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
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).
Table 1—Demographic, Clinical, and Diagnostic Characteristics of AIDS-Related Pulmonary Lymphoma
|1||47||Homosexual||Dyspnea, weight loss, fever|| Small bowel, liver, adrenal gland,peripancreatic|
|Kaposis sarcoma, disseminated CMV infection||♦negative TBBx postmortem||Burldtts-like|
|2||35||Intravenous drug user||Generalizedlymphadenopathy, cough, dyspnea, fever||Mediastinal and abdominal lymph nodes, spleen, small bowel|| Bacterialpneumonia,|
|Negative TBBx, axillary node biopsy, Postmortem||Immunoblastic|
|3||32||Homosexual||Generalizedlymphadenopathy, chest pain, fever||Unknown||None||Negative TBBx, open lung biopsy||Immunoblastic|
|4||31||Homosexual||Cough, weight loss||None||Pcariniipneumonia||Negative TBBx (X 2), open lung biopsy||Immunoblastic|
Table 2—Clinical Course, Treatment, and Outcome of AIDS-Related Pulmonary Lymphoma
|Patient||Clinical Course||Treatment||Time from Diagnosis of AIDS to Death||Time from Diagnosis of Lymphoma to Death|
|1||X-ray progression, catheter related S aureus bacteremia, died 4 weeks later||None||7 months||Diagnosed 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 pneumonia||PROMACE CYTABOM, four courses||4.5 months||4.5 months|
|3||Symptomatic response to chemotheraphy; catheter related S epidermidis bacteremia; x-ray progression||Doxorubicin, cyclophosphamide, ectoposide, prednisone||4 months||4 months|
|4||Surgical removal of one lesion and radiation therapy’; new right lower lobe nodule 7 months later and bilateral progression||Radiation (3,000 R), CHOP||18 months||16 months|