[Primary neurolymphomatosis in the cauda equina as the initial symptom of human immunodeficiency virus]. / Neurolinfomatosis primaria de cola de caballo como manifestacion inicial del virus de la inmunodeficiencia humana.

TITLE: Neurolinfomatosis primaria de cola de caballo como manifestacion inicial del virus de la inmunodeficiencia humana.

Diagnóstico de linfoma de Burkitt mediante PET cerebral con 11C-metionina en paciente VIH positivo con lesiones encefálicas indeterminadas / Burkitt lymphoma diagnosed on 11C-Methionine cerebral PET in an HIV-positive patient with undetermined brain injury

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Burkitt's lymphoma nodular cystic hepatosplenic, in HIV patient. Case report / Linfoma de Burkitt hepatoesplénico quístico nodular, en paciente con VIH. Reporte de caso

Background: Patients with human immunodeficiency virus (HIV) are more likely to develop cancer. Malignant lymphomas are the main cancer group seen in these patients. Diffuse large B-cell lymphoma including central nervous system lymphoma and Burkitt's lymphoma account for 90% of HIV-related non-Hodgkin's lymphomas. Clinical case: A 22-year-old man with fever up to 39 ° C, malaise, excessive tiredness and night sweats, loss of 8 kg of weight, abdominal pain in the right hypochondrium, all 5 months before hospitalization. Hemoglobin: 9.5 g/dL, leukocytes 5.13 x 103/mm3, platelets 124 000 cel/mm3; albumin 2.9 g/dL, alanine aminotransferase 28 IU/L, aspartate aminotransferase 105 IU/L; HIV reactive, beta 2 microglobulin: 20 000 ng/mL. Viral load for HIV 100 034 cp/mL, CD4: 76 cel/mcL (5%). It was performed abdominal ultrasound and denoted cysts in the liver and spleen. Abdominal-pelvic computed tomography with hepatosplenomegaly, retroperitoneal and inguinal adenopathies and free fluid in abdominal cavity. Splenectomy was performed and Burkitt's lymphoma was reported in the histopathological study. Conclusion: HIV predisposes patients to any type of cancer. Intra-abdominal findings should be a warning of lymphoma suspicious and may occur from infiltration of the small intestine, solid organ and soft tissues.

Introducción: los pacientes con virus de inmunodeficiencia humana (VIH) son más propensos a desarrollar cáncer. Los linfomas malignos son el principal grupo de cáncer que se observa en estos pacientes. El linfoma difuso de células grandes B, incluido el del sistema nervioso central y el linfoma de Burkitt, constituyen 90% de los linfomas no Hodgkin relacionados con VIH. Caso clínico: hombre de 22 años de edad, con fiebre de hasta 39 °C, malestar general, cansancio excesivo y sudoración nocturna, pérdida de 8 kg de peso y dolor abdominal en hipocondrio derecho, 5 meses previos a su hospitalización. Se reportó hemoglobina de 9.5 g/dL, leucocitos 5.13 x 103/mm3, plaquetas 124 000 cel/mm3; albúmina 2.9 g/dL; alanino aminotransferasa 28 UI/L, aspartato aminotransferasa 105 UI/L; VIH reactivo, beta 2 microglobulina 20 000 ng/mL. Carga viral para VIH 100 034 cp/mL, CD4 76 cel/mcL (5%). El ultrasonido abdominal mostró quistes en hígado y bazo. La tomografía abdominopélvica reportó hepatoesplenomegalia, adenopatías retroperitoneales e inguinal y líquido libre en cavidad abdominal. Se realizó esplenectomía y en el estudio histopatológico se reportó Linfoma de Burkitt. Conclusión: El VIH predispone a los pacientes a cualquier tipo de cáncer. Los hallazgos intraabdominales deben hacer sospechar de linfoma y se puede presentar desde infiltración del intestino delgado, órgano sólido y tejidos blandos.

Dramatic treatment response of cutaneous plasmablastic lymphoma in an HIV patient: a case report.

Plasmablastic lymphoma is a variant of diffuse large B-cell lymphoma, characterized by rapid progression and is associated with a poor outcome. We report a 35-year-old male with poorly controlled HIV infection and AIDS who presented with skin lesions and swelling throughout the body. Computed tomography (CT) revealed innumerable enhancing soft tissue masses within the subcutaneous soft tissues and lymphadenopathy. Plasmablastic lymphoma was diagnosed, patient was treated with chemotherapy, and post treatment CT demonstrated complete resolution. Imaging plays a key role in the diagnosis and surveillance of this disease.

Coincidental Observation of Global Hypometabolism in the Brain on PET/CT of an AIDS Patient With High-Grade Pulmonary Non-Hodgkin Lymphoma.

AIDS-related dementia complex is the most severe form of cognitive dysfunction in a patient infected with human immunodeficiency virus. The use of FDG PET/CT to diagnose AIDS-related dementia complex has been studied previously and shows various specific metabolic patterns from striatal hypermetabolism in early asymptomatic stage to global hypometabolism in advanced stages. We present a case of a 49-year-old patient with long-standing human immunodeficiency virus infection, where global brain hypometabolism was noted coincidentally on FDG PET/CT done for initial staging of primary pulmonary non-Hodgkin lymphoma.

AIDS-related lymphoma in a young HIV late presenter patient.

Non-Hodgkin's lymphoma (NHL) is an acquired immunodeficiency syndrome (AIDS)-indicative disease. Nowadays, NHL is rarely reported in Europe as indicative disease for human immunodeficiency virus (HIV) testing. We present the case of a 22-year-old Romanian male patient without past medical history, except the swelling of a submental lymph node 11 months ago. The excised node was histologically examined but the patient neglected to take his result. He was admitted for fever, asthenia, and weight loss over 10% of his weight, and night sweats in the last four months. The immunohistochemical analysis of the preserved lymph node samples suggested reactive hyperplasic lymphadenitis with suppuration and necrosis (lymphoid follicles CD20+, CD10+, BCL6+; germinal centers CD23+, CD68+, Ki67+; and interfollicular CD3+). Clinical, biological and imaging evaluations were performed. The diagnostic of lymphoma stage IV Ann Arbor was sustained. Severe immunosuppression and a positive HIV test were found. The patient received antiretroviral treatment, but he developed paraplegia consecutive to a vertebral metastasis, liver and kidney failure and died sooner than two months from the diagnostic time. Pathological examination confirmed NHL with diffuse lymphocyte infiltrate of multiple organs. Advanced lymphoma is a rare indicator condition of HIV diagnostic. Delayed diagnostic of lymphoma implies ethical issues on communication deficiencies between the heath providers and patients, concerning the significance of biopsy. Infectious co-morbidities with necrosis and suppurative lesions are confounder conditions in NHL histological and immunohistochemical diagnosis.

Differentiation of HIV-associated lymphoma from HIV-associated reactive adenopathy using quantitative FDG PET and symmetry.

PURPOSE: To determine the diagnostic accuracy of a semiautomated (18)F-FDG PET/CT measurement of total lesion glycolysis (TLG), maximum and peak standardized uptake value at lean body mass (SUL-Max and SUL-Peak), qualitative estimates of left/right nodal symmetry and FDG uptake for differentiating lymphoma from reactive adenopathy in HIV-infected patients. METHODS: We retrospectively analyzed 41 whole-body (18)F-FDG PET/CT studies performed in HIV-infected patients for clinical reasons. The study received institutional review board approval. Of the 41 patients, 19 had biopsy-proven untreated lymphoma, and 22 with reactive adenopathy without malignancy on follow-up were used as controls. Nodal and extranodal visual qualitative metabolic scores, SUL-Max, SUL-Peak, CT nodal size, and PERCIST 1.0 threshold-based TLG and metabolic tumor volume (MTV) were determined. The qualitative intensity of nodal involvement and symmetry of uptake were compared using receiver operator curve (ROC) analysis. HIV plasma viral RNA measurements were also obtained. RESULTS: All of the quantitative PET metrics performed well in differentiating lymphoma from reactive adenopathy and performed better than qualitative visual intensity scores. The areas under the ROC curves (AUC) were significantly higher for TLG = 0.96, single SUL-Peak = 0.96, single SUL-Max = 0.97, and MTV = 0.96, compared to 0.67 for CT nodal size (p < 0.001). These PET metrics performed best in separating the two populations in aviremic patients, with AUCs of 1 (AUC 0.91 for CT nodal size). TLG, MTV, SUL-Peak and SUL-Max were more reliable markers among viremic individuals, with AUCs between 0.84 and 0.93, compared to other metrics. PET metrics were significantly correlated with plasma viral load in HIV-reactive adenopathy controls. Asymmetrical FDG uptake had an accuracy of 90.4 % for differentiating lymphoma from reactive adenopathy in HIV-infected patients. CONCLUSION: Quantitative PET metabolic metrics as well as the qualitative assessment of symmetry of nodal uptake appear to be valuable tools for differentiating lymphoma from reactive adenopathy in HIV-infected patients using FDG PET. These parameters appear more robust in aviremic patients.

Anorectal opportunistic diseases in human immunodeficiency virus/acquired immunodeficiency syndrome patients: spectrum of cross-sectional imaging findings.

Patients infected with the human immunodeficiency virus, particularly male homosexuals, are prone to develop disorders involving the anorectal and perineal structures. Cross-sectional imaging techniques, such as multidetector computed tomography with multiplanar reformations and magnetic resonance imaging performed with phased-array coils, are increasingly adopted to detect and stage infectious and neoplastic diseases, and to assess posttreatment modifications. Pyogenic perianal sepsis may be usefully investigated with imaging, particularly to assess the presence and topography of abscess collections to allow a correct surgical choice. Rectal inflammatory involvement is frequently detected during intestinal opportunistic infections, such as cytomegalovirus, pseudomembranous, and amebic colitides, including primary and secondary imaging signs consistent with proctocolitis. Anal carcinoma and intestinal lymphoma are increasingly diagnosed; therefore, special attention should be paid to the identification of solid tissue consistent with tumor; furthermore, MRI provides optimal staging and posttreatment follow-up of neoplastic lesions. Knowledge of this varied spectrum of anorectal and perineal opportunistic abnormalities and their imaging appearances should help radiologists to propose appropriate differential diagnoses, suggest correlation with laboratory and microbiological assays or biopsy, and reliably assess therapeutic response.

[Disseminated B-cell lymphoma with cardial involvement in an HIV positive patient]. / Dissemineret B-celle-lymfom med kardiel involvering ved hiv-infektion.

A 44 year-old Somali woman was admitted with chest pain, shortness of breath and weight loss. A transthoracic echocardiography showed extensive intracardiac tumour masses. A transvenous biopsy was performed yielding the diagnosis diffuse large B-cell lymphoma. Thoracic and abdominal computed tomography showed dissemination to several organs. The patient was tested HIV positive and initiated on chemotherapy and antiretroviral therapy. After five months no tumour masses could be visualised by a repeated echocardiographic examination. Unfortunately, the patient died a few months later from cerebral metastasis.

Hodgkin lymphoma in patients with HIV infection: a review.

Hodgkin lymphoma (HL) is one of the most common types of non-AIDS-defining tumors in the HIV-infected. Its incidence however seems to have increased under highly active anti-retroviral therapy (HAART). HIV-HL is a different entity from HL in HIV-negative subjects with a poorer prognosis that is associated with tumor-subtype, EBV-infection, and "B" symptoms. Despite the aggressive nature of the disease, clinical outcome has improved with combination therapies including appropriately timed antiretroviral strategies and the quality of supportive care-notably the use of hematopoietic growth factors. More intensive chemotherapy regimens with or without autologous stem cell transplantation appear to improve survival. Functional imaging such as positron emission tomography and computed tomography (FDG-PET) may help guide treatment strategy and minimize long-term toxicity.

Massive myocardial infiltration by HIV-related non-Hodgkin lymphoma: echocardiographic aspects at diagnosis and at follow-up.

A 23-year-old male presented with severe rest dyspnoea, engorged jugular veins, ankle oedema and heart rate 140 bpm. Computed tomography (CT) scan showed a large mediastinal mass with pericardial and atrial infiltration, pulmonary artery and superior vena cava compression. HIV infection was detected. Echocardiography showed 5 × 4 cm masses both in the right and the left atria, pericardial effusion, thickening of the right and left ventricular walls and hypokinesis; after intravenous contrast medium (SonoVue), the ventricular myocardium showed an increased, granular echogenicity, as did the mediastinal mass and pericardium. Nadroparin, bisoprolol, amiodarone and (suspecting non-Hodgkin lymphoma) steroids were started. After 3 days, at echocardiogram, the thickness of the ventricular walls was reduced and ejection fraction was improved. Mediastinal biopsy disclosed a large B-cell lymphoma. After starting systemic chemotherapy (rituximab, cyclophosphamide, vincristine, doxorubicin) and highly active antiretroviral therapy (HAART), 11 days after admission the patient was in New York Heart Association (NYHA) class 1-2, with normal jugular veins and no oedema. The echocardiogram showed no more pericardial effusion, atrial masses reduced by 50%, normal interventricular septum thickness and ejection fraction. In August 2010, after six cycles of chemotherapy followed by radiotherapy, the patient was in complete remission. This case shows both the echocardiographic findings typical of neoplastic infiltration of the myocardium and the rapid improvement observed within a few days after chemotherapy. In the HAART era patients with HIV-related lymphoma and even massive involvement of the heart may receive aggressive treatment with curative intent. Echocardiography is useful in early assessment of the response to therapy.

Interim fluoro-2-deoxy-D-glucose-PET predicts response and progression-free survival in patients with Hodgkin lymphoma and HIV infection.

BACKGROUND: Interim PET scans in HIV-negative patients with Hodgkin lymphoma has emerged as one of the most important prognostic tools. However, equivalent studies in HIV-positive patients are yet to be performed. OBJECTIVE: We evaluated the prognostic value of interim [18F]-fluoro-2-deoxy-D-glucose-PET (18F-FDG PET) after two or three cycles of chemotherapy using adriamycin, bleomycin, vinblastine and dacarbazine (ABVD) with concomitant HAART in HIV-positive patients with Hodgkin lymphoma. METHODS: Patients with advanced HIV-Hodgkin lymphoma (HIV-HL) from six UK centres were included. Interim PET scans after two or three cycles of ABVD (PET-2 or PET-3) were carried out. Prognostic analysis correlated the 2-year progression-free survival (PFS) rate with the interim PET result. RESULTS: Twenty-three evaluable patients were assessed, 21 achieved a negative interim PET and 22 achieved complete remission by computerized tomography scan criteria after ABVD therapy. After a median follow-up of 27 months (range 12-50), disease progression was seen in one patient. Treatment failure was seen in one of the two interim PET-positive patients and none of the interim PET-negative patients. The 2-year PFS for interim PET-positive patients was 50%, and 100% for interim PET-negative patients (P = 0.0012). CONCLUSION: A negative interim 18F-FDG PET result is highly predictive of treatment success in HIV-HL patients.

Viral hepatitis is associated with reduced bone mineral density in HIV-infected women but not men.

OBJECTIVE: Few studies have examined the impact of viral hepatitis on bone mineral density (BMD), and none have done so among HIV-infected patients. Our objective was to determine whether viral hepatitis was associated with low BMD in HIV. DESIGN: : A cross-sectional study among 1237 HIV-infected patients (625 with viral hepatitis). METHODS: Dual-energy X-ray absorptiometry scans of the lumbar spine and femoral neck were obtained. Clinical data, hepatitis B and C status, and markers of bone metabolism were determined at dual-energy X-ray absorptiometry scanning. Multivariable logistic regression examined the association between hepatitis and low BMD (Z-score < or =-2.0 at the lumbar spine, femoral neck, or both). RESULTS: Mean BMD Z-scores were lower among hepatitis-coinfected women at the lumbar spine {-0.15 versus +0.29; difference = -0.44 [95% confidence Interval (CI) -0.65 to -0.23]; P < 0.001} and femoral neck [-0.64 versus -0.39; difference = -0.25 (95% CI -0.44 to -0.06); P = 0.009] compared with HIV-monoinfected women. No differences in mean BMD Z-scores were observed between coinfected and monoinfected men. After adjustment for age, BMI, duration of HIV, antiretroviral use, physical activity, and smoking, viral hepatitis was associated with low BMD among women (adjusted odds ratio 2.87, 95% CI 1.31-6.29) but not men (adjusted odds ratio 1.19, 95% CI 0.74-1.91). Coinfected women had lower mean parathyroid hormone (60.1 versus 68.1 pg/ml; P = 0.02) but similar mean 25-hydroxyvitamin D (19.1 versus 19.6 ng/ml; P = 0.6) and osteocalcin (3.0 versus 3.2 ng/ml; P = 0.8) concentrations than HIV-monoinfected women. CONCLUSION: Viral hepatitis was associated with a higher risk of low BMD among HIV-infected women but not men.

Vulvar plasmablastic lymphoma in a HIV-positive child: a novel extraoral localisation.

Plasmablastic lymphoma (PBL) has been characterised by the World Health Organization as a new entity. This report describes an unusual case of PBL in a 3-year-old HIV-infected patient showing a cutaneous vulvar lesion with 9 months of evolution and prolapsed vulvovaginal mucosa. Histopathological examination of a biopsy sample showed diffuse submucosal infiltration by large cells with a cohesive growth pattern, and round and vesicular nuclei with fine chromatin centrally or eccentrically placed with one or more prominent nucleoli. Immunohistochemical staining in neoplastic cells was positive for multiple melanoma oncogene (MUM1), CD138, CD45 and epithelial membrane antigen (EMA). The diagnosis was PBL, stage III. Epstein-Barr virus (EBV) expression was positive by EBV encoded RNAs in situ hybridisation. This is believed to be the third case of paediatric HIV-associated PBL reported in the literature, and the first with vulvar localisation, which is a new anatomical location for this entity.

Highly active antiretroviral therapy as the sole treatment for AIDS-related primary central nervous system lymphoma: a case report with implications for treatment.

A 40-year-old male presented to medical attention with Pneumocystis jiroveci pneumonia and HIV infection. His CD4+ count was 18 cells per microliter and his HIV viral load (VL) was more than 400,000 copies milliliter. After 3 weeks of antibiotic therapy, he continued to have global cognitive deficits. A brain imaging study showed a right temporal mass, which on biopsy proved to be primary central nervous system lymphoma (PCNSL). He began highly active antiretroviral therapy (HAART) but declined palliative whole-brain radiotherapy (WBRT). Four months later, his CD4+ count had improved to 153 cells per microliter and his HIV VL was less than 75 copies per milliliter. At 36 months follow-up, he remained in complete remission (CR). Through a literature review, we identified 4 additional PCNSL patients who achieved prolonged remission after the initiation of HAART. One patient required WBRT and ventriculo-peritoneal shunting for signs and symptoms of obstructive hydrocephalus. The other 3 patients presented with stable neurologic findings and were treated with HAART alone. The median initial CD4+ count for these patients was 50 cells per microliter (range, 2 to 220 cells per microliter). All 5 remained in CR with a median follow-up of 23.5 (range, 13 to 36) months. For patients who present with PCNSL as their initial AIDS-defining event, stable neurologic findings, and effective HAART options, initial treatment with HAART alone may be possible, reserving WBRT and corticosteroids for those who show signs of impending neurologic demise. Chemotherapy and other novel approaches could also be considered for selected patients with lesser degrees of immune suppression and high baseline functional status.