Four Cases of Non-Hodgkin's Lymphoma in AIDS patients
A 40-year-old man was hospitalized due to jaundice and lethargic fatigue that started 10 days prior to admission. The patient had complaints of weight loss and night sweats. Four months prior to this admission, he had visited to the Department of ENT at another hospital with the complaint of nasal stuffiness. At that time, the serologic testing for hepatitis B antigen and anti-HIV antibody were positive. He has been treated with zidovudine, lamivudine and efavirenz for two months until admission. He assumed that his AIDS was transmitted from heterosexual contact at abroad ten years ago. On admission, the blood pressure was 120/70 mmHg, the pulse rate 90/min, the respiratory rate 20/min and the body temperature was 36.6℃. He was icteric on the physical examination. The liver was tender and firm in consistency. It was palpated at a three-finger breadth below the right costal margin. His spleen and lymph nodes were not enlarged. The laboratory results were normal apart from an ESR of 120 mm/h; leukopenia 3,930/mm3 (neutrophils: 58.8%, lymphocytes: 31% and monocytes: 8.4%) and hemoglobin 9.4 g/dL. The liver function tests were abnormal: total bilirubin 8.9 mg/dL (direct bilirubin: 6.05 mg/dL), AST 171 IU/L, ALT 100 IU/L and LDH 1063 IU/L. The total number of CD4 and CD8 T lymphocytes was 290/mm3 and 568/mm3, respectively, and the ratio of CD4/CD8 was 0.51. Abdominal enhanced CT scanning revealed multifocal and variable sized homogenous hypodense masses in both hepatic lobes (). A liver biopsy showed a heavy infiltration composed mainly of large lymphoid cells (). Immunohistochemical staining revealed the atypical cells to be CD20 positive (), which established a diagnosis of diffuse large B-cell lymphoma according to the WHO classification. Bone marrow biopsy demonstrated normal cellularity with normal maturation of all three cell lines. There was no malignant cell infiltration. After the patient was diagnosed as having diffuse large B-cell lymphoma, he received VAD (vincristine 0.4 mg, adriamycin 9 mg/m2, dexamethasone 40 mg on days 1-4, and additional dexamethasone on days 9-12 and days 17-20). The patient seemed to show a little clinical improvement, but before starting the second chemotherapy, he developed signs of spinal cord compression (). Emergency radiation therapy was delivered to the spine lesion. CHOP chemotherapy (cyclophosphamide 750 mg/m2, adriamycin 50 mg/m2 and vincristine 1.4 mg/m2 on day 1 and prednisone 100 mg/m2 on days 1-5) and laminectomy induced temporary improvement (). Alas, the paraplegia continued and his clinical condition progressively worsened. He passed away 103 days after starting the second round of chemotherapy from complications of pressure sores, deep vein thrombosis and pulmonary thromboembolism.