Accuracy of a real-time continuous glucose monitoring system in children with septic shock: A pilot study

Aims:

The aim of this prospective, observational study was to determine the accuracy of a real-time continuous glucose monitoring system (CGMS) in children with septic shock.

Subjects and Methods:

Children aged 30 days to 18 years admitted to the Pediatric Intensive Care Unit with septic shock were included. A real-time CGMS sensor was used to obtain interstitial glucose readings. CGMS readings were compared statistically with simultaneous laboratory blood glucose (BG).

Results:

Nineteen children were included, and 235 pairs of BG-CGMS readings were obtained. BG and CGMS had a correlation coefficient of 0.61 (P < 0.001) and a median relative absolute difference of 17.29%. On Clarke''s error grid analysis, 222 (94.5%) readings were in the clinically acceptable zones (A and B). When BG was < 70, 70–180, and > 180 mg/dL, 44%, 100%, and 76.9% readings were in zones A and B, respectively (P < 0.001). The accuracy of CGMS was not affected by the presence of edema, acidosis, vasopressors, steroids, or renal replacement therapy. On receiver operating characteristics curve analysis, a CGMS reading <97 mg/dL predicted hypoglycemia (sensitivity 85.2%, specificity 75%, area under the curve [AUC] =0.85). A reading > 141 mg/dL predicted hyperglycemia (sensitivity 84.6%, specificity 89.6%, AUC = 0.87).

Conclusion:

CGMS provides a fairly, accurate estimate of BG in children with septic shock. It is unaffected by a variety of clinical variables. The accuracy over extremes of blood sugar may be a concern. We recommend larger studies to evaluate its use for the early detection of hypoglycemia and hyperglycemia.     

Differential effects of prophylactic,concurrent and therapeutic lactoferrin treatment on LPS-induced inflammatory responses in mice

Mice injected with endotoxin develop endotoxaemia and endotoxin-induced death, accompanied by the oxidative burst and overproduction of inflammatory mediators. Lactoferrin, an iron binding protein, provides a natural feedback mechanism to control the development of such metabolic imbalance and protects against deleterious effects of endotoxin. We investigated the effects of intraperitoneal administration of human lactoferrin on lipopolysaccharide (LPS)-induced release of tumour necrosis factor alpha (TNF-alpha), interleukin 6 (IL-6), interleukin 10 (IL-10) and nitric oxide (NO) in vivo. Lactoferrin was administered as a prophylactic, concurrent or therapeutic event relative to endotoxic shock by intravenous injection of LPS. Inflammatory mediators were measured in serum at 2, 6 and 18 h post-shock induction. Administration of lactoferrin 1 h before LPS resulted in a rather uniform inhibition of all mediators; TNF by 82%, IL-6 by 43%, IL-10 by 47% at 2 h following LPS injection,and reduction in NO (80%) at 6 h post-shock. Prophylactic administration of lactoferrin at 18 h prior to LPS injection resulted in similar decreases in TNF-alpha (95%) and in NO (62%), but no statistical reduction in IL-6 or IL-10. Similarly, when lactoferrin was administered as a therapeutic post-induction of endotoxic shock, significant reductions were apparent in TNF-alpha and NO in serum, but no significant effect was seen on IL-6 and IL-10. These results suggest that the mechanism of action for lactoferrin contains a component for differential regulation of cellular immune responses during in vivo models of sepsis.     

Use of intravenous immunoglobulin therapy in the treatment of septic shock, in particular severe invasive group A streptococcal disease

Group A streptococcus (GAS) is a β-hemolytic bacterium often found in the throat and skin. The two most severe clinical manifestations of GAS are streptococcal toxic shock syndrome and necrotizing fasciitis. Intravenous immunoglobulin (IVIg) is a gamma globulin made from purified pooled plasma of thousands of donors, consisting mainly of IgG. We report the case of a 40-year-old man admitted after 2 days of vomiting and severe right-sided chest pain. He was hypotensive with a sinus tachycardia, pyrexial, and vasodilated. The only other positive finding was a swollen and erythematous chest wall. Muscle layer biopsies and blood cultures soon grew extensive GAS, and an initial diagnosis of necrotizing fasciitis was made. The clinical syndrome was of severe septic shock secondary to invasive GAS. The patient quickly deteriorated with a worsening metabolic acidosis. Despite maximal intensive care therapy including fluids, vasoactive agents, and also activated protein C, the patient continued to remain profoundly hypotensive. A decision was made to commence IVIg, with the aim of immunomodulation of the inflammatory cascade seen in sepsis. Over the next 24 hours the patient improved, was extubated 3 days later, and subsequently discharged from hospital after 2 weeks. Although the evidence for the use of IVIg in severe invasive GAS disease is limited, we feel that on reviewing the available literature its use in this case was justified. The limited worldwide supply and high costs, together with a limited evidence base, warrant restricting its use to cases in which conventional therapy has failed. The literature for use of intravenous immunoglobulin in invasive GAS infection will be reviewed in this article.     

Left atrial function for outcome prediction in severe sepsis and septic shock: An echocardiographic study

Left ventricular function and B-type natriuretic peptide (BNP) assessments are used to predict mortality in septic patients. Left atrial function has never been used to prognosticate outcome in septic patients.

Objectives:

To assess if deterioration of left atrial function in patients with severe sepsis and septic shock could predict mortality.

Methods:

We studied 30 patients with severe sepsis or septic shock with a mean age of 49.8±16.17. Echocardiographic parameters were measured on admission, Day 4, and Day 7, which comprised left ventricular ejection fraction (EF), and atrial function that is expressed as atrial ejection force (AEF). All patients were subjected to BNP assay as well. Multivariate analyses adjusted for APACHE II score was used for mortality prediction.

Results:

The underlying source for sepsis was lung in 10 patients (33%), blood in 7 patients (23.3%), abdomen in 7 patients (23.7%), and 3 patients (10%) had UTI as a cause of sepsis. Only one patient had CNS infection. In-hospital mortality was 23.3% (7 patients). Admission EF showed a significant difference between survivors and non survivors, 49.01±6.51 vs.. 56.44±6.93% (P<0.01). On the other hand, admission AEF showed insignificant changes between the same groups, 10.9±2.81 vs. 9.41±2.4 k/dynes P=0.21, while BNP was significantly higher in the non survivors, 1123±236.08 vs. 592.7±347.1 pg/ml (P<0.001). The predicatable variables for mortality was Acute Physiology and Chronic Health Evaluation II score, BNP, then EF.

Conclusion:

In septic patients, left atrial function unlike the ventricular function and BNP levels can not be used as an independent predictor of mortality.     

Intravenous ketamine for treatment of super-refractory convulsive status epilepticus with septic shock: A report of two cases

Refractory and super-refractory status epilepticus is a life-threatening neurological emergency, associated with high morbidity and mortality. Treatment should be aimed to stop seizure and to avoid cerebral damage and another morbidity. Published data about effectiveness, safety and outcome of various therapies and treatment approaches are sparse and are mainly based on small case series and retrospective data. Here we report successful management of two cases of super-refractory status epilepticus refractory to anesthetic therapy with midazolam and complicated by septic shock, managed successfully with ketamine infusion.     

持续低效血液透析与连续性肾脏替代治疗在感染性休克急性肾损伤患者的疗效对比

目的对比研究持续低效血液透析(SLED)与连续性肾脏替代治疗(CRRT)在感染性休克急性肾损伤(AKI)患者中治疗效果。方法选择60例感染性休克AKI的患者,其中男性36例,女性24例;年龄28~71岁,平均年龄49.56岁。随机分为SLED组(30例)和CRRT组(30例)。两组患者均按《2016国际严重脓毒症及脓毒症休克诊疗指南》治疗,在此基础上分别予以SLED(每次治疗8~10 h,24 h后重复治疗,每例患者至少进行3次以上)和CRRT[模式为连续性静脉-静脉血液滤过,治疗剂量35~40 mL/(kg·h),初始24 h持续治疗,然后根据病情调整治疗时间]。分别观察两组患者治疗前后的血肌酐、pH、钾离子、每天液体平衡、急性生理与慢性健康评价Ⅱ(APACHEⅡ)评分及治疗期间血流动力学稳定性的变化。并比较两组患者的重症监护病房(ICU)住院时间、90 d病死率。结果与CRRT组比较,SLED组治疗后12 h和治疗后5 d的血肌酐、钾离子水平均显著低于CRRT组(P<0.05)。与CRRT组APACHEⅡ评分[(14.78±3.79)分]比较,SLED组治疗后5 d的APACHEⅡ评分[(10.45±3.02)分]明显低于CRRT组(P<0.05)。两组患者治疗期间,SLED组具有与CRRT组相近的血流动力学稳定性(P>0.05)。其中,SLED组血管加压药指数(VI)为20.32±5.18,血管加压药依赖性(VD)为(22.08±4.41)%;CRRT组VI为21.05±5.63,VD为(22.67±4.95)%。SLED组患者ICU住院时间[(15.32±3.65)d]显著短于CRRT组[(19.76±4.18)d],差异有统计学意义(P<0.05)。但两组患者90 d病死率差异无统计学意义(33.33%vs 36.67%;P>0.05)。结论SLED治疗感染性休克AKI患者的疗效确切,且在治疗期间血流动力学稳定性方面并不亚于CRRT。     

Extracorporeal cytokine elimination as rescue therapy in refractory septic shock: a prospective single-center study

Sepsis is the most common cause of death in medical intensive care units (ICU). If sepsis progresses to refractory septic shock, mortality may reach 90–100% despite optimum current therapy. Extracorporeal cytokine adsorption in addition to regular therapy was studied prospectively in refractory septic shock patients on a medical ICU. Refractory shock was defined as increasing vasopressor dose required to maintain mean arterial blood pressure above 65 mmHg or increasing lactate levels despite protocol-guided shock therapy for 6 h. We analysed noradrenaline requirements after 6 and 12 h (primary endpoint), lactate clearance after 6 and 12 h, SOFA-scores in the first days and achievement of shock reversal (i.e., normalization of lactate concentrations and sustained discontinuation of vasopressors; secondary endpoints). Twenty consecutive patients with refractory septic shock were included; CytoSorb^® treatment was started after 7.8 ± 3.7 h of shock therapy. Following the initiation of adsorption therapy, noradrenaline dose could be significantly reduced after 6 (?0.4 µg/kg/min; p = 0.03) and 12 h (?0.6 µg/kg/min; p = 0.001). Lactate clearance improved significantly. SOFA-scores on day 0, 1 and 2 remained unchanged. Shock reversal was achieved in 13 (65%) patients; 28-day survival was 45%. In severe septic shock unresponsive to standard treatment, haemodynamic stabilization was achieved using cytokine adsorption therapy, resulting in shock reversal in two-thirds of these patients. The study was registered in the German Register for Clinical Trials (DRKS) No. 00005149.     

Selection of acute blood purification therapy according to severity score and blood lactic acid value in patients with septic shock

Aim:

As an alternative method for acute blood purification therapy, continuous venovenous hemodiafiltration (CVVHDF) has been reported as an effective clinical treatment for critically ill patients, but the optimal column for performing CVVHDF remains controversial.

Patients and Methods:

We used direct hemoperfusion using a polymyxin B-immobilized fiber column (DHP-PMX) to treat 88 patients with septic shock. To determine the optimal acute blood purification therapy, we subsequently divided the patients into three groups: the first group underwent CVVHDF using a polymethylmethacrylate membrane hemofilter (PMMA) after undergoing DHP-PMX (28 cases), the second group underwent CVVHDF using a polyacrylonitrile membrane hemofilter (PAN) after undergoing DHP-PMX (26 cases), and the third group did not undergo CVVHDF after undergoing DHP-PMX (34 cases).

Results:

The overall survival rate was 54.5%, and patient outcome was significantly related to the Acute Physiology and Chronic Health Evaluation (APACHE) II score, the sepsis-related organ failure assessment (SOFA) score, and the blood lactic acid value before treatment (all P<0.0001). Only the PMMA-CVVHDF group showed a better outcome (survival rate of 78.6%) compared with the other groups (P = 0.0190). In addition, only the PMMA-CVVHDF group showed a significant improvement in the blood lactic acid level on day 3 (P = 0.0011).

Conclusion:

Our study suggests that the PMX column might be effective during the early phase of septic shock, before a high level of lactic acid is present. Furthermore, a PMMA column might be the most useful column for performing CVVHDF after DHP-PMX treatment, as suggested by the blood lactic acid value.     

Prevalence of occult adrenal insufficiency and the prognostic value of a short corticotropin stimulation test in patients with septic shock

Background:

Corticosteroid insufficiency in acute illness can be difficult to discern clinically. Occult adrenal insufficiency (i.e., Δmax ≤9 μg/dL) after corticotropin may be associated with a high mortality rate.

Objective:

To assess the prevalence of occult adrenal insufficiency and the prognostic value of short corticotropin stimulation test in patients with septic shock.

Materials and Methods:

A total of 30 consecutive patients admitted in the adult intensive care unit of the Sheri Kashmir Institute of Medical Sciences who met the clinical criteria for septic shock were prospectively enrolled in the study. A low dose (1 μg) short corticotropin stimulation test was performed; blood samples were taken before the injection (T0) and 30 (T30) and 60 (T60) minutes afterward.

Results:

The prevalence of occult adrenal insufficiency was 57%. The 28-day mortality rate was 60% and the median time to death was 12 days. The following seven variables remained independently associated with death: organ system failure scores, simplified acute physiology score II score, mean arterial pressure, low platelet count, PaO₂:FIO₂, random baseline cortisol (T0) >34 μg/dL, and maximum variation after test (Δmax) of ≤9 μg/dL. Three different mortality patterns were observed: (I) low (T0 ≤34 μg/dL and Δmax >9 μg/dL; a 28-day mortality rate of 33%),(II) intermediate (T0 >34 μg/dL and Δmax >9 μg/dL or T0 ≤34 μg/dL and Δmax ≤9 μg/dL; a 28-day mortality rate of 71%), and (III) high (T0 >34 μg/dL and Δmax ≤9 μg/dL; a 28-day mortality rate of 82%).

Conclusion:

A short corticotropin test using low-dose corticotropin (1 μg) has a good prognostic value. High basal cortisol and a low increase in cortisol on corticotropin stimulation test are predictors of a poor outcome in patients with septic shock.     

Septic shock due to Vibrio alginolyticus in a cirrhotic patient: the first case in Korea

We describe a case of septic shock due to Vibrio alginolyticus presenting with fever and bilateral leg pain. Despite intensive management with antibiotics and inotropic agents, the patient died from septic shock 1 day after hospitalization. V. alginolyticus was isolated from both leg wounds and a blood culture. To the best of our knowledge, this is the first reported case of V. alginolyticus bacteremia in Korea.     

Clinical outcome and predictors of mortality in children with sepsis,severe sepsis,and septic shock from Rohtak,Haryana: A prospective observational study

Background:

Information regarding early predictive factors for mortality and morbidity in sepsis is limited from developing countries.

Methods:

A prospective observational study was conducted to determine the clinical outcome and predictors of mortality in children with sepsis, severe sepsis, and septic shock. Children aged 1 month to 14 years admitted to a tertiary care pediatric intensive care unit (PICU) with a diagnosis of sepsis, severe sepsis, or septic shock were enrolled in the study. Hemodynamic and laboratory parameters which discriminate survivors from nonsurvivors were evaluated.

Results:

A total of 50 patients (30 [60%] males) were enrolled in the study, of whom 21 (42%) were discharged (survivors) and rest 29 (58%) expired (nonsurvivor). Median (interquartile range) age of enrolled patients were 18 (6, 60) months. Mortality was not significantly predicted individually by any factor including age (odds ratio [OR] [95% confidence interval [CI]]: 0.96 [0.91-1.01], P = 0.17), duration of PICU stay (OR [95% CI]: 1.18 [0.99-1.25], P = 0.054), time lag to PICU transfer (OR [95% CI]: 1.02 [0.93-1.12], P = 0.63), Pediatric Risk of Mortality (PRISM) score at admission (OR [95% CI]: 0.71 [0.47-1.04], P = 0.07) and number of organ dysfunction (OR [95% CI]: 0.03 [0.01-1.53], P = 0.08).

Conclusion:

Mortality among children with sepsis, severe sepsis, and septic shock were not predicted by any individual factors including the time lag to PICU transfer, duration of PICU stay, presence of multiorgan dysfunction, and PRISM score at admission.     

The impact of packed red blood cell transfusion on clinical outcomes in patients with septic shock treated with early goal directed therapy

Background:

The optimal hemoglobin level and transfusion threshold in patients with septic shock treated with an early, goal oriented approach to resuscitation remains unknown.

Aims:

To assess the impact of packed red blood cell (PRBC) transfusion on clinically relevant outcomes in patients with septic shock treated with early goal directed therapy (EGDT).

Settings and Design:

Retrospective cohort study of 93 patients who presented with septic shock, to a single center academic intensive care unit and received EGDT.

Materials and Methods:

Data were collected on patients identified via the Surviving Sepsis Campaign Chart Review database and linked to Project IMPACT database. The PRBC group and no PRBC group were compared by the Pearson chi-square and Fisher’s exact test to analyze statistical significance.

Results:

The PRBC group had a mortality of 41.2% vs. 33.9% in the no PRBC transfusion group (P = NS). The PRBC group also had more mechanical ventilation days (11.2 days vs. 5.0 days, (P ≤ 0.05), longer hospital length of stay (25.9 days vs. 12.5 days, (P ≤ 0.05), and longer intensive care unit length of stay (11.4 days vs. 3.8 days, (P ≤ 0.05).

Conclusions:

In this retrospective cohort study, transfusion of PRBCs was associated with worsened clinical outcomes in patients with septic shock treated with EGDT. Further studies are needed to determine the impact of transfusion of PRBC within the context of early resuscitation of patients with septic shock, as the beneficial effects gained by an early and goal oriented approach to resuscitation may be lost by the negative effects associated with PRBC transfusion.     

Exploration of eosinopenia as a diagnostic parameter to differentiate sepsis from systemic inflammatory response syndrome: Results from an observational study

Results:Median AEC was 0 cells/mm³ in both SIRS and sepsis. TLC and PCT levels were significantly higher (P < 0.001) in culture negative, culture positive, and overall sepsis groups in comparison to SIRS group. At a cutoff of < 50 cells/mm³, AEC demonstrated a sensitivity and specificity of 23% and 68%, respectively. The sensitivity, specificity, positive predictive value, and negative predictive value of TLC were 57%, 71%, 85%, 37% and of PCT were 82.4%, 82.2%, 93%, and 63%, respectively with area under curve of 0.455 for AEC, 0.640 for TLC, 0.908 for PCT.Conclusions:This study suggests that eosinopenia is not a reliable diagnostic tool to differentiate sepsis from SIRS. PCT and TLC are better differential diagnostic biomarkers.     

How to discriminate contamination from bloodstream infection due to coagulase-negative staphylococci: a prospective study with 654 patients

Coagulase-negative staphylococci (CoNS) are frequent contaminants of blood cultures. We aimed to evaluate the systemic inflammatory response syndrome (SIRS) criteria in patients with CoNS bacteraemia for discrimination between true bloodstream infection (BSI) and contamination. Prospective evaluation was carried out of clinical and laboratory parameters in adults with at least one positive blood culture with CoNS at the University Hospital of Basel between 2003 and 2007. Of 3060 positive blood cultures, 654 episodes of CoNS bacteraemia were identified. Of these, 232 (35%) were considered to be true BSI and 422 (65%) were considered to be contamination. Overall, 80% of study participants had at least one SIRS criterion, fever being the most common, and 49% had at least two SIRS criteria. In the multivariate analysis, independent predictors of BSI were fever or hypothermia (OR 2.93, 95% CI 1.91–4.5), tachycardia (OR 2.29, 95% CI 1.50–3.50), tachypnoea (OR 2.4, 95% CI 1.30–4.43), leucocytosis or leucopenia (OR 4.15, 95% CI 2.17–6.36) and the presence of a central venous line (OR 5.38, 95% CI 3.25–8.88). The probability of BSI increased with each additional SIRS criterion, ranging from 42.4% in patients with only one SIRS criterion to 56.7% for those with two criteria, and 72.3% for patients with three SIRS criteria. A positive blood culture with CoNS most likely represents true BSI if the patient has at least three SIRS criteria or two SIRS criteria and a central venous catheter. These simple bedside criteria may guide decision to treat, decreasing the use of glycopeptides.     

新生儿全身炎症反应综合征时TREM-1表达的实验研究

目的探讨新生儿全身炎症反应综合征（SIRS）时,髓系细胞触发受体1（Triggering Receptor Expressed on Myeloid cells-1,TREM-1）在外周血单核细胞核酸和蛋白质水平的表达及其意义。方法实验对象分为正常对照组,SIRS组,严重SIRS组,SIRS伴休克组。实验组病例确诊后各抽取外周血5ml,按照Dapino P的方法分离单核细胞。四组分别提取RNA及总蛋白。用逆转录聚合酶链反应（RT—PCR）检测TREM-1 mRNA的表达,用Western Blot方法检测TREM-1蛋白的表达。结果各组Trem-1 mRNA／β-actin及TREM-1蛋白／GAPDH比值依次增加,组间差异有统计学意义（P〈0．01）。结论新生儿全身炎症反应综合征时TREM-1的表达有明显变化,并随着病情分级严重程度而表达上调。     

Early goal-directed therapy reduces mortality in adult patients with severe sepsis and septic shock: Systematic review and meta-analysis

Introduction:

Survival sepsis campaign guidelines have promoted early goal-directed therapy (EGDT) as a means for reduction of mortality. On the other hand, there were conflicting results coming out of recently published meta-analyses on mortality benefits of EGDT in patients with severe sepsis and septic shock. On top of that, the findings of three recently done randomized clinical trials (RCTs) showed no survival benefit by employing EGDT compared to usual care. Therefore, we aimed to do a meta-analysis to evaluate the effect of EGDT on mortality in severe sepsis and septic shock patients.

Methodology:

We included RCTs that compared EGDT with usual care in our meta-analysis. We searched in Hinari, PubMed, EMBASE, and Cochrane central register of controlled trials electronic databases and other articles manually from lists of references of extracted articles. Our primary end point was overall mortality.

Results:

A total of nine trails comprising 4783 patients included in our analysis. We found that EGDT significantly reduced mortality in a random-effect model (RR, 0.86; 95% confidence interval [CI], 0.72–0.94; P = 0.008;   I² =50%). We also did subgroup analysis stratifying the studies by the socioeconomic status of the country where studies were conducted, risk of bias, the number of sites where the trials were conducted, setting of trials, publication year, and sample size. Accordingly, trials carried out in low to middle economic income countries (RR, 0.078; 95% CI, 0.67–0.91; P = 0.002; I² = 34%) significantly reduced mortality compared to those in higher income countries (RR, 0.93; 95% CI, 0.33–1.06; P = 0.28; I² = 29%). On the other hand, patients receiving EGDT had longer length of hospital stay compared to the usual care (mean difference, 0.49; 95% CI, –0.04–1.02; P = 0.07; I² = 0%).

Conclusion:

The result of our study showed that EGDT significantly reduced mortality in patients with severe sepsis and septic shock. Paradoxically, EGDT increased the length of hospital stay compared to usual routine care.     

Appearance of large scavenger receptor A-positive cells and increased small scavenger receptor A positive cells in peripheral blood is associated with mortality in systemic inflammatory response syndrome and multiple organ dysfunction syndrome

We investigated the association of scavenger receptor A-positive (SRA(+) ) cells in peripheral blood (PB) with mortality in subjects with systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS). A total of 467 subjects with SIRS (62 of 467 satisfied the diagnostic criteria of MODS) were prospectively examined. The subjects were classified into three groups according to the SRA index (number of small SRA(+) cells in 10 high power field, normal upper limit < 30) and the appearance of large SRA(+) cells as follows: group A, large SRA(+) cells were not detected; group B, large SRA(+) cells were detected but SRA index did not exceed 30; group C, the two factors (appearance of large SRA(+) cells and SRA index > 30) coincided. The duration from the diagnosis of SIRS to death in groups A and B was significantly shorter than in group C. The mortality rate in group C was significantly higher than in groups A and B. Kaplan-Meier curves of group C showed significantly worse survival than groups A and B. These results indicate that the coincidence of two factors (appearance of large SRA(+) cells and SRA index > 30) may be useful to predict the outcome in patients with SIRS or MODS.     

Malignant thymoma in a patient with HIV positivity: A case report with a review of the differential cytologic diagnoses

A 33-yr-old African-American male with known human immunodeficiency virus (HIV) positivity underwent CT guided fine-needle aspiration biopsy of an anterior mediastinal mass. The aspirate was composed of a dimorphic population of cells that included small mature lymphoid cells and scattered cohesive groups of large epithelial cells in equal numbers. The neoplasm stained strongly for low weight molecular cytokeratin, epithelial membrane antigen (EMA), leukocyte common antigen (LCA), and Leu-7 which was consistent with a diagnosis of thymoma. Subsequent biopsies determined the neoplasm to be a malignant (invasive) thymoma. This case emphasizes the efficacy of FNA biopsy for the evaluation of anterior mediastinal masses in HIV infected individuals. Additionally, the differential cytologic diagnoses for HIV infected individuals for this anatomic site are discussed. Diagn. Cytopathol. 16:267–269, 1997. © 1997 Wiley-Liss, Inc.