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Year : 2010  |  Volume : 53  |  Issue : 3  |  Page : 551-554
Coexistent lymphoma with tuberculosis and Kaposi's sarcoma with tuberculosis occurring in lymph node in patients with AIDS: A report of two cases


1 Department of Blood Bank, Sir J. J. Hospital and Grant Medical College, Mumbai, India
2 Department of Pathology, Sir J. J. Hospital and Grant Medical College, Mumbai, India
3 Department of Forensic Medicine and Toxicology, Sir J. J. Hospital and Grant Medical College, Mumbai, India

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Date of Web Publication22-Oct-2010
 

   Abstract 

Although there have been a few reports of simultaneous infections and neoplasm in patients with acquired immune deficiency syndrome, no reports of coexistent lymphoma with tuberculosis and Kaposi's sarcoma with tuberculosis occurring in the same lymph node have been described. In this article, we describe coexistent lymphoma with tuberculosis in one case and Kaposi's sarcoma with tuberculosis in another case of human immune deficiency virus-infected individuals.

Keywords: AIDS, autopsy, Kaposi′s sarcoma, lymphoma, tuberculosis

How to cite this article:
Lanjewar D N, Lanjewar SD, Chavan G. Coexistent lymphoma with tuberculosis and Kaposi's sarcoma with tuberculosis occurring in lymph node in patients with AIDS: A report of two cases. Indian J Pathol Microbiol 2010;53:551-4

How to cite this URL:
Lanjewar D N, Lanjewar SD, Chavan G. Coexistent lymphoma with tuberculosis and Kaposi's sarcoma with tuberculosis occurring in lymph node in patients with AIDS: A report of two cases. Indian J Pathol Microbiol [serial online] 2010 [cited 2014 Oct 23];53:551-4. Available from: http://www.ijpmonline.org/text.asp?2010/53/3/551/68285



   Introduction Top


The first acquired immune deficiency syndrome (AIDS) case in India was detected in 1986; since then human immune deficiency virus (HIV) infection has been reported in all the states and union territories. The 2006 estimates suggest that HIV prevalence in India is somewhere between 2 and 3.1 million people-on an average, about 2.5 million people. [1] After sub-Saharan Africa and Nigeria, India has the third largest burden of HIV infection. Pathologic studies are important in patients with HIV/AIDS because accurate diagnosis impacts the management of these patients.


   Case Reports Top


Case 1

A 40-year-old man, citizen of Somalia, presented to the dermatology clinic with painful elevated dark colored skin lesions. There was a past history of tuberculous psoas abscess for which the patient received antituberculosis drugs. He was tested for antibodies to HIV-1 and HIV-2 using Dot immunoassay (Span Diagnostics Ltd., Surat, India) and the sera reactive by this test kit were further tested using rapid immunoconcentration test (Qualpro Diagnostics, Goa, India) and immunoassay for simultaneous and differential detection of total antibodies to HIV-1 and HIV-2 (Qualpro Diagnostics). The patient showed the presence of antibody to HIV-1. His CD-4 cell count was 8 cells/mm 3 . During hospitalization, when required, the patient was referred to physicians for other medical problems.

The histopathologic examination of skin lesions showed features of Kaposi's sarcoma. Immunohistochemical study of tumor for CD-31, CD-34, and HHV-8 showed immunoreactivity to CD-31 and HHV-8 and nonreactivity to CD-34, thus a diagnosis of Kaposi's sarcoma was confirmed. The examination of respiratory system and chest radiograph showed the presence of bilateral pulmonary tuberculosis. Sputum microscopy for acid-fast bacilli was positive; however, culture or drug resistance testing was not carried out. He was treated with antiretroviral as well as antituberculosis drugs, however, there was no improvement in his clinical condition; subsequently, the patient developed cardiorespiratory failure and died. An autopsy was carried out to determine the cause of death. The postmortem examination revealed miliary tuberculosis of lungs, liver, spleen, lymph nodes, and kidneys. The hilar lymph nodes were enlarged and the cut surface of one of the lymph nodes showed a hemorrhagic appearance at the subcapsular region and caseous necrosis in medullary portion [Figure 1]. Microscopic examination of the lymph node showed spindle cell tumor corresponding to the subcapsular hemorrhagic area. The tumor was composed of angiomatoid slit-like vascular spaces containing red blood cells surrounded by spindle cells. Adjacent to the microscopic lesion of Kaposi's sarcoma, eosinophilic granular necrosis was noted [Figure 2]. The spindle cells were arranged in fascicles and their nuclei did not show any atypical features or mitotic activity [Figure 3]. In between the tumor cells, deposition of hemosiderin pigment and infiltration by mononuclear cells were identified. Immunohistochemical study of the tumor for CD-31, CD-34, and HHV-8 was carried out; it showed immunoreactivity to CD-31 and HHV-8, thus a diagnosis of Kaposi's sarcoma was made. In the area of necrosis, there was no evidence of granuloma formation or giant cell reaction. Ziehl-Neelsen stain showed numerous acid-fast bacilli in the necrotic area [Figure 4]. The acid-fast bacilli were not demonstrated in the spindle cell component of Kaposi's sarcoma. Thus, coexistent Kaposi's sarcoma and tuberculosis was identified in the same lymph node.
Figure 1: Cut surface lymph node shows brown hemorrhagic lesion of Kaposi's sarcoma at the periphery, and the central area shows necrosis

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Figure 2: Histology of lymph node shows spindle cell tumor of Kaposi's sarcoma and the area of necrosis (H and E, ×100)

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Figure 3: The higher magnifi cati on shows spindle cell tumor cells and vascular slits (H and E, ×200)

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Figure 4: Ziehl– Neelsen stain shows acid-fast bacilli in necrotic areas (Ziehl– Neelsen stain, ×1000)

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Case 2

A 42-year-old HIV-infected male, resident of Mumbai, was admitted to the Medicine ward for swelling on the left side of the neck, fever, and weight loss of 3 months duration. A previous biopsy of an enlarged cervical lymph node was reported as non-Hodgkin's lymphoma of B-cell type. The diagnosis of HIV infection was made for the first time when he presented with cervical swelling. The patient also received treatment for pulmonary tuberculosis in the past. On examination, the cervical region of the neck showed multiple enlarged lymph nodes, the largest measuring 3 cm in diameter. Ultrasonography of the abdomen showed enlarged lymph nodes in paraaortic region; liver and spleen showed multiple hypoechoic areas. Chest radiograph showed normal features and did not show any evidence of tuberculosis. The laboratory investigations revealed the presence of antibody to HIV-1 and a CD 4 count of 190 cells/ mm 3 . Examination of sputum for tubercle bacilli and culture for tubercle bacilli was not done. The staging of HIV/AIDS of the patient was category C as he was having lymphoma, an AIDS defining condition. The clinical condition of the patient deteriorated and he died due to respiratory failure; a clinical postmortem was performed to determine the cause of death. The financial condition of the patient was very poor; hence, he could not afford the cost of chemotherapy for lymphoma as well as highly active anti-retroviral therapy (HAART) therapy.

An autopsy examination revealed enlarged lymph nodes in the cervical and abdominal regions. The cut section of the enlarged lymph nodes revealed fleshy appearance with focal areas of necrosis. Microscopic examination of lymph node consisted of sheets of large lymphoid cells with a moderate amount of pale cytoplasm and large areas of necrosis [Figure 5]. The nuclei were round or had irregular contours, irregularly distributed chromatin, nucleoli, and frequent mitosis [Figure 6]. Immunohistochemical studies confirmed features of diffuse large B-cell non-Hodgkin' lymphoma, the tumor cells were positive for LCA and CD20, whereas it showed negative results for MPO, CD43, and CD30. The necrotic areas adjoining the lymphoma showed numerous acid-fast bacilli on staining with Ziehl-Neelsen stain [Figure 7]. Thus, in this case, the occurrence of coexistent lymphoma and tuberculosis was identified.
Figure 5: Lymph node shows monomorphic lymphoid populati on of lymphoma and areas of necrosis (H and E, ×100)

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Figure 6: The lymphoid tumor shows large round cells with large nuclei (H and E, ×800)

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Figure 7: Ziehl– Neelsen stain shows tubercle bacilli in necrotic areas (×1000)

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   Discussion Top


The coexistence of different diseases within the same site is a rare feature of AIDS-associated pathology. The literature search showed only 5 cases of coexistent lesions occurring in skin. In 2 cases, coexistent cutaneous cryptococcosis and molluscum contagiosum was described, whereas in another 3 cases, coexistent cutaneous cryptococcosis and Kaposi's sarcoma was described. [2],[3],[4],[5],[6] Reports of coexisting lymphoma with tuberculosis and Kaposi's sarcoma with tuberculosis are rare and to the best of our knowledge are not described in the literature. Coexistent lesions pose problems of diagnostic difficulties, particularly in fine-needle aspiration cytology (FNAC), when aspirates from different areas of an enlarged lymph node are not obtained. Coexisting lesions are also likely to be misdiagnosed even in biopsy material if special stains for the demonstration of microorganisms are not performed. Accurate diagnoses of coexisting lesions have implications on therapeutic management of patients with HIV/AIDS.

The predominant histologic pattern of HIV-associated tuberculosis (when CD4 counts are low) shows nonreactive, abundant granular necrosis, ill-formed or absent granulomas, scanty or no giant cells, scanty or no epitheloid cells, and numerous acid-fast bacilli on a Ziehl-Neelsen stain. Hence, for accurate diagnosis of FNAC/biopsy material obtained from HIV-infected patients, battery of special stains should be carried out for the demonstration of microorganisms.

The treatment of co-infection with HIV and tuberculosis causes a number of difficulties related to high pill burden, adherence issues, toxicity and drug interaction. Similarly, treatment of AIDS-related malignant lymphoma (ARL) remains a therapeutic challenge; and no data exist on patients with ARL suffering from active opportunistic infections. Literature describes only 1 case report of a successful treatment with chemotherapy in addition to tuberculostatic therapy and HAART in a patient with AIDS-related Burkitt's lymphoma and pulmonary tuberculosis. [7] One of our patient was treated with HAART, whereas another patient could not afford chemotherapy as well as HAART therapy.


   Acknowledgment Top


The authors thank Dr. Tanuja Shet, Department of Pathology, Tata Memorial Hospital, Mumbai.

 
   References Top

1.National AIDS Control Organisation, (NACO) Ministry of Health, Government of India, New Delhi, HIV Sentinel surveillance and HIV estimation in India: A technical brief. Available from: http://www.nacoonline.org/NACO/Quick_Links_/HIVData . [cited in 2006].  Back to cited text no. 1      
2.Lanjewar DN, Shroff HJ, Kohli MA, Hira SK. Cutaneous cryptococcosis and molluscum contagiosum occurring in the same lesion in patient with AIDS. Indian J Dermatol Venereol Leprol 1998;64:25-8.  Back to cited text no. 2      
3.Sulica RL, Kelly J, Berberian BJ, Glaun R. Cutaneous cryptococcosis with molluscum contagiosum co-infection in a patient with acquired immunodeficiency syndrome. Cutis 1994;53:88-90.  Back to cited text no. 3  [PUBMED]    
4.Glassman SJ, Hale MJ. Cutaneous cryptococcosis and Kaposi′s sarcoma occurring in the same lesion in a patient with the acquired immunodeficiency syndrome. Clin Exp Dermatol 1995;20:480-6.  Back to cited text no. 4  [PUBMED]    
5.Sofman MS, Heilman ER. Simultaneous occurrence of Kaposi′s sarcoma and Cryptococcus within a cutaneous lesion in a patient with acquired immunodeficiency syndrome. Arch Dermatol 1990;126:683-4.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]  
6.Libow LF, Dobert D, Sibulkin D. Co-existent cutaneous cryptococcosis and Kaposi′s sarcoma in a patient with the acquired immunodeficiency syndrome. Cutis 1988;41:159-62.   Back to cited text no. 6      
7.Lehmann C, Wyen C, Hoffmann C, Fδtkenheuer G. Successful administration of aggressive chemotherapy concomitant to tuberculostatic and highly active antiretroviral therapy in a patient with AIDS-related Burkitt′s lymphoma. HIV Med 2005;6:51-3.  Back to cited text no. 7      

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Correspondence Address:
D N Lanjewar
Government Medical College Miraj, Maharashtra
India
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DOI: 10.4103/0377-4929.68285

PMID: 20699524

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]

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