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CASE REPORTS

Hodgkins Lymphoma with HIVInfection

Pankaj MittalS.R. Daga

From the Department of Pediatrics, B.J. MedicalCollege, Pune 411 001, Maharashtra, India.

Correspondence to: Dr. Pankaj Mittal, SeniorRegistrar, Department of Pediatrics, B.J. MedicalCollege, Pune 411 001, Maharashtra, India. E-mail: docpankajmittal@gmail.com

Manuscript received:April 24, 2006;Initial review completed: May 15, 2006;Revision accepted: June 12, 2006.

The association between Hodgkins Lymphoma(HL) with HIV is common in adults but rare inchildren. A 5-year-old boy, known case of HIV onantiretroviral therapy, presented with prolongedfever, multiple enlarged lymph nodes along withhepatosplenomegaly. A diagnosis of Hodgkinslymphoma was entertained on histopathologicalexamination; further subtyping was done byimmunohistochemistry.

Key words: Hodgkins lymphoma, Pediatric HIV.

HIV-associated malignancies occur muchless frequently in pediatric patients comparedwith adult(1). Advances in anti-retroviraltreatment and management of opportunisticinfections have been accompanied by animproved survival, which in turn has increasedincidence of malignancies in these cases. Themajority of malignancies among HIV-infectedindividuals, children as well as adults arenon-Hodgkins lymphomas (NHL). Theprevalence of NHL between both these agegroups is similar i.e., 0.36-0.57%(1,2).Hodgkins lymphoma (HL) with HIVinfection has been largely reported amongadults(2). We report here an unusual case ofHL in a HIV infected child.

Case Report

A five-year-old boy, resident of WesternMaharashtra, was bought with intermittenthigh grade fever of four weeks duration. Thiswas associated with generalised weakness,lethargy, anorexia and weight loss. Two yearsback he was diagnosed as a case of HIVinfection. Since then he was receivingcotrimoxazole prophylaxis and antiretroviraltherapy in form of stavudine (d4T),lamivudine (3TC) and nevirapine (NVP). Themother too was a known case of HIV infection.The fathers sero-status was not known.Physical examination revealed that the childwas pale and febrile. He had firm, non-tenderand non-matted axillary lymphadenopathy.The liver was soft, non-tender and palpabletwo cm below costal margin, the spleen wasalso enlarged. There were no petechiae,ecchymoses or sternal tenderness. Rest of thephysical examination was unremarkable.

Laboratory investigations revealedhemoglobin 6.2 g/dL, total leucocyte count(TLC) 2.94 109 /L and platelet count150 109 / L. His reticulocyte count was1.2%. Peripheral blood smear showed anormocytic, normochromic blood picture andwas otherwise unremarkable. His immuno-logical profile showed CD4 and CD8 count of164 cells/L (61.2%) and 55 cells/L (20.5$),respectively. The CD4: CD8 ratio was 2.98.Serum proteins were 3.5 g/dL and serumalbumin was 2 g/dL. Urine analysis wasunremarkable. Blood culture showed nogrowth. X-ray chest showed no mediastinaladenopathy. Mantoux test was negative.Abdominal ultrasound revealed hepato-megaly, splenomegaly, retroperitoneal lymph-adenopathy and normal sized kidneys. Feverdid not respond to emperical antibiotics,antimalarials and antitubercular therapy.Excisional biopsy of axillary lymphnoderevealed classical Hodgkins lymphoma of

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CASE REPORTS

lymphocytic depletion type (WHO Classi-fication). Immuno-histochemistry furtherconfirmed the diagnosis. Bone marrow biopsyfrom right postero-superior iliac spine showedinfiltration by tumor cells. He was found to bein stage IV (Ann Arbor staging)(3). The childdied even before the treatment for HL could beinitiated.

Discussion

Pediatric HIV infection presents withdiverse clinical manifestations. Fever asso-ciated with lymphadenopathy and hepato-splenomegaly can be due to opportunisticinfections, tuberculosis, and lympho-proliferative disorders. In absence of guidancefrom blood culture, urine culture and completeblood counts to establish diagnosis for fever inthis case; therapeutic trial of antibiotics andantimalarial were administered. Non-responseprompted biopsy of the maxillary lymphnode which revealed classical Hodgkinslymphoma of lymphocytic depletion type.

HL comprises 6.6% of pediatric malig-nancies. Histological differences of HL inpatients are dependent on variable hostresponses that may in turn be influenced bygenetic and environmental factors(4). HIV-related HL is characterized by advanced stageat presentation, highly malignant clinicalcourse and the preponderant histologicalsubtypes of mixed cellularity and lymphocytedepletion and carries poor prognosis(5,6).Currently, there is little understanding of thepathogenesis of HIV-associated lymphomas.Hodgkins lymphoma associated withimmunosuppressed state is usually associatedwith Epstein-Barr virus (EBV)(7). Nuclearproteins of this virus, such as EBNA and LMPI(latent membrane protein), have been detectedin about 40% cases of classical HL(7)

HL in children and adolescents is curablein over 90% of cases(8). Highly active

antiretroviral therapy (HAART) should beinitiated or continued while the patient isundergoing treatment for the malignancy.However, there is the possibility of an increasein side effects and complex drug interactions.Therapy regimens applied to cure thesemalignancies are generally similar to thoseused with non-HIV-infected children(1).Combination chemotherapy is the mainstayof treatment. Various chemotherapeuticregimens are used. ABVD (Adriamycin,Bleomycin, vinblastine, Dacarbazine) regimeis safe, effective and gold standard treatmentfor pediatric HL. Field radiation therapy isadded to site of bulky and/or residualdisease(3,8). A multidisciplinary team shouldmanage HIV-infected children with malig-nancies, including pediatric hematologists/oncologists, pediatric HIV specialists, andpharmacists.

Contributors: PM carried out work up and was incharge of the patient. SRD was involved in designingof article and critical revision of manuscript andwould stand as guarantor.

Funding: None.

Competing interests: None.

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