Response to highly active antiretroviral therapy as the only therapy in an HIV-infected patient with interfollicular Hodgkin's lymphoma

Hodgkin’s lymphoma (HL) is one of the most frequent neoplasias in human immunodeficiency virus (HIV) infection [1]. Interfollicular Hodgkin’s lymphoma (IFHL) is a peculiar pattern of lymph node involvement by HL characterized by follicular hyperplasia with an expanded interfollicular area with the presence of Reed – Sternberg (RS) and Hodgkin’s cells (HC). Careful observation of RS cells and HC in interfollicular areas of lymph node biopsies with positivity for CD15 and CD30 monoclonal antibodies confirms the diagnosis of IFHL [2,3]. On the other hand, highly active antiretroviral therapy (HAART) has improved the prognosis of AIDSrelated lymphomas including HL [4 – 6]. In fact, there are reports of remission of these lymphomas only with HAART [7,8]. We report a patient with HIV infection diagnosed with IFHL in a limited stage, who was only treated with HAART and remains free from lymphoma 3 years after the diagnosis. A 63-year-old heterosexual man was admitted because of a 2-month history of cough, dyspnea, and vespertine fever. Physical examination only revealed laterocervical, submandibular, and axillary lymph nodes (less than 2 cm in diameter). The hemoglobin value was 120 g/L and the leucocyte count was 7.96 10/L (70% lymphocytes). Lactate dehydrogenase levels were 263 U/L (normal up to 190). HIV seropositivity was shown by enzymelinked immunoabsorbent assay and confirmed by Western blot [9]. Chest X-ray revealed a bilateral interstitial ‘‘ground glass’’ pattern mainly in the upper lung lobes. Arterial gasometry showed hypoxemia (PO2 78 mmHg) and lung function tests revealed a mild restrictive pattern with severe impairment of diffusion parameters. Serology for Toxoplasma gondii, Cryptococcus neoformans, cytomegalovirus, and Treponema pallidum were negative. Thoracic and abdominal computerized tomography (CT) scan revealed bilateral enlargement of axillary, inguinal, and left external iliac lymph nodes of less than of 1.5 cm in diameter. Fiberoptic bronchospcopy with endobronchial bronchoalveolar aspirate failed to detect malignant cells, Pneumocystis jiroveci or Mycobacterium tuberculosis. Transbronchial biopsy showed focal septal fibrosis and a single lesion with the presence of histiocytes and an inflammatory pattern. A thoracotomy with upper left lung lobe biopsy showed interstitial pneumonia with isolated granulomas. Immunohistochemistry study for P. jiroveci, Ziehl – Neelsen staining as well as aerobic and Löwenstein cultures were negative. Left axilar lymph node biopsy showed an expanded interfollicular area with the presence of RS and HC. RS were strongly positive for CD15 and CD30 and negative for CD3, CD45, CD20, and CD21. This diagnosis was made by two independent pathologists. No studies of clonality in HC and RS cells were performed. Epstein-Barr virus latent membrane protein-1 (LMP-1) and the encoded ribonucleic acid (EBER) were negative in paraffin tissue sections. HIV viral load was 506 10 copies/mL and CD4 lymphocyte count was 204/mL. 18-Fluorodeoxyglucose positron emission tomography (PET)-CT scan