Pulmonary Non-Hodgkin’s Lymphoma in AIDS

4 Jan

Pulmonary Non-Hodgkin’s Lymphoma in AIDSThe association between AIDS and non-Hodgkins lymphoma has been well established. After Kaposis sarcoma, malignant lymphoma is the most prevalent HIV-related neoplasm. The majority of non-Hodgkins lymphomas in this population are B-cell in origin and undifferentiated (high-grade). Nearly 80 percent involve extranodal sites, most commonly bone marrow, central nervous system, gastrointestinal tract, liver and skin. Pulmonary involvement in AIDS-related lymphoma is unusual and has been reported in less than 10 percent of cases. No detailed accounts of pulmonary lymphoma in AIPS have been reported. From 1982 through 1987, 648 cases of AIDS have been diagnosed in Colorado, 40 of which (6 percent) had non-Hodgkins lymphoma. Of these, four patients (10 percent) had documented pulmonary involvement and form the basis of this report.

All cases of non-Hodgkins lymphoma diagnosed from May 1982 through December 1987 reported to the AIDS Surveillence Division of the Denver Disease Control Service were reviewed. Case reports of AIDS, death certificates, clinical records and autopsy reports were reviewed for evidence of pulmonary lymphoma. Where necessary, follow-up information was obtained from physicians. Pulmonary lymphoma was documented by open lung biopsy or autopsy.
Case Reports
Case 1

A 47-year-old homosexual man was diagnosed with AIDS in November 1985 when he presented with Kaposis sarcoma and a history of severe herpes zoster one month previously. In March 1986, he was admitted to the hospital with dysphagia, dyspnea, fever and progressive weight loss. Physical examination revealed marked volume depletion, cotton wool spots on funduscopic examination compatible with CMV chorioretinitis, oral candidiasis and cutaneous lesions of Kaposi s sarcoma on the left hip and groin. He did not have lymphadenopathy or hepatosplenomegaly. Chest roentgenogram showed multiple nodules which ranged in size from 0.5 to 1.5 cm in diameter. In addition interstitial infiltrates were prominent, particularly in the right lung fields.
Upper gastrointestinal endoscopy revealed diffuse red raised lesions in the esophagus; histopathology was consistent with CMV esophagitis. Bronchoscopy revealed normal endobronchial anatomy; transbronchial biopsies showed hemosiderin-laden macrophages and intra-alveolar and alveolar lining cell reaction (nondiagnostic). All stains and cultures for Pneumocystis carinii, fungi and mycobacteria were negative. He was treated with gancyclovir through a Broviac subclavian catheter. In May 1986, he was readmitted for a catheter-related Staphylococcus aureus bacteremia. Chest examination revealed diffuse crackles, and chest roentgenogram showed an increase in the size and number of the nodular infiltrates (Fig 1). The catheter was removed and he was treated with intravenous oxacillin for two weeks. He died six weeks later, four months after the first appearance of nodules on chest roentgenogram.
Postmortem examination revealed Burkitts-like lymphoma in both lungs (multiple nodules), liver, peripancreatic fat, right adrenal gland and small intestine. There was no pleural or mediastinal adenopathy. Also, Kaposi’s sarcoma was identified in the lung (patchy parenchymal and pleural involvement) and skin over the left hip. Inclusion bodies of CMV were seen in the lungs, heart, liver and esophagus.

Figure 1. Chest roentgenogram demonstrating multiple, bilateral nodular infiltrates as well as interstitial infiltrates, particularly in the right lung fields (case 1).

Figure 1. Chest roentgenogram demonstrating multiple, bilateral nodular infiltrates as well as interstitial infiltrates, particularly in the right lung fields (case 1).