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| Discussion |
A 35-year-old man, a known seropositive patient, symptomatic since one month
came with complaints of dull aching, non radiating pain in the right hypochondrium
& in the epigastric region associated with intermittent fever. The patient had
history of pulmonary tuberculosis 15 years back & was on antiretroviral therapy
since 1 ½ years. On physical examination, there was mild icterus with tender hepatomegaly.
However no lymphadenopathy was found.
 | |
| Fig.1
. |
Plain and contrast
enhanced CT scans of the abdomen revealed multiple, target lesions with minimal
rim enhancement, hepatomegaly, free fluid in peritoneal cavity & enlarged aorto-caval
lymph nodes.
 |
 | |
Fig.
2 | Fig.
3 . | |
On MRI, these lesions
appear as hyperintense on both T1 & T2 weighted images. This ruled out the possibility
of fungal abscesses which are hypointense on T2 as it contain manganese & iron.
 |
 | |
Fig.
4 | Fig.
5 | |
On liver biopsy, the liver was heavily infiltrated by atypical looking mononuclear cells. There was biliary ductular proliferation. Very little normal liver parenchyma is seen. Some tumor cells showed nuclear moulding. These findings were highly suggestive of a Non Hodgkin's Lymphoma.
 |
Fig.6
|
DISCUSSION:
There are three main categories
of AIDS related lymphoma.
1.Imunoblastic lymphomas {60%}: High grade or diffuse histocytic lymphoma. {large cell} common in older patients.
2. Burkitt's lymphoma {20%}: Small non cleaved cell lymphoma common in young patients .
3. Primary CNS
lymphoma {20%}.
DIFFERENTIAL
DIAGNOSIS:- Lesions due to metastases, Kaposi's sarcoma, disseminated tuberculosis,
bacillary angiomatosis and Pneumocystis carinii may present similar appearances.
INCIDENCE:- Non Hodgkin Lymphoma is present in 3% of HIV positive patients
at the time of their diagnosis and develops in upto 20 % HIV patients during their
life time.
CLINICAL PRESENTATION: - The most common symptom is painless swelling of lymph nodes in the neck, axilla and groin. 80% of patients present with advanced disease/extra nodal presentation; of these, 80% have type B symptoms at presentation like unexplained fever, night sweats, fatigue, weight loss and anorexia.
TYPE
OF NHL: - Low grade, intermediate and high grade lymphoma depend upon microscopic
appearance.
DIAGNOSIS:- Biopsy is necessary to confirm the diagnosis. Other lab parameters & imaging modalities are helpful to monitor and determine the spread of disease.
STAGING OF DISEASE:- Stage I: Disease located to one region; Stage II: located to two regions on the same side of the diaphragm and Stage III: Spread to both sides of the diaphragm involving one organ or area near-by spleen or lymph nodes. In stage IV, spread beyond lymphatic system, involving one or more major organ possibly bone marrow, skin.
TRATMENT
OPTION :- 1} Combination of chemotherapy 2}Radiation therapy usually along with
chemotherapy. 3}Bone marrow transplant in case of recurrence. 4}Immunotherapy.
In a seropositive patient these are usually combined with antiretroviral therapy.
CONCLUSION: -
AIDS Clinical trial group study suggested that prognostic variables in AIDS patients
closely resemble with that of non-AIDS related NHL.
Two year survival for
patients with good prognosis treated with chemotherapy is 50% as compared with
24% for those with poor prognosis.