lymphoid aggregates or fully structured lymph nodes are present in relation to the parotid and submandibular salivary glands . the parotid gland is the only salivary gland to contain lymphoid tissue within its capsule while the submandibular lymph nodes lie adjacent to , but outside the glandular capsule . occasionally , these lymph nodes become the site of human immunodeficiency virus / acquired immunodeficiency syndrome ( hiv / aids)-associated lymphadenopathy and present with clinical and morphological features that may resemble salivary gland disorders.[17 ] unilateral or bilateral parotid gland lymphadenopathy with or without benign lymphoepithelial cysts is recognized as an early or sometimes primary symptom of hiv infection . as only a few cases have been published in literature , we are reporting this case to bring this entity and its cytohistopathological features to the attention of clinicians and pathologists . a 55 year - old woman presented with a nine months history of two painless nodules in the right parotid and submandibular gland regions . the swellings were nontender , firm , well circumscribed and measured 3  2 cm and 2.5  0.5 cm , respectively . no other swellings were felt , either in the involved salivary glands or on the contralateral side . the swellings did not fluctuate in size with the intake of food and the overlying skin was not inflamed . the only relevant past history was herpes zoster six years back , the scars of which were seen on the left side of her face . three months ago , she had undergone fine needle aspiration ( fna ) of these nodules in another laboratory . these smears were reviewed and showed high cellularity consisting of a mixed population of lymphoid cells . seen predominantly were mature small lymphocytes , immunoblasts , plasma cells , occasional multinucleate histiocytic giant cells , and lymphohistiocytic tangles [ figure 1 ] . there were no epithelioid cells , langhans type giant cells , caseous necrosis , warthin - finkeldey giant cells , salivary ductal , acinar , or squamous epithelial cells . lymphohistiocytic tangle and multinucleate giant cell ( inset ) ( pap , 400 ) subsequently , as these nodules progressively increased in size , an excision biopsy was done . grossly the nodules measured 3  2  1 cm and 2.5  1.5  1 cm respectively , were encapsulated , grey - white , and firm . the cut surface was predominantly solid , lobulated , and grey - white , except for a few small cysts measuring 0.3 cm in diameter and containing greenish , gelatinous material . the cortex showed large , irregular , confluent follicles with prominent germinal centres [ figure 2 ] enclosed by mantles of variable thickness with focal disruption and effacement ( geographic follicles ) . scattered interfollicular aggregates of monocytoid b - cells were seen along with numerous , plump , endothelium - lined blood vessels . four small cysts [ figure 3 ] were seen lined by cuboidal to stratified squamous epithelium that was profusely infiltrated by lymphocytes ( benign lymphoepithelial cysts ) . epithelial inclusions of ductal origin were seen amidst the lymphoid tissue [ figure 3 ] ; however , there were no acinar structures . epimyoepithelial lesions consisting of squamous islands infiltrated by lymphocytes were evident [ figure 4 ] but there were no warthin - finkeldey giant cells , granulomas , necrosis , or perinodal salivary gland tissue . the ziehl - neelsen and pas stains were negative for organisms ; a diagnosis of hiv - lymphadenitis of the salivary gland ( hivslg ) was made . intraparotid lymph node with geographic follicles ( h and e , 400 ) lymphoepithelial cyst ( right ) , salivary gland inclusions , and giant cells ( h and e , 100 ) epimyoepithelial islands infiltrated by lymphocytes ( h and e , 400 ) the hiv testing done subsequently was positive but the patient has remained free of any aids - defining illness in the six months follow - up period . exclusive involvement of salivary gland lymph nodes in hiv infection was first reported in 1985 . these patients present with unilateral or bilateral tumor - like masses , especially in the parotid gland , without any other symptoms . the swellings are frequently excised with the erroneous diagnosis of a salivary gland tumor . in hivlsg , the cytological features are similar to those of florid reactive hyperplasia of lymph nodes , except for the presence of foamy histiocytes and squamous cells in cases with associated cystic benign lymphoepithelial lesion . the differential diagnoses include reactive hyperplasia of the intraparotid lymph nodes , chronic sialadenitis , sjgren / mikulicz syndrome , warthin tumor , and hodgkin 's and non - hodgkin 's lymphomas . ulirsch and jaffe initially considered hivlsg to be a sjgren syndrome - like illness and believed that they resulted from autoimmune phenomena . however , demonstration of extensive lysis , hiv antigens , viral particles , and the clinical absence of xerophthalmia , keratoconjunctivitis , and autoantibodies help to distinguish these two entities , which may be cytologically identical . furthermore , benign lympho - epithelial lesion ( blel ) and cystic blel seen in this condition occur within the gland parenchyma whereas the benign lymphoepithelial cysts seen in hiv infection arise within intraparotid lymph nodes . they may or may not be associated with extensive local lymphadenopathy . it has been postulated that progressive intranodal lymphoid hyperplasia leads to entrapment , obstruction , and cystic dilatation of ductular inclusions , leading to swellings mimicking salivary gland tumors . chronic sialadenitis and sialolithiasis are characterized by pain , especially on the intake of food . the inflammation is within the salivary gland proper and reactive germinal centres are not usually a part of the process . aspirates are usually scanty with few lymphocytes , plasma cells , neutrophils , and macrophages in a background of mucus warthin tumors are painless , small , 2 to 4 cm nodules , commonly arising from the parotid gland . this neoplasm is most commonly mistaken for inflammation as the oncocytes are often difficult to recover from cystic lesions . various neoplasms have been described in hiv cases in relation to these nodes , including hodgkin 's lymphoma , non - hodgkin 's lymphoma , and kaposi sarcoma . cytologically , a confident diagnosis of hodgkin 's lymphoma can be made only in the presence of typical reed - sternberg cells or atypical mononuclear hodgkin cells in a background of lymphocytes , eosinophils , plasma cells , and histiocytes . non - hodgkin 's lymphomas in aids patients are usually high - grade , large cell lymphomas characterised on fna by a monotonous population of large , atypical lymphoid cells with noncleaved nuclei , multiple nucleoli , and scanty basophilic cytoplasm . immunohistochemistry or in situ hybridization has shown the presence of hiv proteins or rna on the dendritic cells of the salivary gland lymphoid follicles , indicating their active replication . in conclusion , an awareness of hivlsg may prevent unnecessary surgeries in these patients , a biopsy being necessary only in those cases suspected of harbouring a malignancy .
human immunodeficiency virus infection associated lymphadenitis of the salivary glands ( hivlsg ) and benign lymphoepithelial cysts are described as early events in hiv patients . 
 the diagnosis is not usually made clinically as it mimics a salivary gland tumor . 
 we present here a patient with two painless nodules in the right parotid and submandibular glands . 
 the cytological diagnosis was florid reactive lymphoid hyperplasia . 
 histopathology revealed features of hivlsg with multiple , small , cystic , benign lymphoepithelial lesions .