Conjunctival intraepithelial neoplasia in association with HIV infection.

Conjunctival intraepithelial neoplasia in association with HIV infection Conjunctival intraepithelial neoplasia (CIN) is a rare tumour of the ocular surface, traditionally affecting elderly men. It has recently been reported in young adults of African extraction in association with HIV infection. We report the case of a young African woman recently found to be HIV positive with a long-standing conjunctival lesion. The tumour was biopsied and identified as CIN. HIV testing in young patients presenting with atypical conjunctival lesions is recommended. A 38-year-old Zambian woman was referred for counselling for HIV testing after her husband of 22 years presented with an AIDS-defining illness. She has three children delivered by caesarian section. She received blood transfusions after each operation. She had noted a conjunctival lesion in her left eye that had been slowly increasing in size over the preceding 5 years. This had been reviewed by several physicians in Zambia and was thought to be benign. She was otherwise asymptomatic. On examination, Snellen visual acuities were 6/6 bilaterally. There was an elevated pigmented conjunctival lesion on the medial aspect of the left eye (Fig. 1). The anterior segments were otherwise normal. Dilated fundal examination revealed no evidence of intraocular infection or inflammation. Apart from oral candida, the systemic examination was unremarkable. An enzyme-linked immunosorbent assay HIV test was positive. The CD4 cell count was 143 cells/mm 3 and the viral load was 13 400 copies/ml. She was commenced on triple highly active retroviral therapy and fluconazole for oral candida. The conjunctival lesion was excised and sent to pathology for analysis. Microscopy showed stratified squamous keratinized epithelium within which dysplastic and dyskeratotic cells were seen. There were occasional mitotic figures. A number of melanocytes were noted within the epithelium. These did not show cytological atypia. The appearances were consistent with CIN. This was noted to extend to the resection margins on histology. In view of this, the patient was commenced on a course of topical chemotherapy. This treatment consisted of two 3-week cycles of mitomycin C (0.04%) four times a day, betnesol four times a day and viscotears four times a day 3 weeks apart. She tolerated this therapy well, with no evidence of corneal epithelial toxicity. Her CD4 cell count has increased to 369 cells/mm 3 and the viral load is undetectable (< 50 copies/ml). She remains under regular review. CIN (previously known as Bowen's disease) is the most common tumour of …