Cytomegalovirus infection of the larynx in the acquired immunodeficiency syndrome

Severe acquired subglottic stenosis in neonatal intensive care graduates: a case-control study

OBJECTIVE

To analyse current incidence and risk factors associated with severe acquired subglottic stenosis (SASGS) requiring surgical intervention in neonates.

DESIGN

Retrospective case-control study.

SETTING

Sole tertiary children's hospital.

PARTICIPANTS

Patients who underwent surgical intervention for SASGS from January 2006 to December 2014. For each neonatal intensive care unit (NICU) graduate with acquired SASGS, two controls were selected (matched for gestation and year of birth).

MAIN OUTCOMES AND MEASURES

Incidences were calculated and cases and controls compared using conditional logistic regression analysis to identify risk factors for SASGS.

RESULTS

Thirty-seven NICU graduates required surgical intervention for SASGS of whom 35 were <30-week gestation at birth. The incidence of SASGS in surviving children who had required ventilation in the neonatal period was 27/2913 (0.93%). Incidence was higher in infants <28-week gestation (24/623=3.8%) compared with infants ≥28-week gestation (3/2290=0.13%; p=0.0001). On univariate analysis, risk factors for SASGS were: higher number of intubations (4 vs 2; p<0.001); longer duration ventilation (16 vs 9.5 days; p<0.001); unplanned extubation (45.7% vs 20.0%; p=0.007); traumatic intubation (34.3% vs 7.1%; p=0.003) and oversized endotracheal tubes (ETTs) (74.3% vs 42.9%; p=0.001). On multivariate analysis, risk factors for SASGS were: Sherman ratio >0.1 (adjusted OR (aOR) 6.40; 95% CI 1.65 to 24.77); more than five previous intubations (aOR 3.74; 95% CI 1.15 to 12.19); traumatic intubation (aOR 3.37; 95% CI 1.01 to 11.26).

CONCLUSIONS

SASGS is a serious consequence of intubation for mechanical ventilation in NICU graduates, especially in preterm infants. Minimising trauma during intubations, avoiding recurrent extubation/reintubations and using appropriate sized ETTs may help prevent this serious complication.

Impact of the Acquired Immunodeficiency Syndrome Epidemic on the Practice of Laryngology

In only 10 years, the acquired immunodeficiency syndrome epidemic has already had an enormous impact on many aspects of the practice of medicine. The practice of laryngology typifies the changes that have occurred. Heightened clinical vigilance has been required as the laryngologist encounters new and unusual manifestations of the disease and must take more extensive histories regarding social, behavioral, and sexual practices than were previously necessary. The performance of physical examinations and surgical procedures has also changed as a result of experience with the lethal human immunodeficiency virus. Numerous legal, ethical, and social issues have also been raised by the epidemic and have had a major influence on how medicine is practiced and regulated. In this paper we review the laryngeal and pharyngeal manifestations of acquired immunodeficiency syndrome and discuss illustrative patient examples that demonstrate the impact of the disease. We also consider the diverse groups of issues that attend this epidemic and that continue to modify practice patterns.

Cytomegalovirus causing necrotizing laryngitis in a renal and cardiac transplant recipient

BACKGROUND

Cytomegalovirus (CMV) infection is a common opportunistic pathogen in transplant recipients; however, cytomegaloviral laryngitis is extremely rare.

METHODS

We present a case of disseminated CMV infection and ulcerating necrotizing laryngitis situated in the subglottis of an immunocompromised patient with a renal and cardiac transplant. The patient was initially seen with discomfort in the throat.

RESULTS

Physical examination of the head and neck, fiberoptic laryngoscopy, and CT scan of the larynx were normal. Histopathology of a laryngeal ulcer in the subglottic region showed intranuclear and intracytoplasmic bodies. Immunoperoxidase stain and in situ hybridization studies were positive for CMV.

CONCLUSIONS

In immunosuppressed patients with persistent throat symptoms, the systematic exploration of larynx and bronchus is necessary to rule out the presence of opportunistic infections.

Herpes simplex chronic laryngitis and vocal cord lesions in a patient with acquired immunodeficiency syndrome

Chronic laryngitis in patients with acquired immunodeficiency syndrome may be due to infections or tumors, such as Kaposi's sarcoma and non-Hodgkin's lymphoma. We present what we believe to be the first proven case of herpes simplex virus chronic laryngitis in a man positive for human immunodeficiency virus. Direct laryngoscopy showed leukoplakic lesions on both vocal cords. Biopsy of the lesions showed squamous epithelial cells with the characteristic features of herpes simplex virus, which was confirmed by immunohistochemical stains. We discuss the differential diagnosis of chronic laryngitis in a human immunodeficiency virus infection. Herpes simplex viral infection of the vocal cords should be considered in patients with acquired immunodeficiency syndrome presenting with chronic hoarseness and leukoplakic lesions on direct laryngoscopy, especially with no evidence of Kaposi's sarcoma, tumor, or cytomegaloviral or fungal infection elsewhere. Treatment should be acyclovir, except in the face of acyclovir resistance.