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EN4.46 | HIV Manifestations in ENT — SDL Guide (Part 3)
Self-Assessment: HIV Manifestations in ENT
The following scenarios test your ability to apply the pattern recognition and management principles from this module to clinical cases. These are drawn from the NMC competency EN4.46 (KH level) and are representative of the level of reasoning expected in final MBBS written examinations and clinical problem-solving assessments. Work through each scenario before checking your understanding against the body of the module.
The aim of this self-assessment is not simply to recall isolated facts, but to synthesise findings — a group of clinical signs that, taken together, form a coherent clinical picture. This synthesis skill is what distinguishes a competent clinician from one who treats each finding in isolation. HIV ENT disease is an area where pattern recognition is particularly high-yield because multiple manifestations often co-exist and point to a common underlying cause.
Scenario 1: A 34-year-old man who has not previously been tested for HIV presents with white removable plaques on the tongue, two violaceous lesions on the hard palate, bilateral soft parotid swellings, and multiple non-tender cervical lymph nodes. (a) What three HIV-related ENT diagnoses are present? (b) What investigation do you order next?
Scenario 2: A 45-year-old HIV-positive woman on ART with a CD4 count of 310 presents with right-sided chronic sinusitis not responding to three courses of antibiotics. CT shows right maxillary sinus opacity with areas of calcification and no bone destruction. (a) What pathogen class does the CT calcification suggest? (b) How does management differ from bacterial sinusitis?
Scenario 3: A 29-year-old HIV-positive man presents with hoarseness and mild inspiratory stridor over three weeks. His CD4 count is 60 cells/μL. Flexible nasolaryngoscopy shows purple nodular lesions on both true vocal folds and the epiglottis. What is the diagnosis, and what is the ENT surgeon's immediate priority?
SELF-CHECK
An HIV-positive patient with a CD4 count of 60 cells/μL develops bilateral cervical lymphadenopathy with a rapidly enlarging right-sided neck mass over 3 weeks. FNAC shows large B-lymphocyte cells with immunoblastic morphology. The diagnosis and appropriate management are:
A. Reactive lymphadenopathy; observe and repeat examination in 4 weeks
B. Tuberculosis lymphadenitis; start four-drug anti-tubercular therapy
C. AIDS-related Non-Hodgkin lymphoma (B-cell type); refer to haematology-oncology for systemic chemotherapy (R-CHOP)
D. Kaposi's sarcoma of lymph nodes; start intralesional vinblastine injections
Reveal Answer
Answer: C. AIDS-related Non-Hodgkin lymphoma (B-cell type); refer to haematology-oncology for systemic chemotherapy (R-CHOP)
Rapidly enlarging B-cell lymphoma on FNAC in an HIV-positive patient with a very low CD4 count (60 cells/μL) is AIDS-related Non-Hodgkin lymphoma (NHL) — the commonest lymphoma in HIV, caused by uncontrolled EBV-driven B-cell proliferation in the setting of severe immunosuppression. It is an AIDS-defining malignancy. Management requires systemic chemotherapy — R-CHOP (rituximab + CHOP) is the standard regimen — and ART is continued alongside it. Reactive lymphadenopathy does not produce large immunoblastic B-cells on FNAC and would not be appropriate to observe with a 3-week rapidly growing mass. TB lymphadenitis on FNAC shows caseating granulomas with epithelioid histiocytes and Langhans giant cells, not large B-cells. KS on FNAC shows spindle cells with slit-like vascular spaces, and KS lesions are treated with intralesional chemotherapy or systemic agents — not R-CHOP.