Acute promyelocytic leukemia in a HIV seropositive patient

Acute promyelocytic leukemia with additional chromosome abnormalities in a patient positive for HIV: A case report and literature review

Acute promyelocytic leukemia (APL), especially cases of high-risk with complex chromosomes (CK), is rare in individuals infected with human immunodeficiency virus (HIV), making the establishment of therapeutic approaches challenging; often the treatment is individualized. This report describes a 49-year-old female patient with HIV who was diagnosed with high-risk APL with a new CK translocation and presents a literature review. At diagnosis, the patient presented with typical t(15;17)(q24;q21) with additional abnormalities, including add(5)(q15), add(5)(q31), add(7)(q11.2) and add(12) (p13). The results of acute myeloid leukemia mutation analysis suggested positivity for calreticulin and lysine methyltransferase 2C genes. The patient received all-trans retinoic acid combined with arsenic trioxide and chemotherapy, with morphologically complete remission after the first cycle of chemotherapy. The present report provided preliminary data for future clinical research.

Acute Myeloid Leukemia in Patients Living with HIV Infection: Several Questions, Fewer Answers

Both human immunodeficiency virus (HIV) infection and acute myeloid leukemia (AML) may be considered relatively uncommon disorders in the general population, but the precise incidence of AML in people living with HIV infection (PLWH) is uncertain. However, life expectancy of newly infected HIV-positive patients receiving anti-retroviral therapy (ART) is gradually increasing, rivaling that of age-matched HIV-negative individuals, so that the occurrence of AML is also expected to progressively increase. Even if HIV is not reported to be directly mutagenic, several indirect leukemogenic mechanisms, mainly based on bone marrow microenvironment disruption, have been proposed. Despite a well-controlled HIV infection under ART should no longer be considered per se a contraindication to intensive chemotherapeutic approaches, including allogeneic hematopoietic stem cell transplantation, in selected fit patients with AML, survival outcomes are still generally unsatisfactory. We discussed several controversial issues about pathogenesis and clinical management of AML in PLWH, but few evidence-based answers may currently be provided, due to the limited number of cases reported in the literature, mainly as case reports or small retrospective case series. Prospective multicenter clinical trials are warranted to more precisely investigate epidemiology and cytogenetic/molecular features of AML in PLWH, but also to standardize and further improve its therapeutic management.

Acute Promyelocytic Leukemia and HIV: Case Reports and a Review of the Literature

Acute promyelocytic leukemia (APL) in human immunodeficiency virus (HIV)-infected individuals is very rare. There is currently no consensus regarding the use of anti-cancer drugs with highly active anti-retroviral therapy (ART) in these patients due to their small number. We herein report two cases of APL with HIV-infected patients. Both cases received all-trans-retinoic acid-containing chemotherapies and achieved complete remission. ART was continued throughout the treatment course. The clinical course of these cases suggests that it is preferable to perform standard chemotherapy for APL with ART if patients have an adequate performance status.

All-trans retinoic acid attacks reverse transcriptase resulting in inhibition of HIV-l replication

We previously reported that all-trans retinoic acid (ATRA) inhibited growth in HTLV-1-positive T-cell lines and fresh cells from patients with adult T-cell leukemia. Interestingly, ATRA significantly inhibited reverse transcriptase (RT) activity similar to azidothimidine (AZT) in HTLV-1-positive T-cell lines. To clarify whether ATRA has an inhibitory effect on the replication of HIV, we examined HIV proviral DNA in a HIV-1-positive cell line (8E5) using real time PCR. ATRA as well as AZT reduced the proviral DNA load of 8E5 in a dose-dependent manner. These results suggest that there is a common element of ATRA signaling in both HTLV-1 and HIV. Furthermore, we examined the effects of ATRA on viral replication in primary lymphocytes of three individuals infected with HIV. ATRA reduced viral replication significantly similar to AZT. These findings suggested that ATRA acts as a RT inhibitor, reducing the HIV-1 proviral DNA load. Finally, we conclude that ATRA may be a potential therapeutic agent for HIV infection.

Acute promyelocytic leukemia in HIV-infected adults: a case report and review of therapeutic considerations

The incidence of acute promyelocytic leukemia (APL) in patients with HIV is exceedingly rare, making the establishment of therapeutic approaches challenging and often individualized. We report the case of a 43-year-old female who presented with fatigue and malaise, and was concurrently diagnosed with APL and HIV. Induction and consolidation with all-trans-retinoic acid (ATRA), idarubicin, and mitoxantrone were initiated in conjunction with highly active anti-retroviral therapy (HAART) consisting of tenofovir/emtricitabine, fosamprenavir, and raltegravir. A complete morphologic, cytogenetic, and molecular response was achieved post-induction. Therapeutic strategies should consider overlapping effects of current agents in targeting both pathologies. ATRA has been found to induce apoptosis in HIV-infected leukemic cells, and protease inhibitor therapy has furthermore been reported to be synergistic with ATRA in inducing differentiation of APL cell lines. Pending further investigation, regimens with protease inhibitor backbones may represent a viable first-line strategy for patients elected to receive HAART in addition to ATRA and standard chemotherapy.

Alveolar granulocytic sarcoma of the mandible in a patient with HIV

BACKGROUND

Granulocytic sarcoma (chloroma) occurs primarily in patients with acute myelogenous leukemia although it can also appear in connection with other myeloproliferative disorders.

CASE REPORT

We present the case of a 52-year-old human immunodeficiency virus (HIV)-positive female patient with a CD4+ count of 321 cells/ml, who developed an alveolar granulocytic sarcoma of the mandible. Pathological analysis of the tumor mass showed an infiltrate of immature cells which were positive for CD13, CD33, CD15, CD11b, and CD64, and negative for CD34, CD117, and HLA-DR. The patient achieved complete remission following a 1-week course of chemotherapy, however, 7 months later she developed a second granulocytic sarcoma in the left soleus muscle. The absolute CD4+ count had now reduced to 3 cells/ml with an inversion in the Th/Ts index (0.01), and she died of gram-negative sepsis 1 month later.

CONCLUSIONS

Granulocytic sarcoma is extremely rare in patients with HIV. The case is discussed with reference to the literature.

Acute promyelocytic leukemia after whole brain irradiation of primary brain lymphoma in an HIV-infected patient

The occurrence of acute promyelocytic leukemia (APL) in HIV-infected patients has been reported in only five cases. Due to a very small number of reported HIV/APL patients who have been treated with different therapies with the variable outcome, the prognosis of APL in the setting of the HIV-infection is unclear. Here, we report a case of an HIV-patient who developed APL and upon treatment entered a complete remission. A 25-years old male patient was diagnosed with HIV-infection in 1996, but remained untreated. In 2004, the patient was diagnosed with primary central nervous system lymphoma. We treated the patient with antiretroviral therapy and whole-brain irradiation, resulting in complete remission of the lymphoma. In 2006, prompted by a sudden neutropenia, we carried out a set of diagnostic procedures, revealing APL. Induction therapy consisted of standard treatment with all-trans-retinoic-acid (ATRA) and idarubicin. Subsequent cytological and molecular ana?lysis of bone marrow demonstrated complete hematological and molecular remission. Due to the poor general condition, consolidation treatment with ATRA was given in March and April 2007. The last follow-up 14 months later, showed sustained molecular APL remission. In conclusion, we demonstrated that a complete molecular APL remission in an HIV-patient was achieved by using reduced-intensity treatment.

Acute promyelocytic leukemia and HIV-1 infection: case report and review of the literature

We report a 27-year-old man with HIV-1 infection who developed acute promyelocytic leukemia (APL) with a novel complex three-way chromosomal translocation t(15;16;17). Induction of remission and consolidation with all-trans-retinoic acid (ATRA)- and anthracycline-based chemotherapy was followed by maintenance therapy consisting of ATRA, 6-mercaptopurine (6-MP), and methotrexate (MTX). Highly active antiretroviral therapy (HAART) was continued with brief interruptions. He remains in complete remission 40 months after diagnosis.

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.

Leukemia after liver transplant

INTRODUCTION

Acute leukemia is rare after solid organ transplantation.

METHODS

Review of data on 3 patients with acute leukemia identified among 1365 who underwent liver transplantation at our center, and a review of the literature.

RESULTS

In patient 1, AML-M4 developed 19 months after transplant for cryptogenic cirrhosis. In patient 2, B cell acute lymphoid leukemia was diagnosed 10 months after liver transplant for fulminant hepatitis. Both patients had normal cytogenetics, and achieved complete remission with chemotherapy. In patient 3, acute monocytic leukemia-M3 with t(15;17) arose 18 months after transplant for hepatitis C cirrhosis. This patient received treatment with retinoic acid and chemotherapy, but developed a disseminated intravascular coagulation and died before completing therapy. No patient presented with chromosomal abnormalities commonly seen in secondary leukemia. The latency period to diagnosis after transplant was 10-19 months.

CONCLUSIONS

Acute leukemia, although rare after liver transplantation, should be considered in the differential diagnosis of hematological complications.

Acute myelogenous leukaemia and myelomonocytic blast crisis following polycythemia vera in HIV positive patients: report of cases and review of the literature

BACKGROUND

Acute myelogenous leukaemia (AML) and myeloproliferative diseases are rare in HIV-infected individuals and optimal treatment has not been defined.

PATIENTS AND METHODS

We report on the cases of two HIV-infected men, one with AML and one with myeloid blast crisis after polycythaemia vera (PV). A comprehensive review of the available literature will be presented.

RESULTS

Patient 1, a 57-year-old bisexual man known to be HIV seropositive for more than four years (CDC-category A1), presented with a pulmonary infiltrate. On admission WBC showed leukocytes 5.6 x 10(9)/l and the differential revealed 80% blasts. A diagnosis of AML FAB M0 was made. Pneumonia resolved under antibiotic treatment and the patient received induction chemotherapy. However, he once more developed multiple pulmonary infiltrates and died of respiratory failure despite broad spectrum antibiotic and antimycotic therapy. Autopsy revealed pulmonary aspergillosis. Patient 2 was a 63-year old HIV-positive hemophiliac (CDC A3) with a 10-year history of PV. On admission his white cell count showed leukocytes 256.6 x 10(9)/l with 82% blasts. Cytochemistry revealed myelomonocytic differentiation. The patient died of tumor lysis syndrome with renal and cardio-pulmonary failure two days later.

CONCLUSIONS

This is the first report of an HIV-infected individual with AML M0. The literature describes the cases of 39 HIV+ patients with AML and only one further case with PV. The association of both, myeloproliferative disease and AML with HIV infection is coincidental. However, the proportion of FAB type M4/5 appears to be higher than in the general population. Despite a high risk of treatment associated mortality durable remissions can be achieved in a small proportion of HIV-infected patients with AML.