A 35-year-old man who was HIV-positive and an intravenous drug-user was admitted to the hospital in September 1986 with cough, weight loss and dull substernal chest pain. Fast medical history was remarkable for a presumed Hemophilus influenzae pneumonia in May 1986. Physical examination revealed generalized lymphadenopathy, diffuse rhonchi in the chest, and right sixth and 12th cranial nerve palsies. Chest roentgenogram and chest CT scan (Fig 2) showed multiple bilateral nodules 1.0 to 3.0 cm in diameter. http://medicine-against-diabetes.net/
A right axillary lymph node biopsy showed immunoblastic lymphoma; bone marrow biopsy, head and abdominal CT scans, MRI and lumbar puncture showed no further evidence of lymphoma. Bronchoscopy with transbronchial biopsy revealed interstitial fibrosis with chronic inflammation (nondiagnostic); all stains and cultures were negative for P carinii, fungi and mycobacteria. The pulmonary nodules were diagnosed clinically as malignant lymphoma, and the cranial nerve palsies were presumed to be secondary to Gradenigos syndrome (localized meningitis involving the fifth and sixth cranial nerves).
He was treated with PROMACE CYTABOM and received a total of four courses through a Broviac subclavian catheter. One week after his first course of chemotherapy, his chest roentgenogram showed dramatic clearing of the pulmonary nodules. Three months later he had a catheter-related thrombosis of the left brachial and axillary veins. This was further complicated by S aureus bacteremia and pneumonia and was treated with vancomycin. He died 4 Vz months after the initial diagnosis of lymphoma. Postmortem examination revealed a S aureus soft tissue abscess in the left axilla and S aureus pneumonia in all lobes. Necrotic lymphoma nodules were found throughout the lungs and in some areas were contiguous with the infection. Foci of lymphoma were also found in spleen, small intestine and mediastinal and abdominal lymph nodes.
Figure 2. Chest CT scan demonstrating multiple bilateral nodules (case 2).