AIDS-related non-Hodgkin lymphoma: still a problem in the era of HAART

Despite advances in HAART, patients with HIV infection remain at significantly increased risk for intermediate- and high-grade B-cell non-Hodgkin lymphoma. The reasons for this persistent risk and the clinical and molecular correlates that predict outcomes and treatment responsiveness are areas of active investigation. Here we review the epidemiologic and pathobiologic features of AIDS-related lymphoma along with clinical evaluation and treatment options in patients with this disease.

Thrombotic complications in patients infected with HIV in the era of highly active antiretroviral therapy: a case series

BACKGROUND

Recent reports suggest that patients infected with human immunodeficiency virus (HIV) may have an increased risk of developing thrombosis, but the etiology, risk factors, and clinical course remain largely undefined, with few descriptive case series.

METHODS

We identified 30 patients from an HIV outpatient clinic (treatment population, 650 persons) who had had a total of 43 venous or arterial thromboses during 1996-2002. Data pertaining to demographic characteristics, medical history, thrombosis presentation, and clinical outcomes were abstracted from patient medical records.

RESULTS

The median patient age at the time of thrombosis was 43 years. Although the presence of persistent antibody to phospholipids was the most common abnormal finding in the laboratory, evaluation of thrombophilia, cases of low levels of proteins C and S and antithrombin III, and elevated levels of factor VIII and homocysteine were also identified. Seventy-seven percent of the patients smoked cigarettes, 57% had dyslipidemia, and 43% had a malignancy (most commonly Kaposi sarcoma). Although the Centers for Disease Control and Prevention (CDC) classification for 16 patients (53%) was C3, most showed evidence of immune reconstitution (median CD4 cell count, 290 cells/ mu L) and control of the virus (median HIV load, 2290 copies/mL). Lower extremity, deep vein thrombosis and pulmonary emboli accounted for 66% of all thrombotic events. The median time to diagnosis of thrombosis was 1 day (range, 3 h to 3 weeks).

CONCLUSIONS

Patients in this series were characterized by a relatively young age at the time of thrombosis, a predominance of elevated levels of lipids, a history of malignancy, and an advanced CDC HIV classification but not by a low CD4 cell count or an elevated HIV load.

Plasma cell disorders in HIV-infected patients: from benign gammopathy to multiple myeloma

Plasma cell disorders are not uncommonly reported in young patients with HIV infection. These disorders range from benign polyclonal hypergammaglobulinemia to indeterminate monoclonal gammopathy of unknown significance (MGUS) to malignant dyscrasias, including multiple myeloma and plasma cell leukemia. Hypergammaglobulinemia and oligoclonal banding had been the most frequently reported disorders in the pre-HAART era. In HIV-infected persons, the incidence of MGUS is reported to be around 2.5%, with an approximate 4.5-fold increased risk of multiple myeloma. Many of these HIV-infected patients had been treated with alkylator-based regimens, and these reports predate the current widespread use of thalidomide-dexamethasone combination treatment in multiple myeloma. Although the optimal therapy for an HIV-infected person might with plasma cell dyscrasia is yet to be defined, in the current era of HAART the otherwise healthy HIV-infected patient might be tested like an HIV-negative person. Consequently, treatment with immunomodulatory agents (eg, thalidomide) and proteasome inhibitors (eg, bortezomib) may also be worth considering. High-dose chemotherapy with an autologous peripheral blood stem cell transplant is increasingly being considered as consolidation therapy in the younger non-HIV-infected myeloma patient. In the next few years, it is anticipated that these approaches will be applied more frequently to HIV-infected persons with myeloma.

Granulocytic sarcoma: an unusual complication of aleukemic myeloid leukemia causing spinal cord compression. A case report and literature review

Granulocytic sarcoma (chloroma) is a rare solid tumor resulting from the proliferation of myelogenous leukemia cells. Chloromas usually present as soft tissue or bony masses of the head and neck in patients with acute myelogenous leukemia (AML) of the French-American-British M2 subtype. Occasionally chloromas may occur in patients with myelodysplasia and other myeloproliferative disorders and rarely precede the development of systemic disease. It is distinctly rare for such tumors to cause epidural compression as a first manifestation of disease. Herein, we report the case of a man with a thoracic extradural chloroma whose presentation of progressive lumbar pain ultimately led to the diagnosis of M2 AML. Surgical intervention prior to the onset of paraplegia and the prompt initiation of chemotherapy resulted in an excellent neurological and hematological outcome. We also review the literature of previously reported cases of spinal cord-associated chloroma and focus on the clinical presentation and treatment of this disorder.

Management of AIDS-related Kaposi sarcoma: advances in target discovery and treatment

Kaposi sarcoma (KS) is the most common tumor arising in HIV-infected patients and is considered an AIDS-defining illness by CDC guidelines. Recent advances in the elucidation of the pathogenesis of KS continue to uncover potential targets for therapies. Such targets include the KS herpesvirus/human herpesvirus 8 and the processes of angiogenesis and cellular differentiation. Five agents are currently approved by the FDA for the treatment o KS: alitretinoin gel for topical administration and liposomal daunorubicin, liposomal doxorubicin, paclitaxel, and interferon-alpha for systemic administration. Many more agents, particularly angiogenesis inhibitors and other pathogenesis-targeted therapies, are in clinical development. With increasing recognition that effective antiretroviral regimens are associated with both a decreased proportion of new AIDS-defining KS cases and a regression in the size and number of existing KS lesions, most, if not all, patients with KS should be advised to take antiretroviral drugs that will maximally decrease HIV-1 RNA levels.

Potential drug interaction with paclitaxel and highly active antiretroviral therapy in two patients with AIDS-associated Kaposi sarcoma

Highly active antiretroviral therapy (HAART) consisting of multiple combinations of antiretroviral agents that inhibit HIV (HIV) replication has been associated with improvements in CD4+ T-lymphocyte cell counts, suppression of HIV replication, and regression of HIV-associated Kaposi's sarcoma (KS). Several of these agents have complex drug-drug interactions and have the potential to aggravate paclitaxel-associated toxicities. Herein two patients with KS are described who received paclitaxel while on HAART and who developed life-threatening toxicities. These cases are presented to alert clinicians to potentially serious drug interactions that can occur between various components of HAART and paclitaxel. Clinicians contemplating taxane-based chemotherapy for HIV-associated KS should carefully monitor patients for adverse events and, depending on their patient's HAART regimen, consider reducing the taxane dose.

Failure to eradicate AIDS-associated primary effusion lymphoma with high-dose chemotherapy and autologous stem cell reinfusion: case report and literature review

Primary effusion lymphoma (PEL), also known as body cavity-based lymphoma, is a newly recognized AIDS-related malignancy that is etiopathologically linked to Kaposi's sarcoma (KS)-associated human herpes virus type 8 (HHV-8). PEL is characterized by presentation in serous body cavities without identifiable tumor masses. Tumor cells have high-grade morphologic features, an indeterminate immunophenotype, B-lineage genotype, and contain HHV-8 and often Epstein-Barr virus. PEL rarely responds to systemic chemotherapy. Herein, we describe what we believe is the first patient with AIDS-associated PEL to be treated with high-dose chemotherapy and autologous stem cell reinfusion. Treatment was well tolerated but the patient succumbed to progressive cancer. Our experience with this patient serves to underscore the high mortality rate associated with this unique neoplasm.

Thalidomide-based treatment for HIV-associated multiple myeloma: a case report

The spectrum of hematologic and immunologic abnormalities induced by HIV infection is broad. Although the incidence of HIV-associated B-cell neoplasms has increased, relatively few cases of multiple myeloma have been reported, and even fewer cases have detailed treatment outcome. The case of an HIV-infected man in whom multiple myeloma was diagnosed following progressive anemia and fatigue is described. The patient began treatment consisting of thalidomide, dexamethasone, and clarithromycin, which led to a rapid and dramatic antitumor response. He experienced modest regimen-related toxicities while retaining a normal CD4+ T-lymphocyte count and a nondetectable HIV viral load. The immunologic and antitumor effects of thalidomide in the context of multiple myeloma and HIV infection are also briefly reviewed. Given thalidomide's relatively favorable side-effect profile and purported immunologic benefit, further studies of this drug in the treatment of HIV-associated multiple myeloma should be pursued.

Bee envenomation: a rare cause of thrombotic thrombocytopenic purpura

Thrombotic thrombocytopenic purpura (TTP) is characterized by the pentad of microangiopathic hemolytic anemia, thrombocytopenia, neurologic symptoms, renal insufficiency, and fever. Although many underlying diseases and conditions are associated with TTP, there has been only one previously documented case of bee-sting-associated TTP. In this article, we describe the case of a woman who developed life-threatening TTP temporally related to a honeybee sting and who required prolonged plasma exchange before her condition improved. We also briefly review evolving concepts in the pathogenesis of TTP and speculate on the etiopathogenicity of TTP and bee envenomation.

9-cis-retinoic acid capsules in the treatment of AIDS-related Kaposi sarcoma: results of a phase 2 multicenter clinical trial

OBJECTIVE

To evaluate the safety, dose tolerance, and anti-tumor effects of 9-cis-retinoic acid in the treatment of Kaposi sarcoma (KS) related to acquired immunodeficiency syndrome (AIDS).

DESIGN

Phase 2, open-label clinical trial of oral doses of 9-cis-retinoic acid increasing in 40-mg increments every 2 weeks from 60 mg/m(2) per day to a maximum of 140 mg/m( 2) per day.

SETTING

Five hospital or health maintenance organization outpatient clinics.

PATIENTS

Fifty-seven adult male patients with human immunodeficiency virus and biopsy-proven KS.

MAIN OUTCOMES MEASURES

Safety was evaluated by adverse events, physical examination, laboratory test abnormalities, treatment-limiting toxic effects, and reasons for early withdrawal. Response (>/=50% improvement) was evaluated by an overall KS response and by the area and height from 6 index lesions selected at baseline.

RESULTS

Patients tolerated 60 and 100 mg/m(2) per day. Most patients found 140 mg/m(2) per day intolerable owing to headache. Common treatment-related adverse events were headache, xerosis, rash, alopecia, and hyperlipemia. The patient response rate for the overall KS disease was 19% (11/57), including 1 patient with clinically complete response. The response rate assessed by measuring 6 index lesions during treatment was 39% (22/57). Sixteen responding patients (73%) were refractory to at least 1 previous anti-KS therapy. Patients with CD4( +) counts of 150 cells/ micro L or lower were as likely to respond as patients with counts of higher than 150 cells/ micro L. The median time to response was 8.5 weeks (range, 4.0-21.1 weeks). The median duration of treatment was 15.1 weeks (range, 0.14 to >/=62 weeks).

CONCLUSION

9-cis-retinoic acid capsules have moderate activity and provide durable responses, but substantial toxic effects at higher doses limit its suitability as an anti-KS therapy.

Vacuolar myelopathy and vacuolar cerebellar leukoencephalopathy: a late complication of AIDS after highly active antiretroviral therapy-induced immune reconstitution

Controversy exists as to whether vacuolar myelopathy (VM) responds to highly active antiretroviral therapy (HAART) in a salutary fashion similar to other primary human immunodeficiency virus (HIV)-related neurologic complications such as acquired immune deficiency syndrome (AIDS) dementia complex and progressive multifocal leukoencephalopathy. Herein, we describe the case of a patient with AIDS, non-Hodgkin's lymphoma, and cytomegalovirus colitis, who began HAART and cytotoxic chemotherapy. After 6 months of therapy, restaging studies showed no residual lymphoma or active opportunistic infection. For 2 years he was maintained on HAART, during which time his HIV viral load remained nondetectable and his CD4+ count improved from 20 to 300 cells per microliter. Shortly after developing the acute onset of cerebellar ataxia, he aspirated, developed adult respiratory distress syndrome, and died. At autopsy the spinal cord demonstrated a characteristic vacuolated appearance that extended into the cerebellum. No relation between HIV and the development of VM was discerned by in situ hybridization studies. Experience with this one patient suggests that HAART may not alter the natural history of VM. Whether this case represents yet another variant of the recently described inflammatory immune response syndrome whereby progression of previously quiescent disorders evolve to symptomatic disease after initiation of HAART is uncertain.

Breast enlargement in 13 men who were seropositive for human immunodeficiency virus

Breast enlargement, a condition that was rarely reported in the era before highly active antiretroviral therapy, is emerging as a problem in the treatment of male human immunodeficiency virus (HIV)-infected patients. Evaluation of this condition must distinguish between gynecomastia (proliferation of ducts and periductal stroma), lipomastia (adipose-tissue deposition), and malignancy. We describe 13 HIV-infected men, all of whom had exposure to antiretroviral therapy, who presented with breast enlargement. Nine of these patients had gynecomastia, only 1 had lipomastia, and 3 had lymphoma (2 had non-Hodgkin lymphoma and 1 had Hodgkin disease). Gynecomastia was unilateral in all but a single case. In addition, all but 1 of our patients with gynecomastia had prolonged exposure to protease inhibitors. Six patients had potential causes of gynecomastia other than antiretroviral therapy, including liver disease (in 2 patients), mild hypogonadism (in 1), long-term marijuana use (in 2), and use of medications that have known associations with gynecomastia (in 3). Although most causes of breast enlargement in HIV-infected men are likely to be benign, malignancies other than carcinoma are of concern.

Acute myeloid leukemia in patients infected with HIV-1

OBJECTIVES

Myelodysplasia is a frequent consequence of HIV infection, but acute myeloid leukemia (AML) is rare. Clinical presentations and outcomes of patients with HIV and subsequent AML are reviewed.

METHODS

Five HIV-infected individuals who were subsequently diagnosed with AML were evaluated and treated. A further 42 cases of AML among patients with antecedent HIV infection were identified using MEDLINE, AIDSLINE, and CancerLit searches.

RESULTS

HIV infection was present for a median of 48 months (71-180) before AML was diagnosed and the median reported CD4 cell count was 210 x 106 cells/l. In five instances, a delay in diagnosis occurred when cytopenias were initially attributed to HIV or zidovudine-based therapy. In 45 patients, diagnosis was according to the French-American-British (FAB) leukemia classification schema and in two the FAB type was not specified. M2 (n = 15) and M4 (n = 14) subtypes represented 64% (29/45) of reported cases. Patients with a CD4 cell count < 200 x 106 cells/l (n = 11) had a median survival time of 7 weeks, while patients with a CD4 cell count >or= 200 x 106 cells/l (n = 7) had a median survival of 7 months (P = 0.005). Although long-lasting chemotherapy-induced responses were rare, the majority of treated patients did achieve complete hematologic remissions. Treatment-related morbidity did not appear to be excessive.

CONCLUSION

In the absence of randomized and prospective clinical studies to guide decision making, this analysis indicates that induction chemotherapy may be a reasonable option for selected HIV-infected patients with AML and adequate immune function.

Condyloma acuminatum presenting as a dorsal tongue lesion in a patient with AIDS

Oral lesions have been recognized as a prominent feature of HIV infection and AIDS since the beginning of the epidemic. This report describes the case of a man with advanced AIDS and a nonpainful but enlarging dorsal tongue soft tissue growth of 6 months' duration. Incisional biopsy showed a red, papillary lesion with koilocytosis consistent with condyloma acuminatum. In situ hybridization and molecular techniques were used to identify human papillomavirus (HPV)-31 sequences in warty tissue. Eighteen months later, the lesion recurred and was reexcised without complication. This case is reported to illustrate that venereal transmission may not be as important in warts of the oral cavity as in HIV-associated anogenital warts, because warts of the oral cavity are rarely associated with HPV types 6, 11, 16, and 18. Instead, they may be present as a result of activation of latent HPV infection or perhaps autoinfection from skin and facial lesions. The carcinogenic potential of oral warts in HIV disease is undefined, as is the role of antiretroviral therapy in controlling HPV-associated oral lesions.

HHV-8- and EBV-associated nonepidermotrophic large B-cell lymphoma presenting as a foot rash in a man with AIDS

Human herpesvirus type 8 (HHV-8; Kaposi's sarcoma-associated herpesvirus) is frequently identified in tumor tissue obtained from human immunodeficiency virus (HIV)-infected patients with Kaposi's sarcoma (KS), primary effusion lymphoma (PEL), or multicentric Castleman's disease. The association between HHV-8 and acquired immunodeficiency syndrome (AIDS)-associated solid lymphomas is less clear. Herein, I describe the case of a man with a CD4+ count of 30 cells/microL, and HIV viral load of 90,000 copies/mL, multi-drug resistant HIV infection, and limited stage KS. Biopsy of a progressive dorsal foot rash revealed a dense, deep, lymphoid infiltrate that extended into papillary dermis but without epidermotrophism. Microscopy showed a homogeneous population of anaplastic large B cells that stained positive for CD20 (L26), CD30, and lambda light chain. In situ hybridization of tumor tissue identified Epstein-Barr virus (EBV)-encoded RNA, and polymerase chain reaction amplification yielded HHV-8-specific gene products. Staging studies did not reveal lymphoma elsewhere, and the patient began chemotherapy, but died from septic complications. Autopsy was notable only for the presence of a consolidative pneumonia. Although extranodal presentations are common in the setting of immunodeficiency, reports of AIDS-associated lymphoma presenting as a nonepidermotrophic foot lesion are rare. Such a presentation serves to broaden the differential of skin and foot lesions in the setting of HIV infection. More importantly, this case provides further support that HHV-8 can be associated with solid lymphomas that have an anaplastic large cell morphology.

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.

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.

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.