
Ganapathy Dhanasekar, Specialist Registrar in Otolaryngology, Alisdair Robertson, Research Fellow in Otolaryngology, and Karl Nicholson, Professor of Infectious Diseases1
Department of Otolaryngology, Leicester Royal Infirmary, Leicester, UK
1Department of Infectious diseases, Leicester Royal Infirmary, Leicester, UK
Email: DhanasekarENT/at/aol.com
 
Editor,
We report a case of Kaposi's sarcoma (KS) of the epiglottis in a pregnant lady who presented with stridor. It is very rare for stridor caused by laryngeal KS to be the initial presentation of HIV infection in a pregnant patient that has not been previously reported.
Case Report
A 33-year-old, 13 weeks pregnant lady presented with shortness of breath and noisy breathing. She also had odynophagia, bilateral neck swelling, sore throat and night sweats for the past 3 days. She had a discharging ear and a chronic non-productive cough for 3-6 weeks. Distaclor, commenced initially, was discontinued when she was confirmed to be pregnant. She was on nystatin mouthwashes for her oral thrush. She was a non-smoker and took alcohol occasionally. There was no history of intravenous drug abuse or other risk factors for HIV infection.
On examination she was pyrexic, had inspiratory stridor, tachycardia and tachypnoea. Oral cavity and oropharynx examination revealed extensive candidiasis.
Flexible nasoendoscopy revealed a very large, oedematous and inflamed epiglottis with extensive white patches. The epiglottic swelling was so large that the vocal cords could not be visualized and only the posterior portion of the arytenoids was seen. Neck examination revealed bilateral cervical lymphadenopathy. Lateral soft tissue X-ray of the neck revealed an enlarged epiglottis and a normal trachea. Chest X-ray was clear. Full blood count showed WCC – 6.1×109/L, Hb – 13.2 g/dl and platelets – 215×109/L. Routine blood tests and viral serology was normal. Her CD4 count was 40/mm3.
A provisional diagnosis of severe fungal/bacterial epiglottitis was made. The treatment regime included high dose of intravenous fluconazole, cefuroxime, metronidazole and nystatin mouthwashes. An HIv test was positive which was again confirmed on retesting.
An ultrasound scan revealed an anembryonic and nonviable pregnancy. After discussion with the patient she had a medical evacuation of the pregnancy with mifepristone.
Anti-retroviral therapy and prophylaxis with co-trimoxazole, azithromycin and dapsone was commenced. Two weeks later on review with flexible nasoendoscopy, the epiglottis still appeared inflamed and grossly swollen. A CT scan of the neck and upper thorax showed a 4 cm swelling of the epiglottis extending down into the aryepigolttic folds and into the vestibule. Bilateral cervical lymphadenopathy was also noted on the CT (Fig 1Fig 1).
Fig 1
Fig 1
Fig 1
Axial CT scan of the neck showing the grossly enlarged and irregular epiglottis with bilateral cervical lymphadenopathy.
In view of her slow recovery, a microlaryngoscopy and biopsies of the epiglottis were performed to reach a firm diagnosis. The histopathology revealed necrotic inflammatory tissue with ulceration and dense proliferation of anastomosing vascular channels. A tentative diagnosis of KS was made. The specimen was sent to a tertiary referral centre for human herpes virus 8 (HHV8) staining which proved positive. The diagnosis was finally confirmed when the samples were sent to the national center of KS pathology.
Antiretroviral medical therapy, consisting of efavirenz and zidovudine, was commenced and the patient's symptoms regressed. Eight weeks after her initial presentation the larynx appeared normal, her viral load was undetectable and her CD4 count was raising.
DISCUSSION
The diagnosis was difficult as the patient had no risk factors for HIV infection. Extensive oropharyngeal candidiasis and the fungal appearance of the epiglottitis should alert the clinician to the likelihood of immunosuppression. In such cases a HIV test and an examination and biopsy under general anaesthetic is necessary for histological diagnosis.
This case is noteworthy in three aspects: first – KS of the epiglottis is itself very rare, second – the patient was pregnant, and third – KS with stridor is an atypical initial presentation of HIV infection. Clinicians should be aware of this rare condition as a cause of airway obstruction in the immunocompromised.
Notes
The authors have no conflict of interest.
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