The management of primary central nervous system lymphoma related to AIDS in the HAART era.

PURPOSE OF REVIEW: The review highlights the recent advances in the pathogenesis, diagnosis and treatment of AIDS-related primary CNS lymphoma (AIDS-PCNSL). RECENT FINDINGS: The incidence of AIDS-PCNSL has decreased in the era of highly active antiretroviral therapy (HAART). The prognosis has improved and this most probably in relation both with the HAART-induced immunologic status recovery and subsequently the possibility to use more aggressive treatment strategies. Immunomodulatory effect of HAART seems also to have an indirect antitumor activity on the disease. SUMMARY: The treatment strategy for AIDS-PCNSL in the HAART era tends to become similar to that of the immunocompetent population. In the absence of randomized trials devoted to AIDS-PCNSL, most current national comprehensive cancer network guidelines recommend the use of high-dose methotrexate-based chemotherapy combined or not with whole-brain radiotherapy as initial treatment in addition to HAART. The objective for the future would be that prognosis of AIDS-PCNSL catch up with that of the immunocompetent patients with special attention to systemic and neurocognitive tolerance of the treatments.

New insights into transmission, diagnosis, and drug treatment of Pneumocystis carinii pneumonia.

Pneumocystis carinii has been recognized as a human pathogen for nearly 50 years. We present a case of P carinii infection that typifies clinical presentation in the era of the acquired immunodeficiency syndrome epidemic. The high incidence of P carinii pneumonia in persons infected with human immunodeficiency virus (HIV) has served to focus laboratory and clinical research efforts on better understanding the biology of the organism and on improving diagnosis, treatment, and prevention of this disease. Although inability to culture P carinii has hampered research efforts, molecular and immunologic approaches have led to the recognition that the organism represents a family of fungi with a very restricted host range and have allowed characterization of clinically relevant antigens and enzymes. Molecular epidemiologic studies have identified more than 50 strains of human-derived P carinii and have suggested that recently acquired infection, as opposed to reactivation of latent infection, may account for many cases of clinical disease. Diagnosis has been improved by the development of organism-specific monoclonal antibodies and, more recently, by polymerase chain reaction using multicopy gene targets, together with induced sputum or oral wash samples. Chemotherapeutic prophylaxis is very effective in preventing P carinii pneumonia; the combination of trimethoprim-sulfamethoxazole remains the first-line agent for both therapy and prophylaxis. Prophylaxis needs to be administered only during periods of high risk; in HIV-infected patients responding to effective antiretroviral therapies, prophylaxis no longer needs to be lifelong. Molecular studies have identified mutations in the target of sulfa drugs that appear to represent emerging resistance in P carinii. Resistance to atovaquone, a second-line agent, may also be developing.

Acute abdomen in an HIV-positive man.

AIDS: A report is presented of a 48-year-old gay man, HIV-positive for 7 years, who came to the emergency room due to six hours of abdominal pain accompanied by anorexia, nausea, and dry heaves. Initial examination and laboratory tests showed nonspecific bowel gas, and the patient was discharged with instructions to use an enema at home for constipation. After worsening of symptoms, a private physician diagnosed acute abdomen with surgical consultation. A jejunal perforation secondary to B-cell Hodgkin's lymphoma was diagnosed and the patient was treated with low-dose CHOP (cytoxan, adriamycin, vincristine, and prednisone) for four cycles and had his antiretroviral regimen changed.^ieng

Linfoma nÝo Hodgkin pulmonar associado a síndrome de imunodeficiência adquirida (AIDS): revisÝo da literatura e relato de um caso clínico / Pulmonary non-Hodgkin's lymphoma associated with the acquired immunodeficiency syndrome (AIDS): literature review a case report

É apresentado um caso clínico de linfoma nÝo-Hodgkin pulmonar associado a Síndrome de Imunodeficiência Adquirida (AIDS). Após breve revisÝo da literatura, concentrado-se nas consideraçSes sobre a incidência, aspectos radiológicos e histopatologia, os autores assinalam o acometimento pulmonar pouco frequente pelo linfoma

Predominantly gastrointestinal symptoms and signs in 11 consecutive AIDS patients with gastrointestinal lymphoma: a multicenter, multiyear study including 763 HIV-seropositive patients.

OBJECTIVES: Gastrointestinal lymphoma is a distinct subgroup of lymphoma in HIV-seronegative patients. This study analyzes whether gastrointestinal lymphoma similarly forms a distinct clinical subgroup in HIV-seropositive patients. METHODS: Case control study of medical records of 763 human immunodeficiency virus-seropositive patients admitted to three university hospitals from 1986 through 1992, including 22 with non-Hodgkin's lymphoma. Eleven patients (50%) had gastrointestinal lymphoma, and 11 controls had extraintestinal lymphoma. RESULTS: The clinical presentation in patients with gastrointestinal lymphoma was dominated by gastrointestinal symptoms and signs and gastrointestinal complications. Common symptoms and signs included: change in bowel habits, gross or occult blood per rectum, involuntary weight loss, abdominal pain, abdominal tenderness, peripheral lymphadenopathy, cachexia, and hepatosplenomegaly. Significant gastrointestinal complications during the presenting admission included gastrointestinal bleeding in five, intestinal obstruction in one, and dysphagia from an esophageal stricture in one. Subsequent complications included a walled-off perforating gastric ulcer in one and obstructive jaundice in one. In contrast, the control patients with extraintestinal lymphoma had significantly fewer gastrointestinal symptoms and gastrointestinal complications (p < 0.001 and p < 0.01, respectively, Fisher's exact test). Upper gastrointestinal series or barium enema identified lymphomatous gastrointestinal lesions in all seven patients undergoing these tests. The pathologic diagnosis was made from endoscopic biopsies in six of six patients undergoing panendoscopy, and two of three patients undergoing lower endoscopy. Tumor sites included stomach in six, colon in three, ileum in two, esophagus in two, and duodenum in one. Eight patients had extraintestinal lesions at diagnosis, including four with extraabdominal extranodal lesions. The outcome of gastrointestinal lymphoma was poor with all therapies (mean combined survival = 3.6 +/- 2.2 months), and was not significantly different from that for the controls (mean survival = 4.1 +/- 2.7 months, Student's t test). CONCLUSIONS: This study suggests that gastrointestinal lymphoma in AIDS shares the poor prognosis and aggressive features of extraintestinal lymphoma in AIDS, but has unique localizing features at presentation of predominantly gastrointestinal symptoms and signs, and frequent gastrointestinal complications.