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Case In Point: Coexisting Hodgkin disease and lung cancer in a patient with AIDS

Case In Point: Coexisting Hodgkin disease and lung cancer in a patient with AIDS

Highly active antriretroviral therapy has significantly decreased the morbidity and mortality associated with infectious complications of AIDS and has almost eliminated CNS lymphoma and Kaposi sarcoma. In contrast, the risks of Hodgkin disease and lung cancer have increased. We present an unusual case of concomitant Hodgkin disease and lung cancer in a patient with AIDS. To the best of our knowledge, this is the first case of 2 different primary malignancies presenting simultaneously in a patient with AIDS.

The case

The patient was a 41-year-old man with a history of HIV infection diagnosed 10 years before admission. He had been noncompliant with treatment, and therapy with tenofovir, efavirenz, and lamivudine had not been started until 2 months before admission, when he presented to another hospital. At the time, his CD4+ cell count was 156/µL and his viral load was 45,743 copies/mL. He also had a history of incarceration; had used injection drugs, cocaine, alcohol, and marijuana; and had a 20-pack-year tobacco history.

The patient had been hospitalized 8 months before admission and had been treated for a recurrent Mycobacterium avium-intracellulare infection complicated by development of deep venous thrombosis and pulmonary embolism. During that hospitalization, he was found to have mediastinal lymphadenopathy, and mediastinoscopy with a right paratracheal lymph node biopsy revealed Hodgkin disease (mixed-cellularity subtype) stage 3B (Figure 1).

He received 5 cycles of therapy with mechlorethamine, vincristine, procarbazine, and prednisone (MOPP), the last cycle occurring 3 weeks before admission. In addition, the patient was noted to have right upper lung, bilateral adrenal, and pancreatic masses, which were thought to be related to his Hodgkin disease. These masses had been stable for the past 8 months.

He now presented with a history of 3 weeks of nausea, vomiting, diarrhea, and diffuse abdominal pain, which had not responded to a course of levofloxacin, 500 mg daily, for presumed colitis, or to appropriate pain medications.

Physical examination revealed a middle-aged man in mild respiratory distress, with a respiration rate of 20 breaths per minute. He was afebrile. His heart rate was 98 beats per minute and blood pressure was 120/80 mm Hg. There was no evidence of clubbing, cyanosis, or hypertrophic osteoarthropathy.

The patient had decreased air entry in the right hemithorax. Heart sounds showed a normal S1 and S2, with a loud pulmonic component of the S2. His abdomen was soft but diffusely tender, more so on the right than on the left, with significant hepatosplenomegaly. Findings from a neurologic examination were unremarkable.

Laboratory test results revealed a white blood cell (WBC) count of 10,200/µL, with 70% polymorphonuclear neutrophils, 23% lymphocytes, 7% monocytes, and 0% eosinophils; hemoglobin level of 12.7 g/dL; and hematocrit value of 30%. Arterial blood gases on room air were pH, 7.44; PCO2, 30 mm Hg; and PO2, 78 mm Hg. Admission laboratory values were also significant for a total bilirubin level of 4.3 mg/dL (normal, 0.2 to 1.2 mg/dL); amylase, 175 U/L (normal, 25 to 125 U/L); lipase, 132 U/L (normal, 7 to 60 U/L); aspartate aminotransferase (AST), 66 U/L (normal, 10 to 40 U/L); alanine aminotransferase (ALT), 89 U/L (normal, 10 to 45 U/L); alkaline phosphatase, 1019 U/L (normal, 30 to 120 U/L); lactate dehydrogenase, 350 U/L; and cancer antigen 19-9, 51 U/mL.

Abdominal sonography, CT, and MRI revealed a dilated common bile duct of 1.2 cm, mild pancreatic duct dilatation, bilateral adrenal masses measuring 4 3 2.8 cm on the left and 5.2 3 2.2 cm on the right, and a mass in the pancreatic head measuring 2 3 1.4 cm (Figures 2 and 3). The pancreatic and adrenal masses had expanded since studies completed 1 month earlier. Chest CT revealed a spiculated mass in the right upper lobe mea-suring 3.2 3 2.4 cm, with an adjacent satellite lesion, and a right hilar lymph node measuring 2 3 1.5 cm (Figure 4), unchanged from previous studies.

Bowel rest was prescribed for the patient, and he was given pain management and intravenous fluids. Only mild improvement was achieved: minimum liver enzyme levels reached were AST, 52 U/L; ALT, 76 U/L; alkaline phosphatase, 886 U/L; and total bilirubin, 3.2 mg/dL, with a direct bilirubin of 2.5 mg/dL. The patient's symptoms improved, and he was able to tolerate oral intake. The workup was continued to further evaluate the lung, adrenal, and pancreatic masses.

A positron emission tomo-graphic scan revealed increased tracer uptake in the right upper lung, right hilum and mediastinum, neck and abdomen, and left and right acetabular regions (Figure 5). Results of a CT-guided biopsy of the right upper lung mass and biopsy of the adrenal mass were consistent with non-small-cell lung carcinoma (Figure 6). The pathologic findings included large epithelial cells with nuclei that showed malignant features. The immunohistochemical staining showed uptake for keratin within the cells and abnormal nuclei, which confirmed the presence of carcinoma.

A review of the pathology sections from the previous right paratracheal lymph node biopsy demonstrated a lymphoid proliferation with several binucleated Reed-Sternberg cells and positive staining with CD-30, consistent with Hodgkin disease. This confirmed the concomitant presentation of 2 malignant processes.

The patient was deemed a poor candidate for chemotherapy because of his low performance status. Over the course of his hospital stay, he had fevers and progressively increasing levels of AST (199 U/L), ALT (108 U/L), alkaline phosphatase (1283 U/L), and total bilirubin (11.5 mg/dL, with a direct bilirubin level of 8.1 mg/dL).

The patient was given piperacillin/tazobactam, 3.375 mg IV every 6 hours, and was scheduled to undergo endoscopic retrograde cholangiopancreatography (ERCP) to relieve a presumed obstructive cholangitis. Attempts to place a stent in the common bile duct via ERCP were unsuccessful, but sufficient drainage was eventually established via percutaneous transhepatic cholangiography.

Shortly after this procedure, the patient became encephalopathic and pancytopenic, with a WBC count of 1600/µL and absolute neutrophil count of 700/µL. Acute respiratory distress developed, and the patient was intubated. He required increasing respiratory support and eventually died.


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