Changing Patterns of Lymphoma in the Antiretroviral Therapy Era in Johannesburg, South Africa

BACKGROUND

South Africa has a high HIV prevalence, which associates with an increased risk of lymphoma. Antiretroviral therapy (ART) became accessible in 2004, but the program has substantially expanded. Changes in lymphoma patterns are documented in high-income countries after wide-scale ART including declining high-grade B-cell non-Hodgkin lymphomas (HG B-NHLs), particularly diffuse large B-cell lymphoma, and increased Hodgkin lymphoma (HL). There are limited data from Africa. This study aimed to compare HG B-NHL characteristics in the early (2007) and later (2017) ART era.

METHODS

All incident lymphomas at the National Health Laboratory Service, Johannesburg, were identified using the laboratory information system, and data were collected for each patient.

RESULTS

The total number of lymphoma cases increased from 397 (2007) to 582 (2017). This was associated with improved lymphoma classification and patient referral for oncological care. HG B-NHL remained the most diagnosed lymphoma subtype in 2017 comprising 70% of HIV-associated lymphomas, followed by HL (24%). Diffuse large B-cell lymphoma comprised 65% of all HG B-NHLs and 45% of all lymphomas in people with HIV in 2017. Significantly more patients were on ART in 2017, with improvements in virological control documented. Despite this, 47.6% of patients were not virologically suppressed, and 37.5% of patients were ART-naive at time of diagnosis in 2017. Immunological reconstitution was suboptimal, which may reflect late initiation of ART.

CONCLUSION

Public health initiatives to initiate ART as early as possible and to retain patients in ART programs may assist in decreasing the number of HIV-associated lymphomas in our setting.

Increasing Levels of Serum Heat Shock Protein 70 Precede the Development of AIDS-Defining Non-Hodgkin Lymphoma Among Carriers of HLA-B8-DR3

BACKGROUND

We hypothesized that carriage of presumably high Hsp70-producing gene variants on a specific human major histocompatibility complex haplotype, the 8.1 ancestral haplotype (8.1AH), may predispose HIV-infected individuals to AIDS-non-Hodgkin lymphoma (NHL).

SETTING

We compared serum Hsp70 levels in the years preceding the diagnosis of AIDS-NHL in a matched case-control study (n = 151 pairs) nested in the Multicenter AIDS Cohort Study.

METHODS

We tested the impact of 8.1AH-specific single-nucleotide polymorphism (SNP) and joint SNP-human leukocyte antigen extended haplotypes previously associated with AIDS-NHL in the Multicenter AIDS Cohort Study on the circulating Hsp70 levels in mixed linear models.

RESULTS

We report elevated serum levels of Hsp70 in the 4 years preceding the diagnosis of AIDS-NHL in cases that carry 8.1AH, but not in noncarrier cases and not in carrier- or non-carrier-matched controls. The strongest predictor of higher serum Hsp70 was the haplotype A-G-A-C formed by SNPs rs537160(A) and rs1270942(G) in the complement factor CFB gene cluster, and rs2072633(A) and rs6467(C) in nearby RDBP and CYP21A2 located 70 Kb apart from the Hsp70 gene cluster. The association with A-G-A-C haplotype (beta = 0.718; standard error = 0.182; P = 0.0002) and with other 8.1AH-specific haplotypes including the high-producing tumor necrosis factor-alpha haplotype rs909253(G)-rs1800629(A) (beta = 0.308; standard error = 0.140; P = 0.032) were observed only with NHL identified as an AIDS-defining condition, but not as a post-AIDS condition, nor in combined AIDS and post-AIDS cases.

CONCLUSION

Our combined genetic and functional approach suggests that the altered level of Hsp70 is a correlate of 8.1AH-mediated AIDS-NHL. Further investigation of the Hsp70 gene cluster and nearby loci that are tagged by A-G-A-C could better elucidate the genetic determinants of the malignancy.

CD4-Positive T-Cell Primary Central Nervous System Lymphoma in an HIV Positive Patient

OBJECTIVES

Primary central nervous system lymphomas (PCNSLs) in patients with human immunodeficiency virus (HIV) are predominantly B-cell lymphomas associated with Epstein-Barr virus (EBV) and rarely CD8-positive T-cell PCNSLs.

METHODS

Patient history, laboratory results, cerebrospinal fluid (CSF), imaging, and brain biopsy specimens were reviewed and tested for T-cell receptor clonality.

RESULTS

A 64-year-old HIV-positive woman sought treatment for lethargy and left-sided weakness. Brain imaging showed regional increased T2 signal with restricted diffusion in cerebral hemispheres. CSF flow cytometry revealed CD4-positive T lymphocytes with loss of CD3, CD5, and CD7. EBV-positive T-cell lymphoma was immunohistochemically confirmed on brain biopsy specimens. Molecular analysis detected clonal T-cell receptor gene rearrangement. The patient received intrathecal methotrexate and whole-brain radiation. She did not respond to treatment and was eventually placed in hospice care.

CONCLUSIONS

To our knowledge, this is the first report of CD4-positive T-cell PCNSL in an HIV-positive patient and will help to raise clinical awareness of this previously unknown entity.

γ-Herpesvirus load as surrogate marker of early death in HIV-1 lymphoma patients submitted to high dose chemotherapy and autologous peripheral blood stem cell transplantation

Autologous stem cell transplantation (ASCT) is a feasible procedure for human immunodeficiency virus-1 (HIV-1) lymphoma patients, whose underlying disease and intrinsic HIV-1- and ASCT-associated immunodeficiency might increase the risk for γ-herpesvirus load persistence and/or reactivation. We evaluated this hypothesis by investigating the levels of Epstein-Barr virus (EBV)- and Kaposi sarcoma-associated herpesvirus (KSHV)-DNA levels in the peripheral blood of 22 HIV-1-associated lymphoma patients during ASCT, highlighting their relationship with γ-herpesvirus lymphoma status, immunological parameters, and clinical events. EBV-DNA was detected in the pre-treatment plasma and peripheral blood mononuclear cells (PBMCs) of 12 (median 12135 copies/mL) and 18 patients (median 417 copies/10⁶ PBMCs), respectively; the values in the two compartments were correlated (r = 0.77, p = 0.0001). Only EBV-positive lymphomas showed detectable levels of plasma EBV-DNA. After debulking chemotherapy, plasma EBV-DNA was associated with lymphoma chemosensitivity (p = 0.03) and a significant higher mortality risk by multivariate Cox analysis adjusted for EBV-lymphoma status (HR, 10.46, 95% CI, 1.11–98.32, p = 0.04). After infusion, EBV-DNA was detectable in five EBV-positive lymphoma patients who died within six months. KSHV-DNA load was positive in only one patient, who died from primary effusion lymphoma. Fluctuations in levels of KSHV-DNA reflected the patient’s therapy and evolution of his underlying lymphoma. Other γ-herpesvirus-associated malignancies, such as multicentric Castleman disease and Kaposi sarcoma, or end-organ complications after salvage treatment were not found. Overall, these findings suggest a prognostic and predictive value of EBV-DNA and KSHV-DNA, the monitoring of which could be a simple, complementary tool for the management of γ-herpesvirus-positive lymphomas in HIV-1 patients submitted to ASCT.

AIDS-related primary cardiac lymphoma with right-sided heart failure and high-grade AV block: insights from magnetic resonance imaging

A 44-year-old patient, with personal history of AIDS, was referred to our emergency unit with tachycardia and moderate signs of right-sided heart failure. The cardiac MRI study showed an impairment of the right ventricular free and inferior wall and the interventricular septum. The mass was characterized by notable heterogeneity with mixed areas of hypo- and hypersignal intensity in SSFP and T2-weighted images with fat saturation. There was global hyperenhancement of the mass after gadolinium contrast injection on T1-weighted images with and without fat saturation. The entire right coronary artery was included into the infiltrative mass. One day after the admission, the patient suddenly presented a paroxysmal third degree atrioventricular block, permanently corrected by an implanted cardiac pacemaker. Endomyocardial biopsy conformed the diagnosis of B-cell lymphoma. The patient died 4months after the diagnosis of acute heart failure with multi-organ dysfunction, after a short period of improvement under chemotherapy. We present this case to highlight the importance to consider that a large, solitary, right atrial mass in conjunction with pericardial effusion in a patient with HIV infection should lead to consider, as soon as possible, the diagnosis of lymphoma. MRI has explained the conduction disorders by showing the septal extension of the mass, and by demonstrating right coronary artery involvement.

Diagnosis and management of lymphomas and other cancers in HIV-infected patients

Despite the introduction of highly active antiretroviral therapy or combination antiretroviral therapy (HAART and cART, respectively) patients infected with HIV might develop certain types of cancer more frequently than uninfected people. Lymphomas represent the most frequent malignancy among patients with HIV. Other cancer types that have increased in these patients include Kaposi sarcoma, cancer of the cervix, anus, lung and liver. In the post-HAART era, however, patients with HIV have experienced a significant improvement in their morbidity, mortality and life expectancy. This Review focuses on the different types of lymphomas that generally occur in patients with HIV. The combination of cART and antineoplastic treatment has resulted in remarkable prolongation of disease-free survival and overall survival among patients with HIV who develop lymphoma. However, the survival in these patients still lags behind that of patients with lymphoma who are not infected with HIV. We also provide an update of epidemiological data, diagnostic issues, and strategies regarding the most-appropriate management of patients with both HIV and lymphomas.

[Immunodeficiency related malignant lymphoma: diagnosis and therapy of AIDS-related lymphoma]

AIDS-related lymphoma (ARL) remains a significant burden for specialists in HIV/AIDS medicine. Pathological findings of ARL are often non-typical in various histological types. Diagnosis of correct histological type of ARL by the skilled pathologist is essential. Therapy of patients with ARL is the challenge of integrating treatment appropriate for the stage and histological subset of non-Hodgkin lymphoma. In addition to chemotherapy, essential components of an optimal ARL treatment strategy include antiretroviral therapy and prophylaxis for opportunistic infections.

Temporal trends in presentation and survival for HIV-associated lymphoma in the antiretroviral therapy era

BACKGROUND

Lymphoma is the leading cause of cancer-related death among HIV-infected patients in the antiretroviral therapy (ART) era.

METHODS

We studied lymphoma patients in the Centers for AIDS Research Network of Integrated Clinical Systems from 1996 until 2010. We examined differences stratified by histology and diagnosis year. Mortality and predictors of death were analyzed using Kaplan-Meier curves and Cox proportional hazards.

RESULTS

Of 23 050 HIV-infected individuals, 476 (2.1%) developed lymphoma (79 [16.6%] Hodgkin lymphoma [HL]; 201 [42.2%] diffuse large B-cell lymphoma [DLBCL]; 56 [11.8%] Burkitt lymphoma [BL]; 54 [11.3%] primary central nervous system lymphoma [PCNSL]; and 86 [18.1%] other non-Hodgkin lymphoma [NHL]). At diagnosis, HL patients had higher CD4 counts and lower HIV RNA than NHL patients. PCNSL patients had the lowest and BL patients had the highest CD4 counts among NHL categories. During the study period, CD4 count at lymphoma diagnosis progressively increased and HIV RNA decreased. Five-year survival was 61.6% for HL, 50.0% for BL, 44.1% for DLBCL, 43.3% for other NHL, and 22.8% for PCNSL. Mortality was associated with age (adjusted hazard ratio [AHR] = 1.28 per decade increase, 95% confidence interval [CI] = 1.06 to 1.54), lymphoma occurrence on ART (AHR = 2.21, 95% CI = 1.53 to 3.20), CD4 count (AHR = 0.81 per 100 cell/µL increase, 95% CI = 0.72 to 0.90), HIV RNA (AHR = 1.13 per log10copies/mL, 95% CI = 1.00 to 1.27), and histology but not earlier diagnosis year.

CONCLUSIONS

HIV-associated lymphoma is heterogeneous and changing, with less immunosuppression and greater HIV control at diagnosis. Stable survival and increased mortality for lymphoma occurring on ART call for greater biologic insights to improve outcomes.

Utility of FDG-PETCT and magnetic resonance spectroscopy in differentiating between cerebral lymphoma and non-malignant CNS lesions in HIV-infected patients

BACKGROUND AND PURPOSE

In HIV infected patients, MRI cannot reliably differentiate between central nervous system (CNS) lymphoma and non-malignant CNS lesions, particularly cerebral toxoplasmosis (CTOX). This study prospectively investigates the utility of FDG PET-CT and magnetic resonance spectroscopy (MRS) in discriminating CNS lymphoma from non-malignant CNS lesions in HIV infected patients, and assesses the ability of FDG PET-CT to guide the use of early brain biopsy.

METHODS

10 HIV patients with neurological symptoms and contrast enhancing lesions on MRI were commenced on anti-toxoplasmosis therapy before undergoing FDG PET-CT and MRS. Brain biopsies were sought in those with FDG PET-CT suggestive of CNS lymphoma, and in those with a negative FDG PET-CT scan who failed to respond to therapy. Final diagnosis was based on histology or treatment response.

RESULTS

Two patients were confirmed to have CNS lymphoma and FDG PET-CT was consistent with this diagnosis in both. Six patients had cerebral toxoplasmosis in all of whom FDG PET-CT was consistent with non-malignant disease. One patient had progressive multifocal leukoencephalopathy (PML), FDG PET-CT was equivocal. One patient had a haemorrhagic brain metastasis and FDG PET-CT wrongly suggested non-malignant disease. MRS was performed successfully in eight subjects: three results were suggestive of CNS lymphoma (one true positive, two false positive), four suggested CTOX (two false negative, two true negative), one scan was equivocal.

CONCLUSION

FDG PET-CT correctly identified all cases of CNS lymphoma and CTOX, supporting its use in this situation. MRS was unhelpful in our cohort.

Serum levels of the chemokine CXCL13, genetic variation in CXCL13 and its receptor CXCR5, and HIV-associated non-hodgkin B-cell lymphoma risk

BACKGROUND

CXCL13 and CXCR5 are a chemokine and receptor pair whose interaction is critical for naïve B-cell trafficking and activation within germinal centers. We sought to determine whether CXCL13 levels are elevated before HIV-associated non-Hodgkin B-cell lymphoma (AIDS-NHL), and whether polymorphisms in CXCL13 or CXCR5 are associated with AIDS-NHL risk and CXCL13 levels in a large cohort of HIV-infected men.

METHODS

CXCL13 levels were measured in sera from 179 AIDS-NHL cases and 179 controls at three time-points. TagSNPs in CXCL13 (n = 16) and CXCR5 (n = 11) were genotyped in 183 AIDS-NHL cases and 533 controls. OR and 95% confidence intervals (CI) for the associations between one unit increase in log CXCL13 levels and AIDS-NHL, as well as tagSNP genotypes and AIDS-NHL, were computed using logistic regression. Mixed linear regression was used to estimate mean ratios (MR) for the association between tagSNPs and CXCL13 levels.

RESULTS

CXCL13 levels were elevated for more than 3 years (OR = 3.24; 95% CI = 1.90-5.54), 1 to 3 years (OR = 3.39; 95% CI = 1.94-5.94), and 0 to 1 year (OR = 3.94; 95% CI = 1.98-7.81) before an AIDS-NHL diagnosis. The minor allele of CXCL13 rs355689 was associated with reduced AIDS-NHL risk (OR(TCvsTT) = 0.65; 95% CI = 0.45-0.96) and reduced CXCL13 levels (MR(CCvsTT) = 0.82; 95% CI = 0.68-0.99). The minor allele of CXCR5 rs630923 was associated with increased CXCL13 levels (MR(AAvsTT) = 2.40; 95% CI = 1.43-4.50).

CONCLUSIONS

CXCL13 levels were elevated preceding an AIDS-NHL diagnosis, genetic variation in CXCL13 may contribute to AIDS-NHL risk, and CXCL13 levels may be associated with genetic variation in CXCL13 and CXCR5.

IMPACT

CXCL13 may serve as a biomarker for early AIDS-NHL detection.

Immune reconstitution inflammatory syndrome mimics a relapse of AIDS-related Burkitt lymphoma

Immune reconstitution inflammatory syndrome (IRIS) is associated with clinical manifestations that can overlap with the patients with acquired immunodeficiency disease (AIDS)-related non-Hodgkin's lymphoma. We herein report a case of AIDS-related Burkitt lymphoma which was successfully treated with dose-adjusted etoposide, doxorubicin, cyclophosphamide, vincristine, and prednisone (EPOCH). However, the patient developed a lymphoma-like clinical presentation shortly after the conclusion of chemotherapy. The patient's symptoms were identical to the initial symptoms characteristic of lymphoma; however, the laboratory data revealed no evidence of a relapse of Burkitt lymphoma. A bone marrow examination showed T-cell clonality, even though there were no signs of any progression of the lymphoma. The patient was diagnosed with IRIS, and the clinical manifestations rapidly improved following treatment.

HIV/AIDS associated malignancies of the head and neck

Patients with HIV/AIDS are at increased risk for the development of malignancy. Kaposi's sarcoma, non-Hodgkin's lymphoma and cervical carcinoma in women are regarded as AIDS-defining malignancies. The spectrum of malignancy is, however, changing, particularly where patients receive highly active antiretroviral therapy (HAART). South Africa has the highest number of HIV-infected individuals globally. The possibility of the oral health care worker encountering HIV/AIDS-related pathology therefore seems inevitable. The aim of this article is to heighten the awareness of head and neck malignancies occurring in HIV/AIDS whilst highlighting some of the clinical features in order to facilitate early recognition and diagnosis. It is of clinical significance that in many instances, identification of these malignancies precedes HIV/AIDS diagnosis. Optimal patient management requires close co-operation between the oral health care practitioner and the extended health care team.

Plasmablastic lymphoma in pediatric patients: clinicopathologic study of three cases

Plasmablastic lymphoma (PBL) is an aggressive high grade non-Hodgkin lymphoma which occurs predominantly in adult patients who are concomitantly afflicted with HIV infection. In contrast to several reports and studies of PBL in adult patients, PBL has very rarely been reported in pediatric patients. This article hereby provides collaborative clinicopathologic information of de novo PBL diagnosed in 3 pediatric patients with concomitant HIV infection. Cognizance of this rare tumor in the pediatric population coupled with antiretroviral therapy and prompt initiation of multimodality treatment may, in the future, facilitate improved outcome in pediatric patients with PBL.

Clinical presentation, treatment, and outcomes among 65 patients with HIV-associated lymphoma treated at the University of North Carolina, 2000-2010

HIV increases risk of non-Hodgkin lymphoma (NHL) and Hodgkin lymphoma (HL). The effect of HIV on presentation, treatment, and outcomes of NHL and HL in routine care in the combination antiretroviral therapy (cART) merits further characterization. We performed a retrospective analysis of HIV-infected patients with NHL and HL receiving care at the University of North Carolina at Chapel Hill from January 1, 2000 until December 31, 2010. Statistical analyses were conducted using SAS, version 9.2 (SAS Institute Inc). Sixty-five HIV-infected patients with NHL and HL were identified. Patients with non-CNS NHL and HL presented with advanced disease (85% stage III or IV) and adverse prognostic features. Patients completed 87% of planned chemotherapy cycles, and 68% of patients completed stage-appropriate therapy. Dose reduction, interruption, and/or delay occurred during more than 25% of administered cycles in 64% of patients. Infectious complications, febrile neutropenia, and myelosuppression accounted for 78% of deviations from planned cumulative dose and dose intensity. Primary CNS lymphoma (PCNSL) was associated with poor prognosis, but 2-year overall survival was 66% for all non-CNS lymphoma. Among patients surviving at least 2 years, 75% had CD4 count >200 cells/μl and 79% had HIV viral load <400 copies/ml at last follow-up. Despite advanced disease and difficulty tolerating chemotherapy with optimal cumulative dose and dose intensity, most patients with non-CNS HIV-associated lymphoma survived more than 2 years after diagnosis, the majority with suppressed HIV RNA.

Extranodal non-Hodgkin's lymphoma in HIV

Lymphoma in acquired immunodeficiency syndrome (AIDS) is associated with frequent involvement of extra-nodal sites, rapid clinical progression and aggressive histology. We present a case of extra nodal non-Hodgkin's lymphoma (NHL) with probable multifocal involvement.

[Disseminated B-cell lymphoma with cardial involvement in an HIV positive patient]

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.

Neurological complications in HIV

HIV is neuroinvasive with early involvement of the nervous system and has the potential to cause disease at any site of the neuro-axis during the evolution from seroconversion to late stage HIV. Disease may result from direct viral infection, indirect immune-deficiency driven opportunistic infections, AIDS-defining cancers, antiretroviral (ARV) drug therapy, or less well elucidated associations, such as vascular events (Table 1). Recognition of each of these is paramount in the prevention or attenuation of long-term morbidity. Though the epidemiology of neurological disease has altered substantially since the arrival of combination antiretroviral therapy (cART), with reduced incidence and improved survival, the spectrum of central nervous system (CNS) diseases has remained relatively unchanged. Despite available treatment options, mortality remains high and the morbidity significant. CNS diseases can result in long hospital stays, reduced quality of life and marked disability. The majority of disease occurs in the advanced stages of HIV infection where immunosuppression is the predominant influence. Diagnosis can prove challenging as presentation is often atypical and there can be significant neurological involvement with limited evidence of disease. Multiple aetiologies can co-exist and investigations may yield unexpected results, rendering interpretation difficult. Paradoxically, cART may also alter the way CNS disease manifests and unmask opportunistic infections or cause clinical representation of the opportunistic infections, when it represents immune reconstitution syndrome (IRS). Clinical assessment, imaging (typically magnetic resonance imaging (MRI)) and cerebral spinal fluid (CSF) sampling remain the chief diagnostic tools. This conference summary reviews these differing aspects.

Cancer in HIV-infected persons from the Caribbean, Central and South America

BACKGROUND

HIV-infected individuals have heightened cancer risk. With the advent of highly active antiretroviral therapy (HAART), the frequency of some AIDS-defining cancers (ADC) has decreased although certain non-AIDS-defining cancers (NADC) are becoming more frequent. Cancers among HIV-infected individuals in Latin American and the Caribbean have not yet been carefully studied.

METHODS

Cancer cases among the Caribbean, Central and South American network for HIV Research (CCASAnet) cohort were identified reviewing clinical records and pre-existing databases.

RESULTS

There were 406 cancers reported: 331 ADC (224 Kaposi sarcomas and 98 non Hodgkin lymphomas). Most frequent NADC (n = 75) were Hodgkin lymphoma and skin cancers. Seventy-three percent of NADC and 45% of ADC were diagnosed >1 year after HIV diagnosis. Fifty-six percent of ADC occurred before HAART start. Median time from HAART start until cancer diagnosis was 2.5 years for NADC and 0.5 years for ADC (P = <0.001). Within 3372 HAART starters, 158 were diagnosed with 165 cancers (82.4% ADC); 85 cases were previous to or concomitant with HAART initiation. Incidence of cancer after HAART initiation in 8080 person-years of follow-up was 7.2 per 1000 person-years (95% confidence interval = 5.5 to 9.3) for ADC and 2.7 (95% confidence interval = 1.8 to 4.1) for NADC; incidence was higher in the first 2 months, particularly for ADC (47.6). A pre-HAART ADC was a predictor of mortality after adjusting for age, sex, and CD4 at HAART initiation.

CONCLUSIONS

ADC were the most frequent cancers in this region and were often diagnosed close to HIV diagnosis and HAART start. Incidence of cancer was highest around HAART initiation.

Bronchoscopy and endobronchial disease in patients with human immunodeficiency virus infection

The natural history of human immunodeficiency virus (HIV) infection has been significantly altered since the advent of antiretroviral therapy (ART). However, lung diseases are still common in these patients. This makes flexible fibreoptic bronchoscopy a valuable diagnostic tool. Knowledge of the visual appearance of various diseases would be of utmost importance to the bronchoscopist. Timely recognition of the endobronchial appearance of these diseases can narrow the differential diagnosis and potentially mitigate an avoidable delay in the diagnosis.

Prognostic factors in patients with HIV-associated peripheral T-cell lymphoma: a multicenter study

HIV infection has been associated with an increased risk of developing several types of malignancies, including aggressive peripheral T-cell lymphomas (PTCL). However, this is a rare occurrence with no more than a hundred cases reported in the literature. The purpose of this multicenter study is to describe the characteristics and to identify prognostic factors in patients with HIV-associated PTCL. Data from HIV-positive patients with a pathological diagnosis of non-primary cutaneous, non-leukemic PTCL were gathered retrospectively and are reported using descriptive statistics. Univariate and multivariate survival analyses were also performed. Fifty one patients were included in our analysis. Median age was 38 years with a 5:1 male-to-female ratio. Patients presented with a median CD4(+) count of 173 cells mm⁻³, and a median HIV viral load of 334,787 copies ml⁻¹. The median time from HIV diagnosis to PTCL diagnosis was 4.5 years. About 75% of patients presented with advanced clinical stage and 66% with B symptoms. The most common subtypes were PTCLU (61%) and anaplastic large cell lymphoma (ALCL, 22%). None of the ALCL patients tested expressed ALK. The median overall survival (OS) for the group was 12 months. In the multivariate survival analysis, the use of HAART and patients' performance status were independently associated with OS. HIV-associated PTCL presents predominantly in young men with low CD4(+) counts and high HIV viral loads. Both HIV-related and lymphoma-related factors were associated with OS.

[Lymphomas associated with human immunodeficiency virus infection: retrospective review of medical records]

BACKGROUND

The incidence of lymphoma increases enormously in patients infected with the human immunodeficiency virus (HIV).

AIM

To describe the incidence, clinical and histological characteristics, treatments and survival of lymphomas associated with HTV infection.

MATERIAL AND METHODS

Retrospective review of medical records of patients with HIV and lymphoma, treated in a public hospital, between January 2001 and June 2009.

RESULTS

Twenty-two male patients were included but 14 had immunohistochemical confirmation of the lymphoma. The accumulated incidence for this period was 2.8%. The median age at lymphoma diagnosis was 39.5 years. Twelve patients (86%) had non-Hodgkin lymphoma (NHI) and two (14%) Hodgkin lymphoma. The main pathological type of non-Hodgkin lymphomas was diffuse large B cell in seven cases (50%). The mean CD4 cell count and viral load were 83 cell/mm³ (33.5-113.5) and 26.000 RNA copies/ml (1210-196500), respectively Twelve patients (86%) had B type symptoms of lymphoma at the moment of diagnosis. Eleven patients (29%) received chemotherapy with or without radiotherapy, one patient (7%) received radiotherapy alone and two patients (14%) received palliative symptomatic treatment. Six cases (43%) received highly active antiretroviral therapy simultaneously with chemotherapy. Global mortality in this series was 57% (8 patients) with a median survival time of 5.8 months (2.6-26.2).

CONCLUSIONS

In this series of patients infected with HIV, a predominance of aggressive histological subtypes of lymphomas and low complete remission rates, were observed.

[Successful treatment with hyper-CVAD and highly active anti-retroviral therapy (HAART) for AIDS-related Burkitt lymphoma]

A 38-year-old man was admitted to our hospital because of continuous fever and right facial palsy. He was diagnosed as HIV positive. Abdominal CT scan showed a large mass in the ascending colon. Gallium scintigraphy demonstrated increased uptake in the ascending colon. Colonoscopy was performed and histological examination of the colon tumor revealed Burkitt's lymphoma (BL). He received highly active anti-retroviral therapy (HAART) and his facial palsy improved. Because CD4 count was significantly low at 31/microl, he was treated with dose-adjusted EPOCH (DA-EPOCH) combined with HAART. Although the tumor was decreased in size by DA-EPOCH, we changed to the combination of hyper-CVAD/MTX-Ara-C alternating therapy with HAART in order to increase dose intensity. Six cycles of hyper-CVAD/MTX-Ara-C were performed and complete remission was obtained. In the HAART era, the survival of patients with AIDS-related diffuse large cell lymphoma (DLCL) improved dramatically, whereas the survival of similarly treated patients with AIDS-related BL remained poor. Our case suggests that intensive chemotherapy with hyper-CVAD/MTX-Ara-C combined with HAART may be well tolerated and effective in AIDS-related BL.

[The pattern of central nervous system lesions in HIV-infected patients of the specialized unit in infectious disease hospital]

AIM

To define the incidence and features of brain lesion (BL) in HIV-infected inpatients.

SUBJECTS AND METHODS

Four hundred and fifty-eight patients with Stage 4B HIV infection (AIDS) and central nervous system (CNS) lesion admitted to Infectious Diseases Hospital Two, Moscow, were followed up in 2003-2009. The authors used cerebrospinal fluid (CSF) microscopic and bacteriological assays for DNA of T. gondii, M. tuberculosis, herpes simplex virus (HSV) types 1 and 2, cytomegalovirus (CMV), HSV type 6, and varicella-zoster virus, Cr. neoformans, C. albicans, C. glabrata, and C. krusei. Blood and CSF were tested for IgM and IgG T. gondii antibodies; brain magnetic resonance imaging was carried out.

RESULTS

In patients with late-stage HIV infection, the principal cause of neurological diseases was cerebral toxoplasmosis (34.7% of BL cases) and a generalized process involving the brain, lung, heart, liver, and eyes in 11.5%. There was commonly cerebral toxoplasmosis concurrent with CMV infection with clinical manifestations. 16-32% of the inpatients developed tuberculosis meningoencephalitis that was a manifestation of hematogenous disseminated tuberculosis involving the lung. There was a rise in the incidence of cancers (brain lymphomas, astrocytomas) running with CNS lesion. Mental disorders progressing to dementia were a distinctive property of CMV ventriculoencephalitis, one of the leading factors in the development of AIDS dementia complex. Molecular diagnostic techniques are needed to ascertain the etiology of BL in HIV infection.

CONCLUSION

The CSF test for DNA of causative agents is a specific and most sensitive method for diagnosing a relevant CNS lesion.

Non Hodgkin's lymphoma with cutaneous involvement in AIDS patients: report of five cases and review of the literature

Cutaneous B cell lymphoma (CBCL) is a lymphoproliferative disorder of neoplastic B cell of the skin with a wide range of clinical manifestations. Commonly, the clinical features of CBCL are plaques, nodules, or ulcerative lesions. Skin is one of the common sites for extra-nodal lymphomas in patients with AIDS and B cell type is less common than T cell type. Only recently, the existence of B cell lymphomas presenting clinically in the skin without evidence of extra-cutaneous involvement has been accepted as primary CBCL. Here, we are presenting 5 patients with cutaneous involvement in the setting of HIV/AIDS disease. Two of them were primary cutaneous non-Hodgkin lymphomas. All were CBCL; 3 were immunoblastic, 1 was plasmablastic, and the other was a Burkitt lymphoma. We analyzed the epidemiological, clinical, virological, and immunological characteristics of this group of patients.

Variable impact on mortality of AIDS-defining events diagnosed during combination antiretroviral therapy: not all AIDS-defining conditions are created equal

BACKGROUND

The extent to which mortality differs following individual acquired immunodeficiency syndrome (AIDS)-defining events (ADEs) has not been assessed among patients initiating combination antiretroviral therapy.

METHODS

We analyzed data from 31,620 patients with no prior ADEs who started combination antiretroviral therapy. Cox proportional hazards models were used to estimate mortality hazard ratios for each ADE that occurred in >50 patients, after stratification by cohort and adjustment for sex, HIV transmission group, number of antiretroviral drugs initiated, regimen, age, date of starting combination antiretroviral therapy, and CD4+ cell count and HIV RNA load at initiation of combination antiretroviral therapy. ADEs that occurred in <50 patients were grouped together to form a "rare ADEs" category.

RESULTS

During a median follow-up period of 43 months (interquartile range, 19-70 months), 2880 ADEs were diagnosed in 2262 patients; 1146 patients died. The most common ADEs were esophageal candidiasis (in 360 patients), Pneumocystis jiroveci pneumonia (320 patients), and Kaposi sarcoma (308 patients). The greatest mortality hazard ratio was associated with non-Hodgkin's lymphoma (hazard ratio, 17.59; 95% confidence interval, 13.84-22.35) and progressive multifocal leukoencephalopathy (hazard ratio, 10.0; 95% confidence interval, 6.70-14.92). Three groups of ADEs were identified on the basis of the ranked hazard ratios with bootstrapped confidence intervals: severe (non-Hodgkin's lymphoma and progressive multifocal leukoencephalopathy [hazard ratio, 7.26; 95% confidence interval, 5.55-9.48]), moderate (cryptococcosis, cerebral toxoplasmosis, AIDS dementia complex, disseminated Mycobacterium avium complex, and rare ADEs [hazard ratio, 2.35; 95% confidence interval, 1.76-3.13]), and mild (all other ADEs [hazard ratio, 1.47; 95% confidence interval, 1.08-2.00]).

CONCLUSIONS

In the combination antiretroviral therapy era, mortality rates subsequent to an ADE depend on the specific diagnosis. The proposed classification of ADEs may be useful in clinical end point trials, prognostic studies, and patient management.

Epstein-Barr Virus DNA Quantification: An Adjunctive Diagnostic Marker for AIDS-Associated Lymphoma

We report an HIV-positive patient who developed a unilateral retinitis and subsequent intracranial lesions. The finding of Epstein Barr virus (EBV) DNA at a > 1-log greater concentration in the vitreous compared to blood raised the possibility of a primary CNS non-Hodgkin's lymphoma, which was subsequently confirmed on brain biopsy. EBV DNA quantification acted as a diagnostic marker that led to a change in the management of our patient.

The Oral HIV/AIDS Research Alliance: updated case definitions of oral disease endpoints

The Oral HIV/AIDS Research Alliance (OHARA) is part of the AIDS Clinical Trials Group (ACTG), the largest HIV clinical trials organization in the world. Its main objective is to investigate oral complications associated with HIV/AIDS as the epidemic is evolving, in particular, the effects of antiretrovirals on oral mucosal lesion development and associated fungal and viral pathogens. The OHARA infrastructure comprises: the Epidemiologic Research Unit (at the University of California San Francisco), the Medical Mycology Unit (at Case Western Reserve University) and the Virology/Specimen Banking Unit (at the University of North Carolina). The team includes dentists, physicians, virologists, mycologists, immunologists, epidemiologists and statisticians. Observational studies and clinical trials are being implemented at ACTG-affiliated sites in the US and resource-poor countries. Many studies have shared end-points, which include oral diseases known to be associated with HIV/AIDS measured by trained and calibrated ACTG study nurses. In preparation for future protocols, we have updated existing diagnostic criteria of the oral manifestations of HIV published in 1992 and 1993. The proposed case definitions are designed to be used in large-scale epidemiologic studies and clinical trials, in both US and resource-poor settings, where diagnoses may be made by non-dental healthcare providers. The objective of this article is to present updated case definitions for HIV-related oral diseases that will be used to measure standardized clinical end-points in OHARA studies, and that can be used by any investigator outside of OHARA/ACTG conducting clinical research that pertains to these end-points.

[Burkitt's lymphoma of the caecum in a patient with AIDS: clinical case and review of the literature]

Overall, lymphomas of the gastrointestinal tract are rare, although they are the most frequent extranodal location. The incidence of primary colic lymphoma, above all in the non-Hodgkin variant, is clearly higher in the HIV positive population, especially in subjects with AIDS. The authors present the case of a 51-year-old patient with AIDS undergoing antiviral therapy; he was suffering from abdominal pain and presented a palpable mass in the right iliac fossa; diagnosis was caecal non-Hodgkin lymphoma (NHL); radical right hemicolectomy was carried out with definitive histological diagnosis of Burkitt-type small cell NHL. The NHL of the colon represents no more than 1.2% of all malignant cancers of this part of the intestinal tract. Nevertheless such cases are comparatively frequent in patients with HIV virus, especially in the active phase and clinically proven to be due to immunodeficient syndrome. Of cardinal importance is the differential diagnosis between primary and secondary forms because of the different treatment and prognosis. Frequently such forms are observed in patients with AIDS, at advanced stages and with differentiated and hence more aggressive histotypes, also because they are present in organisms weakened by the underlying disease and by immunodeficiency. Primary NHLs of the colon are relatively frequent and aggressive in patients with AIDS; early diagnosis and treatment are therefore of fundamental importance to improve the oncological outcome for these patients.

[HIV-related multiple non-Hodgkin lymphomas]

A 35-year-old man was admitted with continuous general fatigue and low grade fever. He was HIV-positive, and had gastric diffuse large B-cell lymphoma and renal T-cell anaplastic large cell lymphoma (T-ALCL). We diagnosed double lymphomas related to AIDS. The patient received anti-retroviral therapy, and started the CHOP regimen for the double lymphomas, resulting in transient improvement. However, fever again appeared during HAART and CHOP treatment, and a right inguinal subcutaneous lesion appeared. Biopsy specimen demonstrated null cell ALCL, and this patient demonstrated multiple lymphomas. This case suggested that cancer generation was promoted by low immunity, although it is known that ambivalent tumors such as non-Hodgkin lymphomas can occur frequently.

Cutaneous lesions as the first manifestation of systemic follicular lymphoma in an HIV patient

Human immunodeficiency virus (HIV) patients have an increased incidence of lymphomas, particularly when there is a significant immunosuppression. Most commonly, they are non-Hodgkin B cell type with a high or intermediate grade and have an extranodal presentation. We report the case of a 38-year-old man with HIV infection who presented with a 1-year history of a painless tumor on the back and lymphadenopathies. The diagnosis of B cell lymphoma follicle center cell type was established by skin biopsy. Staging included a bone marrow biopsy revealing infiltration by the lymphoma and a whole-body computed tomographic scan showing multiple cervical and axillary lymphadenopathies with necrotic center. Biopsy of an axillary lymph node revealed caseating epithelioid granulomas and Ziehl-Neelson staining was positive for acid-fast bacilli. The patient started therapy for tuberculosis and polychemotherapy for lymphoma with complete response. This report illustrates a case of simultaneous occurrence of tuberculosis and systemic follicular lymphoma presenting in skin in an HIV patient.

[Small bowel lymphoma detected by MiroCam capsule endoscope in a patient with acquired immune deficiency syndrome]

Human immunodeficiency virus (HIV) infection is a risk factor for developing non-Hodgkin's lymphoma. Most acquired immune deficiency syndrome (AIDS)-related lymphomas are high-grade B cell non-Hodgkin's lymphomas. The use of highly active antiretroviral therapy has reduced the incidence of AIDS-related lymphoma. There have been 7 reports of AIDS-related extra-nodal lymphoma in Korea. We report a case of AIDS-related lymphoma detected by MiroCam capsule endoscopy.

Plasmablastic lymphoma of the oral cavity: a rapidly progressive lymphoma associated with HIV infection

Plasmablastic lymphoma of the oral cavity is a form of non-Hodgkin lymphoma (NHL) and was first described in 1997. We describe a case of plasmablastic lymphoma in an HIV-infected patient who presented with an expanding oral lesion and symptoms of a toothache. We review all cases of plasmablastic lymphoma that have been reported in the literature. Plasmablastic lymphoma is strongly associated with immunodeficiency, and most particularly, with HIV infection. The pathophysiological origin of plasmablastic lymphoma has not been fully characterised, but the presence of Epstein-Barr virus (EBV) has often been documented in biopsy specimens, supporting a role for EBV in the pathogenesis of this lymphoma. The differential diagnosis for an expanding oral lesion includes both infectious and malignant processes. Biopsy is essential for making a correct and prompt diagnosis. Treatment usually involves chemotherapy, but antiretroviral therapy may also have an important role. Infectious disease clinicians should be aware of this newly described and increasingly encountered lymphoma, since it is prominently associated with immunosuppression and may be mistaken for other entities.

Human immunodeficiency virus (HIV)-associated extranodal T cell non-Hodgkin lymphoma of the oral cavity

T cell non-Hodgkin lymphoma is characterized by uncontrolled cellular proliferation of immature malignant clones. HIV-associated T cell non-Hodgkin lymphoma comprises a heterogeneous group of lymphoproliferative neoplastic entities classified according to morphological, immunological, genetic and clinical features. Extranodal T cell non-Hodgkin lymphoma of the oral cavity is uncommon. A case is presented with extranodal T cell non-Hodgkin lymphoma as an initial sign of HIV-infection. The characteristics of HIV-associated non-Hodgkin lymphoma are discussed.