What is the recommended treatment approach for a patient with undetected HIV (Human Immunodeficiency Virus) presenting as lymphoma?

Case Report: Undetected HIV Presenting as Lymphoma

Patients with undetected HIV presenting with lymphoma should receive combination antiretroviral therapy (ART) concurrently with appropriate chemotherapy regimens, with careful attention to drug-drug interactions and supportive care measures. 1

Clinical Presentation

A 38-year-old male presented with right upper abdominal pain and esophageal reflux symptoms. Despite being in good general health with no significant constitutional symptoms, endoscopic evaluation revealed a small bowel tumor and mild esophageal candidiasis. Histopathological examination confirmed Burkitt lymphoma. HIV testing was positive, previously undiagnosed. 2

Diagnostic Approach

• Lymphoma diagnosis requires an excisional biopsy evaluated by an expert hematopathologist using immunohistochemistry and molecular techniques 1
• Complete staging workup includes:
  • Contrast-enhanced CT scan of neck, chest, abdomen, and pelvis 1
  • FDG-PET/CT scan (more sensitive for extranodal disease) 1
  • Bone marrow biopsy 1
  • CSF analysis for cytology and flow cytometry in aggressive NHL 1
• HIV-associated lymphomas often present with:
  • Advanced disease stage 3
  • Extranodal involvement 3
  • B symptoms (fever, night sweats, weight loss) 1
  • Association with oncogenic viruses (EBV and/or HHV-8) 3

Treatment Approach

Antiretroviral Therapy

• ART should be initiated immediately and continued during chemotherapy for all patients with HIV-related lymphoma 1
• ART ensures sustained viral suppression and improves:
  • Chemotherapy tolerability 1
  • Immune recovery 1
  • Overall patient outcomes 1

Chemotherapy Selection

• Treatment should follow recommendations for HIV-negative patients with appropriate modifications 1
• For Burkitt lymphoma and other aggressive NHL:
  • Full-dose intensive chemotherapy regimens are recommended 3, 4
  • Rituximab should be included in CD20-positive lymphomas 1
• For Hodgkin lymphoma:
  • ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) is preferred due to lower toxicity 1
  • Stanford V or BEACOPP regimens are alternatives but with higher toxicity 1
• For primary CNS lymphoma:
  • High-dose methotrexate (3 g/m²) with rituximab and ART is recommended 1

Drug-Drug Interactions

• A multidisciplinary approach including an HIV specialist is strongly recommended 1
• NNRTI-based ART may be preferable to PI-based regimens when combined with chemotherapy 5
• Consider integrase inhibitor-based regimens (e.g., raltegravir) to minimize interactions 2
• ART regimens may need modification to avoid interactions with chemotherapy 1
• Consult specialized resources for specific interactions: www.hiv-druginteractions.org and www.cancer-druginteractions.org 1

Infection Prophylaxis

• PCP prophylaxis is strongly recommended for all patients with CD4 counts <200 cells/μL 1
• Consider PCP prophylaxis even with higher CD4 counts due to expected decline during chemotherapy 1
• Antiviral prophylaxis with acyclovir/valacyclovir for patients with history of HSV/VZV or CD4 <200 cells/μL 1
• Consider antifungal prophylaxis with fluconazole in severely immunosuppressed patients (CD4 <100 cells/μL) 1
• Prophylactic fluoroquinolones for patients undergoing intensive chemotherapy with expected prolonged neutropenia 1

Monitoring and Follow-up

• Regular monitoring of:
  • HIV viral load and CD4 count 1
  • Treatment response using appropriate imaging (CT or PET/CT) 1
  • Drug toxicities, particularly hematologic, hepatic, and renal 5
• Brain MRI with contrast is recommended for CNS lymphoma response assessment 4-8 weeks after chemotherapy 1

Case Outcome

Following diagnosis, the patient was started on lamivudine, abacavir, and raltegravir for HIV treatment alongside chemotherapy according to the B-ALL protocol. Complete remission of the Burkitt lymphoma was achieved after the first cycle of chemotherapy. After completing 6 cycles, the patient's CD4 count recovered to 400 cells/mm³ with HIV viral load of 20-300 copies/mL. 2

Clinical Pearls and Pitfalls

• Pitfall: Delaying ART initiation during chemotherapy

  • Solution: Start ART immediately as it improves outcomes 1

• Pitfall: Overlooking drug-drug interactions

  • Solution: Consult specialized resources and involve pharmacists 1

• Pitfall: Misinterpreting FDG-PET/CT results

  • Solution: Be aware of false-positive rates due to HIV-related lymphoid hyperplasia or opportunistic infections 1

• Pitfall: Inadequate infection prophylaxis

  • Solution: Implement comprehensive prophylaxis based on CD4 count 1

• Pitfall: Dose reduction based solely on HIV status

  • Solution: Full-dose chemotherapy with appropriate supportive care is recommended 1, 3