Abdominal carcinomas mimicking HIV-associated lipodystrophy.

Two cases of abdominal distention and extremity muscle wasting in HIV-infected men who were receiving HAART are reported. In both instances, clinician and patient alike were concerned about the possibility of HIV-associated lipodystrophy. However, further investigation led to a diagnosis of disseminated cancer in both patients.

Primary cutaneous large B-cell lymphoma of the legs: a distinct clinical pathologic entity treated with CD20 monoclonal antibody (rituximab).

Primary cutaneous large B-cell lymphoma of the legs (PCLBLL) is most commonly diagnosed in the elderly, and is generally confined to the lower parts of one or sometimes both legs. Despite treatment with radiotherapy, relapses and extracutaneous involvement can occur, and unlike other low-grade cutaneous-B-cell non-Hodgkin's lymphomas (NHLs), the prognosis is variable, with an estimated 5-year survival rate of 58%. This report describes the case of an 81-year-old man who was diagnosed with PCLBLL. Staging evaluation did not reveal NHL elsewhere. The patient declined recommendations to receive cytotoxic chemotherapy. Instead, he was treated with anti-CD20 monoclonal therapy (rituximab) and his cutaneous lesions completely regressed during a 16-week period. This report suggests that rituximab is a therapeutic option for those patients with PCLBLL who may not be good candidates to receive radiation therapy or chemotherapy. Long-term follow-up and greater experience with rituximab in a variety of clinical settings will ultimately determine the appropriate role of this costly, but relatively safe, antibody-based therapy for CD20+ expressing NHLs.

Penile cancer and human papilloma virus (HPV) in a human immunodeficiency virus (HIV)-infected patient.

Only a handful of cases of penile carcinoma among human immunodeficiency virus (HIV)-infected males have been reported. This is surprising insofar as other anogenital malignancies associated with human papillomavirus (HPV) are over-represented in HIV-infected men and women. Herein we describe the case of an HIV seropositive 64-year-old Caucasian with a CD4+ T-lymphocyte count of 550 cells/mm3 and an invasive squamous cell cancer of the penis. He underwent radical penectomy to treat cancer initially confined to the penile shaft and glans penis, but ultimately succumbed to complications associated with metastatic disease. HPV type 18 was identified by in situ hybridization and polymerase chain reaction (PCR) studies in the primary tumor and in groin and lung metastasis. We also briefly review current thoughts regarding the epidemiology and pathogenesis of penile cancer, particularly in the setting of HPV and HIV co-infection.

Optimal treatment of nevirapine-associated hepatotoxicity remains uncertain.

The cases of 2 patients with nevirapine-associated hepatotoxicity in conjunction with rash and eosinophilia are reported here. Both patients' conditions improved following withdrawal of nevirapine. Previous case reports have described a variety of interventions other than drug withdrawal that might have contributed to resolution of drug-induced hepatitis. Until a better understanding of the clinical spectrum and pathophysiology of nevirapine-associated hepatotoxicity is realized, treatment will remain largely empiric.

Incidence, location, and diagnostic evaluation of metastatic bone disease.

Metastatic carcinoma is the most common malignancy of bone. The clinical presentation of patients with skeletal metastasis is variable. When asked to evaluate a patient with a pathologic lesion or unexplained bone pain, the orthopedic surgeon should follow a logical sequence of steps in evaluating the patient with suspected metastasis to optimize care and avoid complications. In the majority of cases, a systematic approach to the patient with skeletal metastasis leads to the correct diagnosis.

Etanercept for the treatment of human immunodeficiency virus-associated psoriatic arthritis.

Etanercept may play an important role in modulating the inflammatory activity and progression of human immunodeficiency virus (HIV)-associated psoriasis and psoriatic arthritis. We report the case of a 45-year-old homosexual man with a CD4 cell count of less than 0.05 x 10(9)/L and an HIV viral load of 4200 copies/mL (while receiving highly active antiretroviral therapy) who developed extensive psoriatic plaques, 4.5-kg weight loss, onychodystrophy, and psoriatic arthropathy with severe periarticular bone demineralization. The arthritis progressed despite the use of several disease-modifying medications, including corticosteroids, hydroxychloroquine, and minocycline. Because of uncontrolled, progressive, and disabling arthritis and resulting profound disability, he was treated with etanercept. Within 3 weeks, his psoriasis had improved dramatically and his joint inflammation had stabilized. For the next 4 months, immunologic and viral parameters remained stable, but his clinical course was complicated by frequent polymicrobial infections. Etanercept was thus discontinued despite continued improvements in his psoriasis, psoriatic arthritis, and functional status. While both cutaneous and joint manifestations of psoriasis improved dramatically, the experience with this patient dictates that caution and careful follow-up must be exercised when prescribing etanercept in the setting of HIV infection.

Initial observations on the efficacy of highly active antiretroviral therapy in the treatment of HIV-associated autoimmune thrombocytopenia.

BACKGROUND: Immune thrombocytopenic purpura (ITP) occurs in as many as 40% of patients infected with the human immunodeficiency virus (HIV). We sought to evaluate the effect of highly active antiretroviral therapy (HAART) on platelet counts in such patients. METHODS: Data collected from 11 homosexual men with HIV-associated ITP and < or = 50 x 10(9) platelets were analyzed after they were placed on HAART. At initial evaluation, 7 patients were antiretroviral naive, 2 were taking zidovudine alone, and 2 were receiving combination antiretroviral therapy for known HIV infection. For 6 patients with <30 x 10(9) platelets, prednisone was initially coadministered with HAART. The primary outcome measure was the platelet count response to HAART, which was measured weekly until counts had normalized on 3 consecutive occasions, then every 3 months while on HAART. Secondary outcome measures were HIV-viral RNA levels and CD4+ cell counts. RESULTS: One month after the initiation of HAART, 10 evaluable patients had an increase in mean platelet count. This improvement was sustained at 6 and 12 months' follow-up for 9 of 10 evaluable patients. Increases in mean platelet count at 6 and 12 months of the 9 responders were statistically significant. The range of follow-up in the 9 responders is 21 to 46 months (median, 30 months), with no thrombocytopenic relapses. The 9 long-term platelet responders have been maintained on HAART and at 12 months had a mean reduction of > 1.5 log10 in HIV viral RNA serum levels and a marked improvement in CD4+ T-lymphocyte cell count. CONCLUSION: HAART seems to be effective in improving platelet counts in the setting of HIV-associated ITP, enhancing CD4+ cell counts, and reducing HIV viral loads.

Inflammatory pseudotumor causing small bowel obstruction and mimicking lymphoma in a patient with AIDS: clinical improvement after initiation of thalidomide treatment.

A patient with AIDS was diagnosed with inflammatory pseudotumor with small bowel involvement. After receiving thalidomide treatment, serum tumor necrosis factor (TNF) and soluble TNF receptor II levels normalized, his constitutional and gastrointestinal symptoms diminished, and the mass lesion shrunk.

The epidemiologic, pathologic, and clinical features of AIDS-associated pulmonary Kaposi's sarcoma.

AIDS-related Kaposi's sarcoma (KS) occurs principally in homosexual or bisexual men infected with the newly identified human herpes virus-8, also called KS-associated herpes virus. Unlike classical forms of the disease, AIDS-associated KS is a multicentric entity that frequently involves lymph nodes and the GI tract. KS may also occur in the lung, commonly in the setting of extensive mucocutaneous disease and very rarely as an isolated event. The exact incidence of intrathoracic KS in patients with AIDS is unknown. Before the advent of highly active antiretroviral therapy (HAART), pulmonary KS had been reported in approximately 10% of patients with AIDS, 25% of patients with cutaneous KS, and in roughly 50% of postmortem examinations of patients with AIDS, KS, and respiratory infections. In the HAART era, the incidence of KS has declined precipitously in North America and Europe but not in third world countries where HAART is largely unavailable. Pulmonary KS may cause radiographic infiltrates and respiratory symptoms that mimic a variety of other infectious and neoplastic processes. An aggressive diagnostic evaluation of patients who have this condition is essential because chemotherapy and radiation therapy may provide significant palliation, particularly if used in conjunction with HAART. This review briefly explores the changing epidemiology of KS. The pathology and pathogenesis of KS is also reviewed, along with the clinical and radiographic presentation, diagnosis, and management of pulmonary KS.

Simvastatin-induced rhabdomyolysis in an HIV-infected patient with coronary artery disease.

As greater numbers of human immunodeficiency virus (HIV)-infected individuals live to middle-age and beyond, there is growing concern that elevated cholesterol and lipid values will lead to cardiovascular complications in such patients. Furthermore, several of the highly active antiretroviral therapies (HAART) used to reduce levels of circulating HIV and extend acquired immunodeficiency syndrome (AIDS)-related survival are associated with a rise in plasma lipids. Anecdotal reports suggest such rises may be linked to cardiovascular complications. Herein, we review the case of a 74-year-old HIV-infected man with advanced coronary artery disease. He was prescribed simvastatin for control of hyperlipidemia and within 4 weeks developed muscle pain, proximal muscle weakness, myoglobinuria, and a markedly elevated creatinine phosphokinase (CPK). Simvastatin was discontinued, and rhabdomyolysis improved rapidly with conservative care. This report emphasizes this rare, but potentially significant, side effect of statin anticholesterol agents. Medical providers who prescribe statins must remember to check CPK levels when their HIV-infected patients complain of muscle pain. Discontinuing the offending drug will usually result in rapid diminution of muscle pain and inflammation and improve muscle strength.

Occupational exposure to human immunodeficiency virus: what healthcare providers should know.

PURPOSE: The author reviews the risks of occupational exposure to HIV and provides a rationale for new postexposure guidelines for healthcare workers. OVERVIEW: Approximately 50,000 percutaneous exposures occur yearly among healthcare workers in the United States. Of these, approximately 5000 involve exposures to blood that is known to be infected with HIV. The risk of transmission after percutaneous exposure to HIV-tainted blood has been estimated to be 0.3%, but the risk may be considerably higher to the healthcare worker if any of the following is present: a deep injury; visible blood on the sharp device; a procedure that involves a needle placed in the patient's artery or vein; and a patient with advanced AIDS. The increasing resistance of HIV strains to antiretroviral therapy continues to make treatment more difficult. CLINICAL IMPLICATIONS: Postexposure prophylaxis with zidovudine may reduce the risk of occupational infection by 80%. Advances in the ability to ameliorate HIV transmission rates and to treat individuals with resistant disease through innovations in drug therapy, engineering of controls for injury prevention, and more focused postexposure evaluation offer the hope of reducing this infrequent, but dangerous, occupational threat.

Retinoid-induced hypercalcemia in a patient with kaposi sarcoma associated with acquired immunodeficiency syndrome.

Retinoids are commonly used for the treatment of nonmalignant skin disorders and occasionally for the treatment of various neoplasms including epidemic Kaposi sarcoma (KS). Dry skin and mucus membranes, muscle and joint aches, alopecia, headaches, and liver and lipid abnormalities are the most frequent medication-related side effects. Very rarely, this class of drugs is associated with the development of hypercalcemia. The authors report the case of a man with acquired immunodeficiency syndrome (AIDS)-associated KS who, while participating in a phase II clinical trial of LGD 1057 (9-cis-retinoic acid) for treatment of epidemic KS, developed hypercalcemia, mental status changes, and renal insufficiency. The etiologic factors of retinoid-induced hypercalcemia are imperfectly understood, but with drug withdrawal his serum calcium, mental acuity, and renal function quickly normalized. Hypercalcemia occurs infrequently in the setting of AIDS and when present, is usually mediated by opportunistic infections. Clinicians should be alert to this potentially life-threatening iatrogenic complication that responds favorably to drug withdrawal.

Extramedullary facial plasmacytomas with anaplastic features: a diagnostic dilemma with implications for treatment.

Extramedullary plasmacytomas (EMPs) are rare plasma-cell tumors of the soft tissue that occur predominantly in the nasal sinuses and oropharynx. Subcutaneous and cutaneous plasmacytomas of the face are distinctly unusual. The authors report a case of rapidly expanding EMP involving the lip and contralateral nasolabial fold of a native Alaskan man with a 25-year history of recurring solitary bone plasmacytomas (SBP). An incisional biopsy revealed sheets of monotypic plasmablasts with anaplastic features. The pathologic and clinical findings were most consistent with a Richter transformation from a low-grade to a high-grade malignancy, or anaplastic myeloma (AM). With combined chemotherapy and radiation therapy, he achieved a complete response. The clinical and laboratory features of this most unusual plasma-cell dyscrasia are reviewed with an emphasis placed on diagnosis and treatment.

Cost-effectiveness analysis comparing liposomal anthracyclines in the treatment of AIDS-related Kaposi's sarcoma.

Liposomal formulations have been shown to alter the efficacy and toxicity profiles of anthracylines for patients with HIV-related advanced Kaposi's sarcoma (KS). Using decision-analysis models, the costs and cost-effectiveness of the two U.S. Food and Drug Administration (FDA)-approved liposomal formulations of these agents were estimated. Estimates of costs, effectiveness, and cost-effectiveness were derived from clinical trial data of separate, randomized phase III trials of pegylated liposomal doxorubicin (20 mg/m2 every 3 weeks) and liposomal daunorubicin (40 mg/m2 every 2 weeks). Clinical response rates were 59% for pegylated liposomal doxorubicin and 25% for liposomal daunorubicin. Despite higher acquisition costs for pegylated liposomal doxorubicin, total estimated costs of treatment for KS and chemotherapy-related hematologic toxicities were similar ($7,066 U.S. compared with $6,621 U.S. for liposomal daunorubicin). Cost-effectiveness profiles, defined as average costs per responder, favored pegylated liposomal doxorubicin ($11,976 U.S./responder versus $26,483 U.S./responder for liposomal daunorubicin), reflecting the higher reported response rate in the phase III trial. Sensitivity analyses suggested that the costs and cost-effectiveness results would not differ markedly when evaluated over a range of assumptions, including response rate, neutropenia rate, and dosage variations.

Malignant melanoma in an HIV-infected man: a case report and literature review.

Although it is not proven by causative association, several studies indicate that patients with acquired immune deficiency syndrome (AIDS) have a high risk for developing cutaneous malignancies, especially lymphoma and Kaposi's sarcoma. Other malignant cutaneous lesions seen in this patient population include basal-cell carcinoma, squamous-cell cancer, Bowen's disease, and rarely, malignant melanoma. We review the clinical course of a human immunodeficiency virus (HIV)-infected man with a superficial spreading melanoma of the scapula treated with wide local excision. Ten years later, he was diagnosed as having metastatic and widespread disease. By placing our patient's experience in context with other case reports, we sought to determine whether malignant melanoma in the HIV-infected population presents atypically or has a more aggressive natural history. The appearance of malignant melanoma in homosexual men may be coincidental or reflective of the expanding spectrum of HIV-associated diseases. Of the 22 patients reported to have malignant melanoma and HIV, approximately one-third had metastatic disease at the time of initial examination, and those with a decreased CD4+ cell count were most likely to have systemic symptoms. Melanomas among patients with HIV infection were often atypical in appearance, being multiple or metastatic, as is the case in other well-defined immunosuppressed groups. Further epidemiological and clinical studies are required to determine whether melanoma occurs more frequently or is more likely to metastasize in persons with HIV disease. Laboratory investigators must also concentrate on those factors in the setting of HIV disease that may contribute to melanocyte activation. Our patient's fulminant clinical course should alert clinicians to carefully evaluate patients with HIV infection and unusual pigmented cutaneous lesions, or who have a prior history of malignant melanoma.

Regression of acquired immunodeficiency syndrome-related pulmonary Kaposi's sarcoma after highly active antiretroviral therapy.

Kaposi's sarcoma (KS) is the most common neoplasm affecting people with the human immunodeficiency virus (HIV) infection. The skin is the most common site of disease; however, KS can also involve visceral organs such as the lungs, leading to severe morbidity and contributing to death in almost 30% of patients with the acquired immunodeficiency syndrome (AIDS). New antiretroviral strategies incorporating combination nucleoside analogues with a protease inhibitor lead to increased circulating CD4+ lymphocyte counts, decreased plasma levels of HIV, and decreased mortality from AIDS-defining opportunistic infections. The effects of highly active antiretroviral therapy (HAART) on AIDS-associated KS remain largely unknown. Herein the case of an antiretroviral-naive man with advanced AIDS (CD4+ helper T-lymphocyte count, 35/mm3; HIV viral RNA quantification, more than 800,000 copies/mL), and symptomatic pulmonary KS is described. After HAART was initiated, his CD4+ cell count increased fourfold, his HIV-viral load decreased to nondetectable levels, and the pulmonary KS regressed dramatically. To my knowledge, this report represents the first documented case of pulmonary KS regression after the initiation of HAART. Although this finding is preliminary, if confirmed by other clinicians, the effect of potent antiretrovirals on KS growth and development will have important implications on the manner in which KS is staged and treated.

AIDS-associated secondary lymphoma of bone: a case report with review of the literature.

Although musculoskeletal lesions are not reported as commonly as pulmonary or central nervous system abnormalities in human immunodeficiency virus (HIV)-positive individuals, a wide variety of osseous and soft-tissue changes are seen in these patients. We describe the case of a 35-year-old injection drug user with acquired immune deficiency syndrome (AIDS) who presented with diffuse adenopathy, lower extremity pain and swelling, subcutaneous nodules, and constitutional symptoms. Radiographic images showed bilateral lytic lesions of the tibia and accompanying soft-tissue masses. Biopsy of the bone and soft-tissue abnormalities established a diagnosis of Burkitt's-like non-Hodgkin's lymphoma (NHL). By recognizing the heterogeneity of AIDS-associated NHL presentations, and the potential clinical overlap between malignancy, infection, and other rheumatologic abnormalities, physicians may obtain appropriate diagnostic studies and offer treatment recommendations.