Pulmonary Non-Hodgkin’s Lymphoma in AIDS: Results

10 Jan
2015

Case 4
A 31-year-old HIV-positive homosexual man was admitted to the hospital in August 1987 with a 25-pound weight loss and cough, fever and night sweats for three weeks. His past medical history was significant for hepatitis B infection. Physical examination revealed a temperature of38°C, oral candidiasis and difluse bilateral rales. Chest roentgenogram showed difluse bilateral interstitial infiltrates and two well-defined nodules 2.5 cm in diameter in the right middle lobe.

Bronchoscopy with bronchoalveolar lavage revealed cysts of P carinU, and transbronchial biopsy of one of the nodules was nondiagnostic. He was treated with trimethoprim-sulfamethoxazole with resolution of symptoms and interstitial infiltrates, but the nodules remained (Fig 4). One month later, repeat bronchoscopy with transbronchial biopsies of a nodule was nondiagnostic. He subsequently underwent open-lung biopsy and histopathologic study of the nodules revealed immunoblastic lymphoma. Involvement of the pleura or mediastinum was not specifically noted. He received 3,000 rads to the right lower lung field with modest shrinkage of residual nodules over four weeks. Repeat chest CT scan six months after initial roentgenogram showed new infiltrates in the right lower lobe. He received three courses of CHOP as well as intermittent zidovudine (AZT). Ten months later, he had recurrent P carinii pneumonia, adequately treated with pentamidine and trimethoprim-dapsone. He developed new nodules in the right lower lobe seven months into his course with indolent bilateral progression and died 18 months after initial chest x-ray appearance of nodular disease. An autopsy was not performed. review
Results
The demographic, clinical and diagnostic characteristics of four cases of HIV-related non-Hodgkins pulmonary lymphoma are summarized in Table 1. Three patient were homosexual; one had a history of intravenous drug use. The clinical manifestations were nonspecific in all four patients; two patients had generalized lymphadenopathy, and pulmonary symptoms rarely dominated the clinical picture. Three patients had stage IV disease and one had stage IE disease. Concomitant P carinii pneumonia occurred in one patient and another had pleuropulmonary Kaposi’s sarcoma at autopsy.
Chest roentgenograms showed multiple pulmonary nodules in three patients. The nodules were relatively well circumscribed and were 0.5 to 3.0 cm in diameter. One patient had bilateral interstitial infiltrates (case 3). Hilar or mediastinal lymphadenopathy or pleural effusions were not seen. Fiberoptic bronchoscopy with transbronchial biopsy failed to establish the diagnosis in all four cases. A definitive diagnosis of pulmonary lymphoma was obtained with open-lung biopsy in two patients and by autopsy in two patients. The histopathologic cell type was high-grade in all patients (three immunoblastic, one Burkitts-like lymphoma).
The clincial course, treatment and outcome of AIDS-related pulmonary lymphoma are summarized in Table 2. One patient (case 2) had significant clinical and radiographic resolution of pulmonary disease after his first course of chemotherapy. Three of four patients survived only four months after their diagnosis of lymphoma. The proximate causes of death were probably multiple in patient 1, overwhelming staphylococcal infection in patient 2, and pulmonary lymphoma in patient 3. Patient 4 with primary pulmonary lymphoma (stage IE) died 18 months after the initial radiographic appearance of pulmonary disease.

Figure 4. Chest roentgenogram demonstrating right middle lobe nodules (case 4).

Figure 4. Chest roentgenogram demonstrating right middle lobe nodules (case 4).

 

Table 1—Demographic, Clinical, and Diagnostic Characteristics of AIDS-Related Pulmonary Lymphoma

Patient Age(yr) TransmissionCategory ClinicalManifestations ExtrapulmonaryLymphoma

Involvement

OtherOpportunistic

Diseases

Diagnosis
Method LymphomaHistology
147HomosexualDyspnea, weight loss, fever Small bowel, liver, adrenal gland,peripancreatic

felt

Kaposis sarcoma, disseminated CMV infection♦negative TBBx postmortemBurldtts-like
235Intravenous drug user Generalizedlymphadenopathy, cough, dyspnea, feverMediastinal and abdominal lymph nodes, spleen, small bowel Bacterialpneumonia,

Candida

esophagitis,

disseminated

zoster

Negative TBBx, axillary node biopsy, PostmortemImmunoblastic
332Homosexual Generalizedlymphadenopathy, chest pain, feverUnknownNoneNegative TBBx, open lung biopsyImmunoblastic
431HomosexualCough, weight lossNone PcariniipneumoniaNegative TBBx (X 2), open lung biopsyImmunoblastic

Table 2—Clinical Course, Treatment, and Outcome of AIDS-Related Pulmonary Lymphoma

PatientClinical CourseTreatmentTime from Diagnosis of AIDS to DeathTime from Diagnosis of Lymphoma to Death
1 X-ray progression, catheter related S aureus bacteremia, died 4 weeks laterNone7 monthsDiagnosed postmortem 4 months from 1st x-ray with nodules
2 X-ray resolution of pulmonary disease after 1st course of chemotherapy; progressive worsening with catheter related S aureus bacteremia and pneumoniaPROMACE CYTABOM, four courses4.5 months4.5 months
3 Symptomatic response to chemotheraphy; catheter related S epidermidis bacteremia; x-ray progressionDoxorubicin, cyclophosphamide, ectoposide, prednisone4 months4 months
4Surgical removal of one lesion and radiation therapy’; new right lower lobe nodule 7 months later and bilateral progressionRadiation (3,000 R), CHOP18 months16 months
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