Correspondence

HIV Infection Masquerading as Monoclonal Gammopathy of Unknown Significance

N Engl J Med 2003; 349:2362-2363December 11, 2003

Article

To the Editor:

Lu et al. (Sept. 18 issue)1 report human immunodeficiency virus (HIV) infection presenting as monoclonal gammopathy of undetermined significance (MGUS) in a 46-year-old man and argue that young patients with MGUS should be screened for HIV infection. We believe that undue emphasis was placed on the presence of MGUS in this patient. Critically, the history of invasive, recurrent pneumococcal infection, a well-established clinical feature of HIV infection, should have sufficed to alert the clinicians to the possibility of HIV infection.2 Furthermore, it would have been interesting to know his lymphocyte count during convalescence, since patients with recurrent pneumococcal infection and HIV have low CD4 T-cell counts at presentation.2

Although a spectrum of immunoglobulin abnormalities, ranging from polyclonal hypergammaglobulinemia to MGUS, are well recognized in HIV infection, we do not believe that this case report constitutes sufficient evidence to warrant screening all young patients with MGUS for HIV infection. We would contend that this case highlights the importance of screening young patients with recurrent pneumococcal infection for HIV infection, rather than screening young patients with MGUS for HIV infection.

Aamir Aslam, M.R.C.P.
Siraj A. Misbah, F.R.C.P., F.R.C.Path.
John Radcliffe Hospital, Oxford OX3 9DU, United Kingdom

2 References

1
Lu CM, Dezube BJ, Pantanowitz L. HIV infection masquerading as monoclonal gammopathy of undetermined significance. N Engl J Med 2003;349:1192-1193
Full Text | Web of Science | Medline

2
Turett GS, Blum S, Telzak EE. Recurrent pneumococcal bacteremia: risk factors and outcomes. Arch Intern Med 2001;161:2141-2144
CrossRef | Web of Science | Medline

Author/Editor Response

We wholeheartedly agree with Drs. Aslam and Misbah that young patients with recurrent pneumococcal infection should be screened for HIV infection. However, their recommendation does not negate our recommendation that young people with MGUS also be screened for HIV infection, particularly those at increased risk for HIV infection. Indeed, had our patient been tested for HIV infection when his initial MGUS was detected, his recurrent pneumococcal infections might have been avoided. Therefore, we do not believe that undue emphasis was placed on his MGUS. In fact, the emerging literature appears to support our initial proposal to consider HIV infection as a cause of MGUS in young patients.1 The only CD4 cell count obtained in this young man's case (9 per cubic millimeter) was on his final admission to the hospital. Before that, a CD4 cell count was not ordered because a diagnosis of HIV infection was not entertained.

Liron Pantanowitz, M.D.
Chuanyi M. Lu, M.D.
Bruce J. Dezube, M.D.
Beth Israel Deaconess Medical Center, Boston, MA 02215
lpantano@bidmc.harvard.edu

1 References