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33 FACULTEIT GENEESKUNDE EN GEZONDHEIDSWETENSCHAPPEN Academiejaar 2009 - 2010 Lymphadenopathies in HIV Alexei B. Byzov Promotor: Prof. Dr. J. Philippé Co-promotor: Prof. Dr. A. Pivnik Scriptie voorgedragen in de 2de Master in het kader van de opleiding tot MASTER IN DE GENEESKUNDE 1. Abstract ........................................................................................................................................... 2 2. Introduction ..................................................................................................................................... 3 3. Materials and methods..................................................................................................................... 4 4. Results ............................................................................................................................................. 5 4.1. HIV virus ............................................................................................................................... 5 4.1.1. History and epidemiology ................................................................................................. 5 4.1.2. Biology of the virus ........................................................................................................... 5 4.1.3. Treatment of HIV .............................................................................................................. 7 4.2. Lymphatic system and lymph nodes: structure and function................................................. 7 4.3. Phases of HIV infection and changes in the lymph node morphology .................................. 8 4.4. Lymphadenopathy the main symptom of HIV infection ..................................................... 10 4.5. Physical examination of the patient with lymphadenopathy: how to examine and what to look for? ............................................................................................................................................ 12 4.6. Lymphadenopathy in HIV-positive patients as a result of opportunistic infections ............ 16 4.6.1. HIV-LA in tuberculosis ................................................................................................... 17 4.6.2. HIV-LA in nontuberculous mycobacteriosis................................................................... 19 4.6.3. HIV-LA in cytomegalovirus............................................................................................ 21 4.6.4. HIV-LA in/and Pneumocystis jirovecii ........................................................................... 22 4.6.5. Other opportunistic infections associated with HIV........................................................ 22 4.7. Lymphadenopathy in HIV-positive patients as a result of malignancies............................. 24 4.7.1. HIV-LA in Kaposi sarcoma............................................................................................. 25 4.7.2. HIV-LA in Hodgkin lymphoma ...................................................................................... 27 4.7.3. HIV-LA in Burkitt lymphoma ......................................................................................... 30 4.8. Russian experience of 2002-2005 ........................................................................................ 35 5. Discussion ..................................................................................................................................... 36 6. References ..................................................................................................................................... 43 1 1. Abstract HIV virus heeft een belangrijke invloed op wereld en het aantal geïnfecteerde mensen stijgt progressief. Deze literatuurstudie gaat de lymfadenopathie (LA), één van de belangrijkste symptomen van een HIV infectie, bestuderen. Verschillende infecties die LA veroorzaken bij HIV positieve individuen worden besproken. Ook maligne aandoeningen als oorzaak voor LA bij HIV zijn onderzocht. Klinische aspecten en specifieke eigenschappen van LA van verschillende oorsprong worden onderzocht. Een doel van de studie is om te zien of LA kan gebruikt worden als diagnostisch criterium voor de exploratie naar verborgen en nog niet gediagnosticeerde HIV gevallen. Deze studie is gebaseerd op de zoektocht in PubMed – database. Op basis van verschillende sleutelwoorden en gerefereerde literatuur wordt er een literatuurselectie gemaakt. Een stage van 6 weken in Moskou (Rusland) leverde ook een extra bijdrage en beter inzicht van het probleem. Tuberculose (TB), Nontuberculeuze mycobacteriose (NTB), Cytomegaalvirus (CMV) en Pneumocystis jirovecii (PJP) zijn gekend als de voornaamste oorzaken voor HIV geassocieerde LA. Associatie van HIV met verschillende kwaadaardige aandoeningen, die LA als klinische presentatie hebben, worden beschreven: Kaposi sarcoom (KS), Hodgkin lymphoom (HL) en bepaalde subtypes van non-Hodgkin lymphoom, vooral het Burkitt lymphoom (BL). Aan de hand van literatuuronderzoek wordt een beschrijving gegeven van belangrijke aandachtspunten in de anamnese en het klinisch onderzoek die kunnen bijdragen tot een diagnosestelling van een HIV infectie. Criteria voor een differentiaal diagnose tussen maligniteiten en infectieuse oorzaken van LA worden geschetst. Persisterende en veralgemeende LA is nauw geassocieerd met HIV infectie en moet de aandacht van iedere arts trekken op een mogelijke HIV infectie en vereist indien verdacht aanvullende HIV-testen. De incidentie van HIV was 2.3% in de groep van individuen met LA als een klinische presentatie. Tot slot worden ook de situatie in Moskou met betrekking tot HIV behandeld en de innovaties besproken gerelateerd met de behandeling van HIV geassocieerde lymfomen. 2 2. Introduction Since the discovery of the HIV in 1980s, the virus has extended its influence on the whole world. A devastating effect on some regions and the impact that the virus has already made worldwide makes it one of the greatest medical challenges of the 21st century. HIV has a high rate of spread and in our modern world with global traveling and constant movement of the people, no country can declare itself ‘free from HIV’. The virus of HIV infects lymphocytes and during the progression of this chronic infection it has a devastating effect on the immune system of the individual. The chronic progression of HIV infection results in the acquired immunodeficiency syndrome (AIDS). Due to the fact that lymphocytes are the target cells for the infection, the symptom of enlarged lymph nodes (LNs), lymphadenopathy (LA), is one of the most common and consistent symptoms during the HIV infection. The aim of this study was to provide a literature analysis on the association between the symptom of LA and progression of HIV. LA is a symptom that can be found in every stage of HIV infection. Nevertheless LA is not a specific symptom for HIV and it can be found in HIV negative individuals as result of various infections or diseases. A special focus of this study was made on finding the particular associations between the symptom of LA and HIV infection. In general HIV positive individuals suffer from various infections in more progressive HIV. These infections may lead to LA. The emphasis of our study was to identify and describe these particular, distinctive infections that usually accompany HIV. The list of identified associated infections consists of Tuberculosis (TB), Nontuberculous mycobacteriosis (NTB), Cytomegalovirus (CMV) and Pneumocystis jirovecii (PJP). We describe them and put emphasis on the clinical features of LA in these infections. Another goal of the study is to determine specific malignancies that are associated with HIV and are also responsible for the symptom of LA. Literature data search was made to identify and describe these associated tumors. A closer look is taken on Kaposi sarcoma, Hodgkin lymphoma and Burkitt lymphoma. The incidence of these malignancies in HIV positive individuals was compared to the incidence in the general population. The clinical aspects of LA in the different associated infections and malignancies were one of the major goals of this study. The possibility of the detection of hidden HIV infections by means of LA as a diagnostic criterion was 3 another focus of our literature study. The evaluation of the medical literature written about the possibility of identification or suspicion of a hidden HIV infection with only basic clinical evaluation (medical history, anamnesis and physical examination) was made. The Russian experience on the subject of LA associated to HIV was also a priority of this study. Due to the fact that most of the Russian data is published in Russian little of this information reaches the western world. Exploration of the treatment modalities of HIV associated malignancies in Moscow was made. Therefore a 6-week internship in medical institutions in Moscow, Russia took place. 3. Materials and methods In this study the PubMed-database was used as a main source for the selection of relevant publications. ‘Lymphadenopathy’, ‘lymphadenitis’ and ‘HIV’ terms and combination of an etiological agent have been used as keywords for the ‘search’ option tool. Available articles were further preselected based on the relevancy, publication date and the impact factor of the journal. Further selection was made based on information described in the publications with focus on most recent data. Frequently the link ‘related articles’ was used as an additional tool. Similar selection criteria were applied for the selection of relevant references. The second main source for collection of relevant data were reference lists of pre-selected publications. In this case authors names of chosen articles and/or terms indicated in a title were used in a direct search in the Pub-Med database. Again, one of the criteria for the search was the publication date. The most recent papers were preferred but when an article was considered to present “crucial” findings, this was considered sufficient for the selection. As a rule of thumb the first and the last author’s names of the “crucial” articles were used as further keywords to find more detailed information and recent results. Textbooks and relevant internet sites were used to gather the basic, well-known data about the lymph node structure, HIV and lymphadenopathy. 4 4. Results 4.1. HIV virus 4.1.1. History and epidemiology The first data related to the virus of human immunodeficiency (HIV), describing an abnormal development of pneumocystic pneumonia and Kaposi sarcoma in male homosexuals were published in 1981 (Centers for disease control. Los Angeles 1981; Centers for disease control. New York 1981). These studies described a few cases when patients suffering from pneumocystic pneumonia also showed an additional abnormal symptom of a generalized LA. It was soon afterwards discovered that the agent responsible for this remarkable disease was a retrovirus. In 1982 a new term was introduced: acquired immune deficiency syndrome (AIDS). Since that time an enormous body of information on HIV and AIDS has been collected. HIV infection is a worldwide epidemic. According to the World Health Organization there is an estimated 33.0 million of people living with HIV. This statistics are provided by the UNAIDS/WHO report published in 2008 (Table 1). Table 1: Global HIV/AIDS estimates, end of 2007 People living with HIV/AIDS 33.0 million Adults living with HIV/AIDS 30.8 million Women living with HIV/AIDS 15.5 million Children living with HIV/AIDS 2.0 million People newly infected with HIV 2.7 million Children newly infected with HIV 0.37 million AIDS deaths 2.0 million Child AIDS deaths 0.27 million 4.1.2. Biology of the virus According to Medical Microbiology (Mims et al., 2004), HIV is a member of the genus Lentivirus belonging to Retroviridae family. Lentivirus means ‘slow’ virus and this name is given to the group 5 due to the long interval between the initial infection and the onset of severe symptoms (Chiu et al., 1985). Two genetically distinct viral types have been identified. HIV-1 which is present in Europe, Asia, America and Central Africa and HIV-2 which is only situated in the Western Africa (Tebit et al., 2007). The virus is an enveloped RNA virus and is transmitted in single stranded, positive-sense ssRNA form. After the transmission the reverse transcriptase, which is also present in the virus, transforms the single-stranded RNA to a double-stranded DNA and then the virus DNA is integrated and transcribed with help from the cellular system of the host. After such integration there are two possibilities: either the virus becomes latent and the infected cells continue their function without any disturbance to the host cells or the virus becomes active and starts to replicate itself. In the latent stage the HIV can be ‘sleeping’ for several years or even a decade. When a huge number of viruses are formed a cell ruptures and lysis occurs resulting in the spread of the virus to the extracellular compartment (Potter et al., 2007). The process of the selection of target cells that are infected by HIV is based on the recognition of CD4 receptors on the host cells’ surface by the virus. The cells that have such CD4 receptors on their cell surface are T-lymphocytes, monocytes, dendritic cells and microglia. T-lymphocytes have one of a crucial function of the immune system in the recognition of infectious agents; they are called CD4 ‘Thelper’ cells. The activation of CD4 ‘T-helper’ cells takes place as a response of the immune system to various microbial agents. When these cells are in the naïve state no replication of HIV takes place, only when the T-lymphocytes are activated the HIV may proceed with the replication (Mims et al. 2004). The main function of the CD4 ‘T-helper’ cells is activation of other cells of the immune system such as B-lymphocytes and cytotoxic T cells (Fahey et al., 1990). An abnormal activation of the immune system has been shown to be a major factor in the disease progression. A pool of activated CD4 Tcells is formed that can be targeted by HIV and this may lead to the exhaustion of the immune system (Potter et al., 2007). There are four ways of the virus transmission: sex, blood contact (contaminated needles), breast milk and transmission from an infected mother to her child at birth. The majority of HIV infections are acquired through unsafe sex. A contact between infected sexual secretions from one partner with oral, genital or rectal mucous from another partner is required for this way of transmission. The dendritic cells swallow the virus particle and bring it across the mucosa to the lymphatic system, to the lymph node (Lekkerkerker et al., 2006). 6 Contaminated needles are responsible for the transmission in the population of intravenous drug users and hemophiliacs. This form of transmission is also seen in blood transfusions when the donor blood was not adequately checked for the virus. Breast-feeding, in utero transfer and transmission during childbirth are responsible for the vertical transmission. HIV infection has four stages: it begins with an incubation period that is followed by an acute infection, latency stage and AIDS (Boily et al., 2009). 4.1.3. Treatment of HIV Currently highly active antiretroviral therapy (HAART) is a common treatment applied to HIV infected patients (Commented Drug Repertorium, 2010). HAART is aggressive treatment that is given to suppress the viral replication, to delay and slowdown the evolution of the infection. The treatment is given in function of the viral load and the CD4 count. As a rule several types of medications such as: nucleoside reverse transcriptase inhibitors (NRTIs), protease inhibitors (PI) and non-nucleoside reverse transcriptase inhibitors (NNRTI) are prescribed. If the drugs are administered one at a time there is a great chance for the resistance therefore the drugs are given in association. One of the keys to success of the therapy and low incidence of resistance is a good compliance of the patient. The percentage of the resistance that develops due to low compliance is high. Long-term effects of HAART are not yet known. The treatment is also given in prevention as prophylaxis when there is a great risk for contamination or after an accidental exposure. A regular therapy consists of an association of two NRTIs and PI or two NRTIs and NNRTI. Since the introduction of HAART there have been significant changes in the frequencies of the HIVassociated diseases. The incidence of opportunistic infections has decreased significantly along with the incidence of Kaposi sarcoma and non-Hodgkin lymphomas. Paradoxically an increase of the Hodgkin lymphomas has been observed. The introduction of HAART has not only changed the spectrum of the associated disease but also decreased the mortality, particularly malignancy (Commented Drug Repertorium, 2010), (World Health Organization, 2009). 4.2. Lymphatic system and lymph nodes: structure and function The lymphatic system is a well-organized network that is formed by functionally interrelated 7 lymphoid tissue, and transportation pathways of tissue fluid/lymph and lymphoid cells. It consists of different cellular components, lymphatic vessels and fluids. The most common cells of the lymph are the CD4 T-lymphocytes and antigen presenting cells (APCs) such as dendritic cells and macrophages. The organized lymphoid tissues form small rounded or oval shaped masses: the lymph nodes (LNs) (Olszewski, 2003). A LN has a bean form shape and is under normal conditions not larger than one centimeter. (Angeli and Randolph, 2006) There are approximately 600 LNs in our body and they are commonly localized in the base of all of the extremities, near to big blood vessels and are also situated in different groups. The main groups that can be distinguished are the LNs in cervical, submandibular, axillary, mediastinal, retroperitoneal and inguinal regions (Greer et al., 11th edition). A closer look on the structure of the LN reveals an inner parenchyma that is surrounded by a capsule of a connective tissue. This fibrous capsule penetrates the parenchyma and forms a fibrous supporting meshwork. Further two histological regions of the parenchyma can be distinguished: a peripherally situated cortex and a central medulla. Through the hilus blood vessels enter and leave the lymph node (Greer et al., 11th edition). Two main functions of the whole lymphatic system are the maintenance of fluid balance and extravascular homeostasis and the formation of an immunological barrier system. It is in the lymph node that a first encounter between an APC and a lymphocyte takes place. When a pathogenic organism, for example a virus, is located in the peripheral organs or tissues an immunological answer is induced. APCs such as dendritic cells or macrophages phagocytate or swallow up the pathogenic particle and bring it through the system of lymphatic vessels to a LN. This particular LN is the most proximal one that is found in the draining pathway of the lymph. After entering the LN APC interacts with naïve, not activated T-cells, presenting it with the pathogenic particle. An activation of the T-cell then takes place (Olszewski, 2003). 4.3. Phases of HIV infection and changes in the lymph node morphology After intensive studies and research that has proceeded for two and a half decades enormous body of information concerning HIV biology was gathered. The fact that the spread of the infection is so rapidly progressing made a great impact on the amount of studies that were dedicated to uncover the pathology and the anatomy of the virus. Now the dynamics of the HIV infection and its impact on the immune system is relatively well understood (Klimas et al., 2008). 8 It was found that HIV has a strong tropism for lymphoid tissues. Basically the virus infects the target cells that have certain cell surface molecules one of which is CD4. The virus attaches itself to a CD4 receptor and a coreceptor and then penetrates the cell (Klimas et al., 2008). After the infection an incubational period of several weeks takes place. At this stage the patient does not have any symptoms of the infection. • Acute phase On average an acute phase has a duration of 28 days, but the symptoms last normally for a week. The viral load is the amount of viruses that can be found in the peripheral blood. This is a result of a fast replication specific to the acute stage of the infection hence viral particles can be found in the blood in abundance. The virus migrates to the lymph nodes and causes reactive lymphadenitis. Along with the enlargement of the lymph nodes symptoms of fever, rash, myalgia, pharyngitis, hepatomegaly, splenomegaly and malaise are also frequent. Patients can also complain about headache, nausea and weight loss. These symptoms basically lack specificity so it is a challenge to diagnose HIV at this stage of the infection. An acute phase of the infection is highly contagious and patients should be prevented from spreading the infection so an early diagnosis is very important (Levy, 2006). At this stage of the HIV-infection enlarged lymphoid follicles with reactive germinal centers characterize the structure of LN. There are aggregates of small lymphocytes that can focally penetrate into the germinal centers and make their contribution to the follicle lysis and the destruction of the germinal center (Caponetti and Pantanowitz , 2008). • Latent phase It is hard to estimate the normal duration of this phase because it can vary from several weeks to a decade and has therefore a very diverse length. The phase of the virus latency is marked by a decrease in the viral load, so a fairly low amount of the virus is present in the peripheral blood. However, large amount of the virus are localized in the follicular dendritic cell network of the LN. Also depletion in the amount of the lymphocytes, accumulation of plasma cells and the progressive involution of the germinal centers are specific changes of the LN structure and morphology for this stage of HIV infection. The depletion of the lymphocytes results in the drop of the amount of CD4 cells from normal levels of 1000 to 1400 cells 9 per µl to several hundreds (Caponetti and Pantanowitz , 2008). When the amount of CD4 drops below 500 cells per µl holes in the immune system begin to appear. Patients begin to suffer from minor, yet not threatening infections like condylomas, fungal infections, herpes simplex, thrush and vaginal candidiasis (Centers for Disease Control and Prevention. 1993). • AIDS phase It is stated that when the number of cells drops under the level of 200 cells per µl acquired immune deficiency syndrome (AIDS) develops. AIDS is a complex of well-known disorders that are normally associated with low number of CD4 cells. At this stage of the infection patients begin to suffer from serious infections such as Pneumocystis jirovecii (PJP), cytomegalovirus (CMV), toxoplasmosis, infections of the eye and the intestine. Also weight loss is observed and HIV dementia can occur. At this stage of the infection specific cancers, Kaposi sarcomas and lymphomas, form a threat to the severely immunosuppressed patients (Centers for Disease Control and Prevention. 1993). The progression of the infection has also a great impact on the morphology of LN. Follicles in the LN become small or are already totally absent and have hyalinized ‘burnt-out’ germinal centers. In the LN there is also depletion in the lymphocytes but the amount of plasma cells is increased (Caponetti and Pantanowitz, 2008). To conclude it should be underlined that the LN structure undergoes a progressive remodeling through out the HIV infection that eventually results in the damage of the normal immune system. The finding and identification of the morphological changes in the LN can therefore be diagnostical for the stage of the infection and the material for such an evaluation can be acquired with fine needle aspiration (FNA) or an open biopsy. It has to be mentioned that HAART treatment is associated with immune reconstitution so the morphological patterns can be altered in patients who underwent such a treatment (Caponetti and Pantanowitz, 2008). 4.4. Lymphadenopathy the main symptom of HIV infection Lymphadenopathy (LA) is usually translated as a ‘lymph gland disease’. Typically the affected lymph nodes are swollen so the meaning of this definition has transformed to ‘the enlarged lymph nodes’. So LA is an enlargement of the LNs of more than 2 cm and this symptom must be present for at least 3 months in two or more LNs. However the term LA refers to the lymph nodes that are abnormal not 10 only in size, but also in consistency, location and mobility. A simple and clinically useful system of classification of LA is to identify localized LA and the generalized LA. The localized LA is when lymph nodes are abnormal only in one region of the body. The generalized LA can be stated when the lymph nodes are enlarged or abnormal in two or more noncontiguous areas. The generalized LA is an indication that a systemic disease is present, so further investigation is therefore necessary. Distinguishing between the localized and the generalized lymphadenopathy is a very important step in the evaluation of a patient and helps to determine the differential diagnosis (Ferrer, 1998).. Lymphadenopathy is frequently a symptom deriving from an obvious cause, but in some cases, when the root of the abnormal lymph node or lymph node group is less clear further diagnostic investigation should take place. It is a diagnostical challenge to be able to distinguish between a self-limiting LA and a LA that is caused by a serious disease (Ferrer, 1998). The majority of localized lymph nodes are seen in the head and neck region, less in inguinal region and seldom in axillary lymph node groups. A supraclavicular localized LA is frequently identified as a malignant enlargement so further investigation of this type of localized LA is essential. Basically when a localized LA is identified further physical examination becomes crucial not to miss a generalized LA and to be able to diagnose the abnormal lymph nodes in other regions of the body (Ferrer, 1998). Due to the fact that the generalized LA is an indication of a systemic disease a biopsy is an absolute necessity when the reason for the LA is not clear after the initial evaluation. The biopsy should be made on the most abnormal and preferably the largest LN and not on the LN that is most accessible. Patients with unexplained localized LA who have constitutional symptoms or signs, risk factors for malignancy or LA that persists for 3 or 4 weeks should also undergo a biopsy (Ferrer, 1998). Lymphoadenopathy is one of the profound and persistent signs during the progression of the HIV infection. The HIV virus infects primarily the CD4 lymphocytes therefore the lymph nodes are commonly involved during all the stages of the infection. LA is also one of the first, earliest symptoms and signs of the HIV infection. It is seen among other general symptoms typical for a retrovirus infection and is associated with a change in peripheral blood counts, a lymphocytosis (Ferrer, 1998). The syndrome of ‘persistent generalized lymphadenopathy’ was described as one of the first symptoms of HIV infections. This type of LA is present throughout the life of the patient. The swelling in atypical areas is regularly present such as supracondylar and submandibular regions. This is usually accompanied with symptoms of fever with night sweats, malaise, weight loss of more than 11 10% in 6 months and diarrhea. Therefore LA is the most consistent symptom of HIV infection throughout the progression of the clinical course (Ferrer, 1998). There are various types of LN abnormalities in HIV positive patients: reactive lymphadenitis, granulomatous lymphadenitis, with a further division to tuberculous and nontuberculous subtype, pyogenic lymphadenitis and fungal lymphadenitis, also malignancies are regularly seen such as Kaposi sarcoma Hodgkin, non-Hodgkin lymphomas, carcinomas and metastasizes (Gill et al., 2007). Fine needle aspiration (FNA) cytology is an important technique of the LN biopsy. This method is cost-effective, with a fairly low risk and provides a rapid diagnosis. Studies have shown that FNA cytology has an established role in the differential diagnosis of infection, persistent generalized lymphadenopathy and malignancy in HIV-infected patients. Lowe and colleagues describe a study on 62 HIV-positive patients. The total amount of FNA cytology procedures was 73 and different LNgroups were investigated: axillary (17%), cervical and supraclavicular (29%), inguinal (15%) and other (2%). The most common diagnosis was persistent generalized LA (50%) followed by infection (22%) and malignancy (18%); inflammation (10%) was also observed (Lowe et al., 2008). An Indian study also performed a study on FNA cytology of the LN. Their goal of the research was to evaluate FNA as a guiding tool to diagnose the etiology of the LA. They also tried to find out if this method was useful in finding undiagnosed HIV positive cases with already a present symptom of persisting LA. The research was made on 1082 LA cases and the incidence discovered and previously undiagnosed HIV positivity was 2,3%. People with an undiagnosed HIV are unaware of their infection and are transmitting the virus further. So a diagnosis of HIV is crucial and clinicians should always keep a possibility of HIV positivity in mind when they encounter patients with unexplained and persistent LA (Gill et al., 2007). 4.5. Physical examination of the patient with lymphadenopathy: how to examine and what to look for? A clinical practitioner that encounters a lymphadenopathy should make a detailed anamnesis of the patient’s medical history and interrogate him/her about present symptoms, complaints and the progression of LA. A paper written by Ferrer describes the evaluation procedure of a patient with LA that will help to gather all the information that is needed to form a correct differential diagnosis. The questions that should be asked and the way a patient has to be examined are taken from Ferrer’s review work (Ferrer, 12 1998). Ferrer suggests that the interrogation has to include 4 essential key points: • Are the localized symptoms related to a specific site? • Does the patient have any constitutional symptoms such as fatigue, weight loss, fever or night sweats • Epidemiological clues should be explored, such as travel history or risk behavior • Patient has to be asked if there is a medication intake that can on itself be a reason for LA (Allopurinol, Atenolol, Carbamazepine, Cephalosporins, Penicillin, Sulphonamides, etc.) Other questions that could be asked are: • Does the patient feel ill? • What was the speed of the onset of LA? Did it appear in several hours or days or has it been slowly developing during several months? • How long has the lymph node been noticeably enlarged? • Are the nodes painful? • Recent viral illness or is somebody from the surroundings diagnosed with a viral infection? • Was there a TB exposure? • Are there any pets around? • Is there a habit of eating raw vegetables or meat? • Were there previous infections suggestive of an immunologic deficiency? • Family antecedents Physical examination After a detailed anamnesis and medical history of the patient a careful physical examination should follow. Special attention should be given to the lymph nodes. Characteristics of the enlarged lymph node have to be carefully examined. It is very important to estimate the size and the consistency of the nodes. When an evaluation of a localized LA takes place a careful examination of the region from which the lymph drains to this particular LN has to be made. Attention should be given to identify the presence of skin lesions, evidence of infection or inflammation and the tumors. Careful examination of the whole body has to be made to be able to exclude the generalized LA with the presence of abnormal lymph nodes in the other regions of the body. Each examination should include a careful palpation of anterior and posterior cervical LN, submandibular, axillary and inguinal lymph nodes. 13 When a lymph node is detected, the following characteristics have to be estimated: size, pain/tenderness, consistency, matting and location. • Size A normal lymph node has a maximum size of less than one centimeter, so every node that is larger should be marked as abnormal. Some say that a distinction in the location has an impact on the size of abnormality and that inguinal nodes should be considered abnormally enlarged when there size is greater then 1.5 cm, whereas epitrochlear nodes have a lower level of abnormality namely 0.5 cm. Size of the lymph node has not much of specific information for the diagnosis of a particular cause, however there is a direct relationship between the size and the possibility for a cancer. • Pain and tenderness When a lymph node enlarges a stretch of its capsule can be a cause of pain. Pain is usually associated with an inflammation or suppuration, but can also be as a result of the hemorrhage into a necrotic center of a malignant node. Tenderness is not reliable for a differentiation between a benign and malign cause of LA. • Consistency The consistency of the abnormal lymph nodes is very various, therefore helpful in the narrowing of the differential diagnosis. A firm but rubbery consistency is suggestive for a lymphoma. A softer LN is more characteristic in an infectious or inflammatory condition. Suppurant nodes can be fluctuant. When a stone-hard lymph node is found it is typical indication for a malignancy, metastasis of a cancer. • Matting When a group of lymph nodes feels to be connected or seem to be moving as a unit, these LN are called ‘matted’. Matted LN can be present in benign situation such as TB or sarcoidosis or in malignant circumstances for instance lymphoma or cancer metastasis. • Location Anatomical location of the abnormal lymph nodes is very important in differential diagnosis. Careful examination of the head and neck reveals the most common cause of the swelling, the enlarged cervical lymph nodes. A doctor should stand behind the seated patient and be methodically 14 palpating the anatomical areas of the neck. If there is a presence of cervical adenopathy further examination has to take place to detect a local cause, for example an infection, ear, nose and throat inspection is also indicated. The axillary lymph nodes are examined with the patient lying on the back and the examinator using the right hand to palpate the left axillae and left hand for a right axillae palpation. Several groups of the nodes are identified in the axillae: medial, lateral, posterior, central and apical groups. Inguinal nodes are easily examined when the abdomen investigation is performed. Confusion between an enlarged inguinal LN and irreducible femoral hernia can take place. When inguinal LNs are enlarged they may cause an abnormal fullness of the central abdomen when it is palpated. A supraclavicular LN enlargement is frequently associated with a malignancy. A Valsalva's maneuver performed by a patient during palpation of the supraclavicular fossa increases the chance of detecting of supraclaviculair LN. For this group of LN another parameter should also be taken into account – the right or left location. The drainage of the lymphatic flow from thorax and abdomen is associated with the left supraclavicular node, the Virchow’s node, so the enlargement can be a signal of testicular, ovarian, pancreas, kidney, prostate, stomach or gallbladder pathology. The right supraclavicular LA is associated with a malignancy of mediastinum, lungs or oesophagus. When generalized LA is present, signs of systemic illness have to be carefully evaluated. The identification of rash, mucous membrane lesions, hepatomegaly and splenomegaly, arthritis can be helpful. The enlargement of liver and milt, hepato and splenomegaly, is seen in many conditions including mononucleosis-like syndrome, lymphoma or sarcoidosis. Detailed and careful clinical history of the patient and a physical examination will as a rule help to identify the easily diagnosable reasons for a LA such as upper respiratory tract infection, pharyngitis, periodontal disease, conjunctivitis, lymphadenitis, insect bites, recent immunization, cat-scratch disease or dermatitis, and no further assessment is necessary. If the clinical history and examination are suggestive for a particular disease, a number of specific tests that will verify the diagnosis have to be applied. If the tests results give a positive conclusion, treatment can be started. Unexplained LA is diagnosed when the cause is not identified after the initial evaluation or when the presumptive diagnosis is not confirmed with the tests or by clinical course. Specific tests are necessary in the case of generalized LA because it is an indication of the presence of systemic disease, therefore further testing has to be made. A biopsy of the LN has to be performed from the largest and the most 15 abnormal of the LN and not from the one that is most accessible. Localized unexplained LA has to undergo a biopsy if there is a worrisome clinical picture or the presence of constitutional symptoms. Biopsy is preferred over a fine needle aspiration of the cells because of its lower risk for the ‘seeding’ of possible malignant cells and therefore danger for metastasis, another reason for the biopsy is the preserved architecture of the lymph node which has extra diagnostic information. If malignancy is suspected, the obtained material may be further explored by histological examination, flow cytometry, genetic research and breeding on special medias. The molecular investigation on fresh material can also be made. The blood tests have to be made and several parameters are crucial for the differential diagnosis. A total white blood count should be made with a differentiation of the leukocytes. If any reactive lymphocytes are present they should be recognized and their quantity measured. Further the levels of C- Reactive Protein (CRP) and Lactate Dehydrogenase (LDH) have to be evaluated and erythrocytes sedimentation rate (ESR) measured. CRP and ESR are used as markers of the inflammation. An echo of the lymph node is important along with an echo of abdomen and RX of the thorax. More accurate information about the lymph node enlargement, the position and the consistency can be achieved by using ultrasound. In some cases computer tomography (CT-scan) along with Positron Emission Tomography (PET-CT) and Magnetic resonance imaging (MRI) are used. It should be also pointed out that not all the swellings are from the lymph nodes. Other reasons for an enlargement should be distinguished such as lymphangioma’s and haemangioma’s, primary tumors, cysts, etc. Enlargement of the lymph nodes that persists for at least three months in at least two extrainguinal sites is defined as persistent generalized lymphadenopathy and is common in patients in the early stages of HIV infection. Other causes of generalized lymphadenopathy in HIV-infected patients include Kaposi's sarcoma, CMV, toxoplasmosis, tuberculosis, cryptococcosis, syphilis and lymphoma (Ferrer 1998; Howard and Hamilton, 2007). 4.6. Lymphadenopathy in HIV-positive patients as a result of opportunistic infections During the progression of HIV infection weakening and deterioration of the immune system slowly 16 takes place. The number of CD4 cells declines making the patient vulnerable and susceptible to various infections, especially opportunistic infections. When a patient still has the an amount of 600 or more per µl CD4 cells, the immune system remains protective enough against opportunistic infections. But when the counts of CD4 further decline and reach a number of fewer than 350 cells per µl the immune system is becoming to be impaired and risk for associated infections increases. When the AIDS phase is reached there is an imminent risk and the infection can lead to serious complications (Ong, 2008). In this thesis the relation between HIV and the following infections will be described: Tuberculosis (TB), Nontuberculous mycobacteriosis, Cytomegalovirus, Pneumocystis jirovecii, Fungi, Toxoplasmosis, Mycoplasmosis, Cryptococcosis and Clastridiosis. 4.6.1. HIV-LA in tuberculosis TB is caused by Mycobacterium tuberculosis and the infection is spread by airborne transmission. This is an efficient way of transmission given that infected people spread an enormous amount of mycobacteria by coughing. The waxy coat of mycobacterium allows it to endure drying so it can survive in air for a sufficient period of time. After the inhalation of M. tuberculosis it is phagocytosed by alveolar macrophages in which M. tuberculosis survives and even multiplies. It is then transported to a lymph node where a cell-mediated immune response is triggered. If 4-6 weeks after the infection a purified protein derivate of M. tuberculosis is introduced into the skin, an infection is detectable by a local induration and eryhtema 2-3 days later. To prevent a general infection lymphokines are released that activate the macrophages and increase their ability to destroy the mycobacteria. Activated T cells are responsible for the release of these lymphokines. Tubercles are small granulomas containing epithelioid cells and giant cells. These pulmonary lesions together with activated lymph nodes are called the primary complex. Perfectly healthy people may have tubercles that are fibrotic or calcified which remain after a primary infection; they are detected with chest radiography as radio-opaque nodules. In immunocompromised patients the mycobacteria are not contained within the tubercles and they may cause a disseminated disease through the invasion of the bloodstream, leading to miliary tuberculosis (Mendelson, 2007) If a reactivation of ‘sleeping’ mycobacteria occurs, secondary tuberculosis is observed. This usually happens when the patient’s immune system is weakened by the progressing HIV infection. The clinical presentation of tuberculosis with HIV is associated with the symptoms of cough, fever 17 present for a period of time longer than 2-4 weeks, diarrhea, weight loss (more than 20% body weight or more than 10kg), oral thrust, haemoptysis, history of herpes zoster and lymphadenopathy (Huang and Crothers, 2009). Extrapulmonary tuberculosis and mycobacteremia becomes more common as is frequently seen when the level of the immunosuppression increases and HIV-infection progresses. When in HIV-positive patients fever is encountered which cannot be explained and which persists for a fairly long time, diagnosis of extrapulmonary tuberculosis has to be excluded. The clinical presentations of abdominal TB are the visceral lesions and intra-abdominal LA that can be visualized by a computed tomography (Jones et al., 1993). Mediastinal adenopathy is a very common symptom in AIDS patients. However, a molecular typing of isolates from HIV positive patients with a primary or reactivated TB showed that mediastinal adenopathy was not a direct indication of primary TB. It reflects an ineffective immune system response and can therefore become a result of reactivation of the previously acquired TB (Jones et al., 1997). HIV and tuberculosis in Russia and Eastern Europe: According to the report by C.K Vorkas and C. van der Horst dating from November of 2009 there is a 12.3% prevalence of multi-drug-resistant tuberculosis in Eastern Europe. The cumulative mortality of HIV/TB is also elevated in Eastern Europe in comparison with the rest of the world and is 33%. The authors report that only 44.5% of the patients have been treated with the recommended regimens (isoniazid, rifampicin and pyrizinamide). The situation is considered to be alarming and the effects of HIV-TB epidemics are predicted to be devastating (Vorkas and van der Horst, 2009). • IRIS When HAART is given for the first time to patients with a profound immunosuppression and low counts of CD4 cells, an immune Reconstitution Inflammatory Syndrome (IRIS) may occur. IRIS is described as a deregulated and excessive inflammatory answer, which is directed to the antigens of opportunistic infections and has an influence on the course and clinical presentations of the disease. It has been estimated that the level of immunosuppression is directly proportional to the appearance of IRIS. According to the WHO report, HAART is frequently given only at the stage of low CD4 counts in developing countries and this may result in a higher prevalence of IRIS. There are two forms of IRIS. The first one reveals an acute opportunistic infection. The second one is a “paradoxical” form. It is seen when the patient was already diagnosed with an opportunistic infection 18 and received a correct treatment with response to the therapy and therefore shows sterile microbiologic cultures. After the administration of HAART a clinical deterioration is seen, the recurrence of the symptoms of opportunistic infections occurs and inflammatory manifestations in one or more organ systems are observed. In such a clinical condition it is obvious that alternative causes of deterioration should be excluded. The problem of a heterogeneous presentation of opportunistic infections in HIV positive patients with variable immunopathological mechanisms in patients receiving HAART makes it difficult for a clinical practitioner to diagnose with certainty the immune reconstitution inflammatory syndrome. Basically, on its own IRIS has a wide range of clinical presentations. Therefore it is difficult to assess the contribution of excessive inflammation to the presentation of the illness IRIS is seen in association with TB, CMV, Cryptococcus neoformans, Mycobacterium avium complex, PJP, Kaposi sarcoma, non-Hodgkin lymphoma and other diseases (Davies and Meintjes, 2009). 4.6.2. HIV-LA in nontuberculous mycobacteriosis Nontuberculous mycobacteria (NTM) refer to all the species in the family of mycobacteria that may cause human disease, but do not cause tuberculosis (TB). There are more than 130 species known and the infection occurs when a contact with the infected, contaminated environment takes place. Most species of NTM have no pathogenic effect on humans but in the conditions of immunosuppression predisposing conditions may lead to opportunistic infection. The species are divided in slow and rapid growers, slow growers normally are responsible for pulmonary and lymphonodal disease and rapid growers affect cutis, bones and joints (Tortoli, 2009). Infections of the lymph nodes In infantile cases a unilateral cervical lymph node swelling is usually observed. The swelling is painless, sometimes has fistulas and has a variation in size between different patients. Usually a surgical excision is needed because anti-microbial treatment is ineffective (Tortoli, 2009). IRIS with a reaction of bilateral superficial and deep lymph nodes can take place. This paradoxical immune reaction to pre-existing undiagnosed opportunistic infections happens after the administration of HAART and as a result of the restoration of immune system. The species responsible for the pulmonary infection is Mycobacterium avium complex (MAC) with its 19 two major species M. avium and M. intracellulare. Normally patients with this type of pulmonary infection are severely immunocompromised with counts of CD4 under 100 cells per µl but after the introduction of HAART the number of the patients with MAC declined considerably (Tortoli, 2009). In AIDS patients the most frequent symptoms are cough, fever and rapid weight loss. RX of the thorax shows mediastinal or hilar adenopathy and the progression is very rapid. A few weeks after the infection granulomatous lesions of cutis and soft tissues develop. The infection spreads and involves satellite lymph nodes that can evolve to ulceration, cellulitis and cutaneous dissemination. This type of infection is normally transmitted by a direct contact with infected water or fish, trauma or surgical wounds. The HIV patients are mostly infected by Mycobacterium haemophilum that results in painful soft tissue abscesses and often relapses. This particular specimen is often undiagnosed because of its strict growth requirements (Tortoli, 2009). • Disseminated Mycobacterium avium complex (MAC) infection This is the first opportunistic infection that was detected in AIDS patients. It is thought to be the most common bacterial opportunistic infection in adults with HIV- 1 virus in the western world with an annual frequency of 10-20% at the AIDS stage of the disease. Another study report showed that around 50% of all the patients with CD 4 counts lower than 100 cells per µl have MAC. A retrospective cohort study of 2081 HIV positive adults showed that MAC was associated with elevated mortality independent of the CD4 counts. This is suggested because the disease is a marker of immune system failure and the disseminated infection gives an additional effect on morbidity (Moore and Chaisson 1996). The survival period of disseminated MAC was very short (average of 120 days) before the development of specific combinational therapies and HAART. A huge breakthrough was made with the introduction of HAART that allows maintaining the CD4 counts above the risk level (more than 100 cells per µl) and this makes the disseminated MAC quite rare in HIV infected patients today. Nevertheless patients with a profound immune suppression continue to be at risk for disseminated MAC. Basically HAART has a primary prevention effect rather than increase of survival after the diagnosis with disseminated MAC. The infection is spread via local lymphatics and haematogeneously. The bacteria are phagocytosed by mononuclear cells and spread throughout the body in liver, spleen and bone marrow. Mixed infections with other NTM are reported and a large number of other NTM species is also responsible for disseminated infections in AIDS patients. 20 Apart from lymphadenopathy the clinical presentations of MAC are: fever, weight loss, fatigue, anemia, night sweats, abdominal pain, diarrhea, hepatomegaly and splenomegaly. The problem for a clinician is that these symptoms lack specificity and can be associated with other opportunistic infection or malignancy common in HIV-association (Karakousis et al., 2004). It has been shown in a number of case-control studies that patient with AIDS and disseminated MAC are more likely to have systemic symptoms such as fever, night sweats, respiratory and gastrointestinal symptoms, elevated values of alkaline phosphatase and lactate dehydrogenase, and reduced levels of hemoglobin (Gordin et al., 1997; Rolla et al., 1999). These systemic symptoms mimic disseminated TB infection and it is not simple to discriminate between these two entities. Factors that are most commonly seen in disseminated TB are night sweats, peripheral LA, acid-bacilli smears of the sputum, chest RX with hilar enlargement and the absence of previous AIDS illness. Factors more associated with MAC are hepatomegaly, splenomegaly, leucopenia, elevated levels of alkaline phosphatase of more than twice the normal levels, and elevated serum γ-glutamyl transpeptidase of more than 3 times of the normal (Hsieh et al., 1998). 4.6.3. HIV-LA in cytomegalovirus CMV is the largest human herpesvirus, has only one serotype and is transmitted by saliva, urine, blood, semen and cervical secretions. This virus is responsible for the most frequent viral pneumonia seen in HIV patients (Huang and Crothers, 2009). After clinically silent infection in the upper respiratory tract, CMV spreads locally to lymphoid tissues and then systemically in circulating lymphocytes and monocytes to involve lymph nodes and the spleen. The virus inhibits T-cell responses, and there is a temporary reduction in their immune reactivity to other antigens (Huang and Crothers, 2009). The incidence of CMV disease in HIV-infected patients has declined sharply after the introduction of HAART, however many are still at risk for CMV disease. According to the earlier studies there has been an under-diagnosis of CMV in HIV – patients and frequently the diagnosis was made postmortem. The two most frequent manifestations of CMV are retinitis and gastrointestinal disease. Retinitis is an end-organ manifestation of CMV in HIV-positive patients. With the exception of retinitis the HIVpositive cytomegalovirus infection is very unspecific in the clinical characteristics. The clinical presentation of CMV in HIV-positive patients does not differ much from HIV-negative patients, but the progression of the disease is much more aggressive. The virus is often detected in bronchoalveolar 21 lavage in patients with an advanced immunosuppression when the evaluation for opportunistic infections takes place. Basically the risk for CMV sharply increases when CD4 counts are below 100 cells per µl. Most cases of pneumonia are in patients with CD4 counts of less than 50 cells per µl (Huang and Crothers, 2009). The main symptoms of CMV are cough, fever and dyspnoea and are present for 2-4 weeks. LA may be present but is not a common symptom. A study made by the group of Salomon et al reports hilar and mediastinal adenopathy in 2 cases from 18 patients with HIV associated CMV pneumonia (Salomon et al., 1997). 4.6.4. HIV-LA in/and Pneumocystis jirovecii Pneumocystis jirovecii is the most frequent opportunistic infection to cause pneumonia in AIDS. (Fujii et al., 2007) This genus is very successful in immunocompromised hosts. Pneumocystic organisms are from the fungi group, however they seem to be atypical fungal microorganisms and are not able to grow in vitro in fungal culture media. In AIDS patients frequently a co-infection with CMV has been reported. (Fujii et al., 2007) After the introduction of the combinational antiretroviral therapy, HAART, and the decline in AIDSassociated mortality the incidence of associated pneumonias has also changed. Classical symptoms of PJP are fever, non-productive cough and dyspnoea. The onset of the symptoms can be less acute in patients with a severe immunosuppression who already reached the AIDS phase in comparison to the individuals with higher CD4 counts (Fujii et al., 2007). Pneumocystosis with an extrapulmonary involvement is quite rare and seen in patients with a severe immunosuppression. Lymphadenopathy of hilar and mediastinal lymph nodes is atypical (Ong, 2008). There is not much literature written about the HIV associated LA in the cases with pneumocystosis. 4.6.5. Other opportunistic infections associated with HIV A number of others opportunistic infections have an increased incidence of contamination of immunosuppressed HIV positive individuals. As a rule these infections flourish when the counts of CD4 T-lymphocytes are below 200 cells per µl in the AIDS phase. They can also be the reason to the persisting LA that is specific to this terminal stage of the disease progression. 22 When the immune system begins to show a lack of its own function normal commensal microorganisms begin to invade the body. Some species of fungi, Candida and Aspergillus, are examples. Candida is a normal commensal of the skin, gastrointestinal and genitourinary tract. When it succeeds in the infection of the body it is then associated with a wide spectrum of diseases that are challenging to diagnose because they do not show specific symptoms. Due to reduction of immune mucosal function the opportunistic infections such as candidiasis have greater chance to infect and cause the oral lesions. Oral lesion is a symptom that should make the doctor suspicious of severe immunosuppression in a particular individual (Enoch et al., 2006). Also Aspergillus cause very vague and non-specific symptoms in immunosuppressed individuals, so even invasive Aspergillus may be asymptomatic (Enoch et al., 2006). Protozoan parasites such as Toxoplasma are also observed as opportunistic infections in AIDS too. Toxoplasmic encephalitis is the most commonly recognized cause of the central nervous system disease in AIDS patients. At least 30% of patients with AIDS who have preexisting toxoplasma antibodies will ultimately develop toxoplasmic encephalitis. A highly lethal syndrome of disseminated toxoplasmosis, fever and sepsis-like syndrome with hypotension and disseminated intravascular coagulation has been described in HIV-positive patients (Schmidt-Hieber et al., 2009). Atypical bacteria such as Mycoplasma, which do not have a true cell wall, may also cause a lot of problems for immunosuppressed individuals. Mycoplasma pneumonia usually manifests itself in lower or upper respiratory tract, but extrapulmonary manifestations such as central nervous system are common too (Waites et al., 2008). Encapsulated round oval yeast, surrounded by a polysaccharide capsule, Cryptococcus neoformans, with its two pathogenic subtypes is also a threat in HIV-positive patients. HIV-infected individuals present with similar clinical features as immunocompetent patients, however they are more likely to develop disseminated infection. The route of the infection is pulmonary via inhalation of infective particles. In immunocompetent patients inhalation of yeast is followed by a localized immunological response with a granulomatous reaction that contains the organism before symptoms of dissemination occur; in immunocompromised dissemination is almost a rule and the subsequent blood spread can involve any organ. The cryptococcal infection is also more likely to threat patients with a severe immune suppression, such as patients in AIDS-stage of the disease with CD4 counts of less than 50 cells per µl. Cryptococcal infection may lead to meningitis or meningoencephalitis. In the era of HAART the incidence of cryptococcal meningitis is dramatically reduced (Waters and Nelson, 2005). 23 4.7. Lymphadenopathy in HIV-positive patients as a result of malignancies There is an association between a group of tumors and HIV-infection that results in a sufficiently increased prevalence of the certain malignancies in HIV positive individuals. Different types of malignancies are seen at different stages of the HIV–infection, and are therefore linked to the level of the immunosuppression. The most common AIDS- associated cancers are Kaposi sarcoma and nonHodgkin lymphoma (NHL), their rates are increased after even a modest immune suppression. Hodgkin lymphoma (HL) is also associated with HIV but it is more frequently seen when the immune deficiency is more profound. There are also several unusual lymphoproliferaitve entities that have an increased incidence in HIV positive cases: primary effusion lymphoma, Castleman’s disease, EBVassociated lymphoproliferaitve disorder, T-cell lymphomas and primary central nerve system lymphoma (Navarro and Kaplan, 2007). The risk for Kaposi sarcoma is increased by 1000-fold and the incidence is linked to a severe immune deficiency and the increase of the risk has an exponential rate with a decline of CD4 counts, but incidence is also elevated in patients with a moderate CD4 count decrease. After the introduction of HAART a dramatic decrease in Kaposi sarcoma cases was observed and is now stabilized on the much lower level than before HAART era, nevertheless this level is substantially higher in comparison with a healthy population (Grogg et al., 2007). NHL is increased about 70-fold in HIV patients. Different types of NHL have a different relationship with the immunosuppression: diffuse large B cell lymphoma has an elevated incidence in patients with a severe immune deficiency (50-100 CD4s per µl), Burkitt lymphoma occurs more frequently at any stage of immune suppression and primary brain lymphoma is more likely to develop when the CD4 counts are less than 50 cells per µl. Clinical studies showed a decrease in the rate of NHL in patients with advanced HIV after the introduction of HAART therapy. Most studies show a more limited decrease in Burkitt lymphoma rates (Grogg et al., 2007). HL is 10-fold higher in HIV patients. No decrease after the introduction of HAART has been reported and two large United States studies have even reported an increase in the rate. HL rates are higher in patients with a moderate immune deficiency than with more profound deficiencies (Grogg et al., 2007). 24 4.7.1. HIV-LA in Kaposi sarcoma Kaposi sarcoma (KS) was for the first time described by Moritz Kaposi in 1872 (Kaposi, 1872). Before the AIDS time it was a slowly progressing and rare tumor of low extremities that was mostly seen in elderly man. The slow progression of the tumor resulted in a low rate of mortality. But in 1980’s an unusually high incidence of Kaposi sarcoma was seen in homosexual young males. Patients were much younger than previously seen and the sarcoma was present in abnormal sites and had a very aggressive progression. All these patients were positive for HIV (Centers for Disease Control, 1981). Kaposi sarcoma associated virus (KSHV) is a human herpesvirus 8 (HHV-8). This HHV-8 virus is the essential pathogenetic factor and was isolated from an HIV positive patient in 1994 (Chang et al., 1994). One of the most important differences between the HIV positive KS and HIV negative type is the aggressive progression and the mortality rate of the disease. When the immunodeficiency is untreated and is severe the mean survival time is very short and is not more than one year (Brockmeyer and Barthel, 1998). The prevalence of the KS is also related to the grade of the immunosuppression. In pre HAART era KS was occurred in 25% of homosexual man, this prevalence is not significantly lower at 5-7% in the same risk group (Rezza et al., 1999). First clinical symptoms are red-brown plaques that grow into nodules and begin to ulcerate. These are widespread lesions that are located preferably on the upper body (neck, trunk and arms). Plaque lesions are often asymptomatic, can be single or multiple, are found in groups or can be widely spread. In the progression of the disease the lesions become more numerous, they involve skin, oral mucosa, lymph nodes and visceral organs (lungs, liver, spleen and gastrointestinal tract). The progression of these plaques is an enlargement, they join together and evaluate to a nodule. Macular lesions, plaques and nodular lesions are seen in oropharyngeus, lesions are spotted in gastrointestinal tract from oesophagus till the rectum and anus. In 60% of the cases generalized lymphadenopathy is present. Systemic symptoms such as fever, diarrhea, weight loss, malaise and fatigue may accompany the disease. Progressive viral disease such as anogenital herpes, herpes simplex, herpes zoster and cytomegalovirus are commonly observed (Potthoff and Brockmeyer, 2007). To make the diagnosis of KS the following investigations should take place: a complete examination of the skin and oral and genital mucosa, lymph nodes and abdominal ultrasound, chest X-ray. If there 25 is a mucosal involvement a gastroduodenoscopy and colonoscopy are necessary. A proliferation of endothelial-like cells and fibroblasts are seen in the histology (Potthoff and Brockmeyer, 2007). Immunohistochemistry is a standard method of KSHV identification. This method proved to be more reliable than other diagnostic methods. For the recognition of Kaposi sarcoma monoclonal LANA-1 antibodies are used, it also allows to recognize the subtypes of Kaposi sarcoma lesions, is present in the mantle zone of multicentric Castleman’s disease and KSHV- positive lymphomas. PCR is an extremely sensitive technique but with a fairly high amount of false positive results coming from contamination. This method of detection allows detecting and identifying KSHV in different tissues and can be used on fresh or frozen material. In situ hybridization is also a possible diagnostic method for KSHV. Staging of HIV associated KS was introduced and it is based on the location and the degree of the immunosuppression (Krown et al., 1989). Table 2. Staging of HIV-associated Kaposi sarcoma (Krown et al., 1989). T0 Tumor T1 Immune system Tumor (macular) is limited to the skin, lymph node and hard palate Visceral tumor, tumor-associated edema or ulceration or extensive oral tumor (nodular) I0 CD4 cells > 200 per µl I1 CD4 cells ≤ 200 per µl S0 Systemic diseases S1 No history of opportunistic infections or oral candidiasis, no constitutional symptoms, History of opportunistic infections, oral candidiasis or other HIVassociated diseases, constitutional symptoms In the pre HAART era a treatment of a low dose of interferon had a poor result in patients with a severe immunosuppression, when the AIDS phase was already established. If patients had a higher amount of CD4 (>400 cells per µl) it gave a 45% of remission (Rasokat et al., 1989). Nowadays chemotherapeutics, liposomal anthracyclines, are used as a monotherapy. This is the first choice of treatment and induces a remission in 80% of the cases. Main side effects of this protocol are 26 neutropenia, nausea and palmoplantaire erythrodysesthesia. When local therapy is used such as cryotherapy, laser or excision recurrence and reappearance of the lesions may happen. KS is also a radiosensitive tumor so radiotherapy may be applied. 80-90% of individual lesions regress after radiotherapy. Lymph nodes are treated with a total of 40Gy, which are divided in 5 times 2Gy per week. An increasing knowledge in the pathogenesis of KS allows developing new medication that will aim at the specific targets for molecular therapy (Potthoff and Brockmeyer, 2007). 4.7.2. HIV-LA in Hodgkin lymphoma Thomas Hodgkin described this lymphoma in 1832 when he saw 7 patients with generalized LA, splenomegaly, high fever and cachexia. This disease had neither a relationship with an infection nor was it a metastasis of another tumor but still it had a lethal outcome (Hodgkin, 1872). Hodgkin lymphoma (HL) is a tumor of lymphatic tissue that has a characteristic morphological substrate with gigantic poly-nucleus cells of Reed-Sternberg. The cells are localized in a particular cell arrangement, which is made out of a mixture of tumor and non-tumor reactive cells (lymphocytes, eosinophils, neutrophils, plasma cells) sometimes surrounded by collagen fibers. The HIV-HL has a different pathological and histological picture compared to seronegatieve HL. HIVHL has a much more aggressive clinical behavior and presentation. This has a major negative effect on the prognosis of the disease along with a necessity for a specific treatment. A different pathology spectrum is also encountered. A more mixed cellularity is seen; there is lymphocyte depletion and a larger proportion of neoplastic cells of Reed-Sternberg. An association with Epstein-Barr virus (EBV) is mentioned in 90% of the cases. The EBV genomes are episomal and clonal and probably this elevated frequency shows that it is a relevant factor in the pathogenesis of HIV-HL (Grogg et al., 2007). A study by Biggar and his group made an evaluation of 317428 persons with AIDS during 477368 person years (py’s) and found out that HL was had occurred in 173 cases (36.2 per 105 py’s). Also the incidence was 53.7 per 105 py’s in patients with CD4 counts from 150-190 cells per µl in comparison with 20.7 per 105 py’s when CD4 counts were fewer than 50 cells per µl. They suggest that there is a lower incidence of HL in severe immunocompromised cases and that the incidence of HL is decreased with declining CD4 counts. This can explain the paradoxical rise in the incidence of HL after the 27 introduction of HAART therapy (Biggar et al., 2006). Staging • Stage I is involvement of a single lymph node region or single extralymphatic site • Stage II is involvement of two or more lymph node regions on the same side of the diaphragm or of one lymph node region and a contiguous extralymphatic site • Stage III is involvement of lymph node regions on both sides of the diaphragm, which may include the spleen and/or limited contiguous extralymphatic organ or site • Stage IV is disseminated involvement of one or more extralymphatic organs. Normally patients with HL present themselves with asymmetrical superficial lymph node enlargement that is painless and non-tender. This lymph node is firm but rubbery. Normal it is located in the cervical region (60-70%), but it can also be situated in axillary region (10-15%) or in the inguinal area (6-12%). The enlarged LN may also be located retroperitoneal; it is then hard to discover such a LN without a computer tomography or other visualization techniques. A spontaneous increase and decrease in the size of the LN is possible. Mediastinal involvement is possible (6-11%) and it is a feature of nodular sclerosing type. The LNs may become matted. A normal beginning is an enlargement of the peripheral single LN and then a progression by contiguity with lymphatic system. In 50% of the patients a splenomegaly is encountered but the size of the spleen enlargement is not massive. Hepatomegaly is possible as well. A late complication of Hodgkin is a cutaneous involvement. This is seen in 10% of the patients and is an unusual presentation as well as the involvement of the organs, bone marrow, gastrointestinal system, lungs, spinal cord and the brain. Other symptoms (B symptoms) typical for HL are fever, pruritis and profound night sweats. Some patients complain that the areas where the lymphoma is present become painful after an intake of small amounts of alcohol. Frequent symptom is a weigh loss and the feeling of weakness and fatigue. There are indications of anorexia and cachexia (Hoffbrand et al., 2001). 28 Figure 1. HIV-positive patient with Hodgkin lymphoma. Photo is taken in Hospital №60 (Moscow, Russia) by Prof. Dr. A.V. Pivnik Figure 2. HIV-positive patient with Hodgkin lymphoma. Photo is taken in Hospital №60 (Moscow, Russia) by Prof. Dr. A.V. Pivnik 29 A comparison between a HIV-HL that developed before the beginning and after of HAART therapy was made. 84 patients were receiving HAART at least 6 months before the onset of HL and 206 patients received HAART only after the diagnosis of the HL. These patients were divided in 2 groups and their results were compared. In the HAART pre-treated group B symptoms were less frequent, higher leukocyte and neutrophils counts were registered. A better overall survival was associated with: mixed cellularity, absence of extranodal involvement and B symptoms (Chimienti et al., 2008). Another study had a similar investigation counting 104 HIV-HL patients and it reported that the complete remission rates differ between the groups and that they were significantly higher in the HAART pre-treated group (91% vs. 70%) (Berenguer et al., 2008). 4.7.3. HIV-LA in Burkitt lymphoma BL is a distinct pathologic entity, a highly aggressive non-Hodgkin lymphoma, characterized by a diffuse proliferation of small non-cleaved cells of B-lymphocyte origin. For the first time this tumor was mentioned in 1897 in Uganda in black children aborigines with a tumor of facial skeleton, a ‘jaw sarcoma’. In 1958 it was described and allocated by an English surgeon and traveler Denis Burkitt (Burkitt, 1958). Later, in 1961, G.T.O’Conor has described a histologic picture of this tumor, having characterized it as lymphoblastic lymphoma with low degree of a differentiation with great number of histiocytes (O’Conor , 1961). The incidence of the Burkitt lymphoma (BL) has had a giant increase after the HIV virus appearance. If we compare the prevalence of non-Hodgkin’s lymphoma in the general population with the prevalence of, this lymphoma in HIV positive patients we will find a significant difference with 1-2% in the normal group and 35-40% in HIV- positive individual. (Spina et al., 1998). Burkitt’s lymphoma is the second most common pathologic type of lymphoma encountered among patients with AIDS (Levine, 2008). Three types of Burkitt lymphoma are distinguished: endemic, sporadic and immunodeficiencyassociated type. Endemic type: usually in black children aborigines of equatorial Africa and migrants from Africa to New Guinea. The disease peak is 4-7 years with a considerable higher prevalence in boys compared to girls (3:1) Approximately 95% of endemic Burkitt lymphoma is Epstein-Barr associated. Sporadic type: typical morphology, immunophenotype and cytogenetics of Burkitt lymphoma revealed in not endemic zone with characteristic clinical features. In the USA and Western Europe is the occurrence of Burkitt in adults estimated to be approximately 1-2 % of all the lymphomas, with an age 30 median of 30 years. Children’s Burkitt lymphoma is responsible for 30-50 % of all lymphomas. Boys are 2,5 times more likely to get the disease than girls. Unlike the endemic type, only 30 % of sporadic Burkitt lymphoma is Epstein-Barr associated. The immunodeficiency-associated type is found in 35-40 % of all HIV-associated lymphomas. An age median: 35-40 years (addicts – 29 years, homosexuals – 37-42 years). The overwhelming majority are men (up to 90 %). EBV is found in 30-40 % of cases. There is a geographical difference of this association. In the western countries (USA, Europe) there is no Epstein-Barr but in Africa there is a positive relation between EBV and immunodeficiency- associated type of Burkitt lymphoma (Bariakh et al., 2009). It is frequently noted in patients with HIV infection with CD4 counts still exceeding the 200 cells per µl. No difference was found in the clinical characteristics of the patients with AIDS and various levels of immune status with CD4 amounts lower and higher than 100 cells per µl (Spina et al., 1998). A significant difference was found in the ‘median overall survival’ with BL between HIV positive and negative cases and ‘disease free survival’ of 4 years was observed in 53% of HIV negative and only in 7% of HIV positive patients (Spina et al., 1998). Also a difference in the complete response rate that was defined as complete disappearance of all evaluable disease for at least 4 weeks was seen. The complete response rate in HIV positive individuals was seen in 40% compared to 65% in HIV negative (Spina et al., 1998). Generalized LA is one of the main symptoms for Burkitt lymphoma associated to immunodeficiency. HIV-associated type of Burkitt lymphoma has a similar clinical progress as the sporadic type. Typically there is extranodal involvement, abdominal localization of the tumor and peripheral lymph nodes. Other symptoms are splenomegaly and invasion of the bone marrow happens in 30% of the cases. The involvement of central nervous system is seen on average in 15% of the cases. The histological picture does not differ from a non-HIV type (Bariakh et al., 2005). The main symptoms that can be present are acute abdominal pains with nausea and vomiting, bowel obstruction, gastrointestinal bleeding. Basically the symptoms can mimic acute appendicitis or intussusception. Intra-abdominal presentation will usually affect intra-abdominal lymph nodes and the bowel, however kidney, pancreas, breast or ovarian involvement is also possible. At the time of diagnosis the size of the lymphoma frequently exceed 10 cm and this is called ‘bulky disease’ (Blum et al., 2004). Staging according to the Murphy staging system Stage I 31 • A single tumor (extranodal) or single anatomic area (nodal) with the exclusion of mediastinum or abdomen Stage II • A single tumor (extranodal) with regional node involvement • Two or more nodal areas on the same side of the diaphragm • Two single (extranodal) tumors with or without regional node involvement on the same side of the diaphragm • A primary GI tract tumor, usually in the ileocecal area, with or without involvement of associated mesenteric nodes only Stage III • Two single tumors (extranodal) on opposite sides of the diaphragm • Two or more nodal areas above and below the diaphragm • All the primary intrathoracic tumors (mediastinal, pleural, thymic) • All extensive primary intra-abdominal disease • All paraspinal or epidural tumors regardless of other tumors site(s) Stage IV • Any of the above with initial CNS or bone marrow involvement Diagnosis of BL is made on the presence of medium sized B-cell population, CD10 positive with a high proliferative rate and multiple genetic lesions: translocation involving MYC gene, point mutations in regulatory regions associated with MYC and within TP53 tumor suppressor gene. The pathognomonic criteria for a BL are the translocation t(8;14)(q24;q32) or its alternatives t(2;8)(p12;q24) t(8;22)(q24;q11) (Bariakh et al., 2005). Peripheral blood involvement is less common but possible in HIV positive patients, and neoplastic cells have the characteristics of L3 acute lymphoblastic leukemia (ALL). The population of the cells is uniform with indistinct nucleoli. A unique morphological variation, AIDS-associated, is plasmacytoid differentiation. Cells have eccentrically placed nuclei and abundant cytoplasm that contains immunoglobulins (Grogg et al., 2007). BL has a very high speed of cell replication and therefore the highest doubling time of any tumor. As a result BL grows very fast and the tumor can become very large in a short amount of time. To obtain 32 such a high rate of cell proliferation a large number of mitosis and apoptosis takes place, phagocytic histiocytes containing nuclear debris are seen on low magnitude microscopy as a characteristic ‘starrysky’ appearance (de Leval and Hasserjian, 2009). It is a therapeutical challenge to treat a HIV positive patient with an intensive chemotherapy; the immunocompromised state of the patients is thought to be the main difficulty due to the infections rate. High active antiretroviral therapy (HAART) is administered to HIV positive patients and this allows treating them with standard chemotherapeutical protocols that are used for HIV negative patients (Blinder et al., 2008). Other studies (Levine, 2008; Bariakh et al., 2005) suggest that HIV positive patients will have better results after treatment with a more intensive therapy than HIVnegative individuals. Due to very high proliferation rates of this type of lymphoma the chemotherapy cycles should be administered in high doses and with small breaks in between. The capacity of the tumor cells to develop resistance lowers the effect of less aggressive protocols with lower dose of chemotherapy. The drugs must have a sufficient half-live to be able to sustain a therapeutical drug concentration in the blood and it should be not lower than 2-3 days to be able to kill the tumor cells. The consideration that new protocols will be toxic for HIV positive patients have led to treatment of BL-HIV with the protocols that are normally given to diffuse large B-cell lymphoma, however this opinion has changed in recent years. HAART administration has led to a decrease of opportunistic infections (Bariakh et al., 2005). 33 Figure 3. HIV-positive patient with Burkitt lymphoma. Photo is taken in Hospital №60 (Moscow, Russia) by Prof. Dr. A.V. Pivnik Figure 4. HIV-positive patient with Burkitt lymphoma. Photo is taken in Hospital №60 (Moscow, Russia) by Prof. Dr. A.V. Pivnik 34 4.8. Russian experience of 2002-2005 During three years (2002 –2005) 80 patients with HIV infection were observed. All patients were examined by a standard scheme with an identification of antibodies to HIV in the ELISA test, viral load, and broad panel of diagnostic tests for opportunistic infections. Biopsies of the lymph nodes were made and they underwent a standard processing, sections were stained with haematoxylin – eosin (Pivnik et al., 2006). The vast majority of cases were admitted in an expanded stage of AIDS with a minimum of CD4 count (less than 200 cells per µl) and high viral load (hundreds of thousands of copies per µl), with duration of infection for at least 5 years. Main or a concomitant syndrome was a local or generalized LA that was revealed in a variety of manifestations of AIDS. The intravenous use of psychotropic drugs was detected in 94% of the patients, and the remaining cases occurred due to homosexual and heterosexual transmission. The majority of the patients were young people from 18 to 30 years, with a predominance of men. The reason for biopsy of peripheral lymph node was the uncertainty of diagnosis of the disease that determined AIDS and its severity. Localized enlarged lymph nodes were usually in the neck and supraclavicular areas, rarely in the axillae. Inguinal lymph nodes were commonly enlarged, dense, up to 2 cm, painless, with unchanged skin. Distribution of patients by diagnosis was: tuberculosis diagnosed in 33 patients (41%), lymphoma in 23 (29%) and Hodgkin lymphoma in 5 patients (6%), reactive LA in 15 (19%), germ cell tumors in 3 patients (4%), sarcoidosis in 1 patient (1%). Reactive LA was determined the following histological picture: follicular hyperplasia - 9 patients, involution - 2 patients, bacterial lymphadenitis with necrosis - 4 patients. Malignant lymphomas were seen in 29 patients, in 35% of all LA cases (Pivnik et al., 2006). In LA three different histological patterns are identified, reflecting an immune response to HIV from lymphoid hyperplasia through a stage of involution and lymphoid depletion, vascular neoplasia and sclerosis. Type A: pattern of acute virus infection Enlarged lymphoid follicles with hyperplasive germ centers and intensive cytolysis, phagocytosis of nuclear remnants, histiocytes and numerous mitoses. Small lymphocytes of the mantle zone are penetrating the follicle. In the surrounding blood vessels and sinuses multiple haemorrhages are seen along with an accumulation of cells monocytoid nature. Cells are large, uniform, with light cytoplasm 35 and round dark nucleus. Some neutrophils are seen in the sinuses. Type B: includes properties of type A and C. The structure of the follicle becomes less clear, partial involution of the germinal centers, lymphoid depletion, accumulation of plasma cells and proliferation of blood vessels within and around the follicles. This pattern suggests subacute LA or intermediate phase of progression of HIV infection. Type C: Lymph node is atrophic, with small follicles and a distinguished diffuse vascular proliferation. Follicles are small, almost without lymphocytes, often with a central penetrating arteriole. In a later stage follicles are indistinguishable, with the focal hyalinosis. In the cortex between the follicles there is a significantly reduced number of lymphocytes, pronounced vascularization is seen. Often plasma cells and diffuse fibrosis are seen. The picture looks like a chronic LA with atrophy of the follicles, significant angiogenesis and fibrosis. So the LA may be due to an acute stage of HIV infection, which is reflected in the histology of type A, a progressive decrease in CD4 lymphocytes, characteristic of type B or profound immune depression in AIDS, which is reflected in the involution of lymphoid follicles and angiomatosis in type C. LA with HIV infection in the first two stages of the disease (acute and latent) reflects the sequence of morphological changes in the picture: hyperplasia of lymphoid follicles and their involution and depletion. Clinical symptoms of LA are local or generalized swelling of painless, elastic, movable lymph nodes larger than 2 cm. Laboratory findings are reduction of circulating CD4 lymphocytes and increasing viral load. In the AIDS stage, LA represents a disease it caused: opportunistic infections and tumors. More rare has the LA a reactive nature, such as follicular hyperplasia in a fresh variety of viral infections in patients with cured lymphoma. Therefore the biopsy of an enlarged lymph node in HIV-infected patients in the stage of AIDS allows to make the correct diagnosis of one or more diseases that define AIDS with a minimal cost (Pivnik et al., 2006). 5. Discussion As presented in the previous chapters, lymphadenopathy is one of the most profound symptoms of HIV infection (Gill et al., 2007). Nevertheless, LA is a very broad symptom that can also develop in individuals that have no HIV infection or immune decline, thus a direct link cannot be made between LA and HIV. Several particular characteristics such as persistence and generalization of LA have be to taken into account and a hidden HIV infection must be suspected. It is therefore a challenge to 36 diagnose a HIV infection based only on the anamnesis and clinical examination. In the following section a description of the list of questions that should be asked in the anamnesis and items that should be inspected during physical examination is made. These are essential for a diagnosis of hidden HIV infection based only on the symptom of LA. • Anamnesis Aside from the medical history of a patient attention to the profile of the individual should be given. This is essential to identify if the individual is a part of a risk group population that has a greater chance of acquiring the HIV virus. Such groups of people are intravenous drug users, homosexuals, people that come from or have been in the parts of the world with a significantly higher incidence of HIV. One of the examples of such a region is Sub-Saharian Africa where two thirds of the people living with HIV/AIDS worldwide and 76% of the AIDS deaths (The global HIV/AIDS epidemic, 2009) are registered. A special attention has to be given to individuals that practice homosexuality because of the higher risk of HIV transmission in the ‘men seek men’ group compared with a general population. Intravenous drug users also have an increased risk of HIV transmission because of the repetitive use and exchange of contaminated needles. The statistics show that younger people have a greater chance of HIV infection, so this age can also be used as an important criterion for the risk profile estimation. In spite of all ‘high risk groups’, the HIV virus can nevertheless be present in individuals who do not posses any risk factors or do not have a behavior ‘at risk’ (Klimas et al., 2008). Persistent LA that does not react to the treatment has to raise a suspicion of immune deprivation as a result of HIV. When a patient with such a symptom undergoes a questionnaire a special attention has to be given to the number of times, the frequency of the infections and illnesses that took place in recent time that patient call recall. It is best to compare this number of the infections to the previous frequency, the number of infections and illnesses that patient had years before. Does the patient feel that he becomes ill more easily and that there is not always a reason or an explanation for the infections that he acquires? If patient reports an increase in the frequency, information concerning the progression and the duration of these infections has to be required. It is alarming when the patient reports that as a rule it takes longer to recover and that common infections, which also occurred in the previous time, have a much more severe presentation nowadays. Information about the appearance and the onset of LA has to be gathered. The speed of the enlargement of the LNs can be indicative to the discrimination between infected LA and malignant LA. A fairly quick enlargement that took place in the matter of hours is more suggestive for an inflectional type of LA. A malignant LA progresses slower and the speed of the onset is moderate. Due to the fact that some malignant LA, such as for example BL have a very high proliferation rate 37 and therefore a fast growth time, it is very tricky to be able to distinguish the etiology of LA based on the speed of its appearance (Ferrer, 1998). The generalization of the LA is also a characteristic to an insufficient immune system and should also be taken into account and considered as an alarm symptom. Generalized LA is a symptom of the systemic disease and several LN groups are involved, they are larger than 1 cm and are not matted (Gill et al., 2007). If such LA is persistent for more than 3 months and the reason for LN involvement cannot be discovered it is very suggestive for a hidden HIV infection (Gill et al., 2007). Special attention has to be given to the presence of the secondary symptoms that normally accompany the persistent generalized lymphadenopathy and can therefore be indications of HIV infection. Night profound sweats, feeling of malaise, weight-loss, cough, dyspnoea, fever, diarrhea and other signs of systemic illness can be present with LA. As it was seen in the results these symptoms accompany different types of LA, infectious and malignant, so it is hard to discriminate the basis for the LN swelling using these secondary symptoms. • Physical examination A careful investigation of the LA is a very important and essential part of the physical examination of the patient. It is well known that there is an association of HIV with a several types of tumors resulting in a significant increase of their prevalence in HIV positive patients. Therefore, a malignant LA can be encountered and it may be the first clinical symptom of a discrete HIV-infection. A malignant LA has some specific characteristics that will help to discriminate it from infection-based LA. A malignant LN has normally a greater size and it is fair to state that there is a direct relationship between the size and the chance that the enlarged LN is malignant (Ferrer, 1998). BL, for example, has a high rate of proliferation and frequently results in ‘bulky’ LN (>10cm) (Blum et al., 2004). Malignant LN are generally not painful unless there is a hemorrhage into necrotic center of the node. Painful LN are mostly associated with inflammation and are therefore common in infected LN. The consistency of the LN is more a specific feature that can help in differential diagnosis. Normally lymphoma presents with LN that have a rubbery consistency, these LN are firm but not hard. The hard LNs are suggestive for a malignant LN or a cancer metastasis from elsewhere (Ferrer, 1998). Therefore, stone hard but not painful LA is by all means an alarm symptom. However, when LNs are matted it can be a symptom of a malignant LA, a lymphoma or metastasic cancer, but are also possible in benign LNs during an infection with TB or sarcoidosis. The location of the LA is also essential for the differential diagnosis, for example more than the half of LA in HIV-HL cases are located in the cervical region. A supraclavicular LA is commonly associated with a malignancy. For a supraclavicular LA the right or left side of the enlargement is also important due to different drainage 38 of the lymphatic flow in both sides. Swelling of atypical regions, persistent enlargement in irregular areas such as supracondylar and submandibular regions is common in HIV positive cases (Ferrer, 1998). The LA that is a result of ongoing opportunistic infections has a slightly different clinical presentation and the time of onset. In these reactive LNs an inflammation takes place. When inflamed a rapid enlargement of the LN results in the elongation of the capsule and this makes these enlarged LN painful while palpated. The speed of the onset is quicker than the speed of growth in malignant LA (Ferrer, 1998). Along with an investigation of the LN a thorough examination of the rest of the body has to be made. The abdominal palpation can result in a complaint of abdominal pain and hepatomegaly and/or splenomegaly can be encountered. Also symptoms of anemia if present have to be recognized. If the physical examination directs towards possible malignant LA it is advised to consult a hematologist to evaluate the patient correctly and to determine the further way of diagnosis and the treatment. Fine needle aspiration cytology (FNAC) can be performed and it should either confirm or reject the primary diagnosis made on the basis of the clinical evaluation. Nevertheless all the precautions have to be made to minimize the chance for ‘seeding’ and further spread of the possible malignancy. If the LA is easily accessible an open LN biopsy is one hand a safer procedure and on the other hand it has a more diagnostic reliability because not only the cells but also the structure of the LN itself can be examined and evaluated. An estimation of HIV progression is possible by taking a closer look on the damage and the alteration from the normal structure of the LN. The group of Gill published results of 6-years study conducted in India that assessed the incidence of HIV positive individuals, previously undiagnosed for HIV, with LA as a clinical presentation (Gill et al., 2007). A number of 1082 cases of extra-inguinal LA were analyzed. The screening for HIV was performed on the blood samples using three different tests. Fine needle aspiration cytology (FNAC) was performed on palpable and enlarged LN (more than 1 cm in size). Three groups of LNs were included in the study: cervical, axillary and extra-inguinal. When patients had multiple LNs enlargement, aspiration from several sites was performed. During this study 25 cases of hidden and previously undiagnosed HIV infection were discovered. Therefore an incidence of 2.3% of HIV positives individuals was found in patients presenting with LA. Among the HIV-positives individuals, 15 were male and 10 female, this population was mainly in third and fourth decade and the oldest patient was 50 years old. None of LA was malignant, 8 cases had reactive lymphadenitis, 15 had TB 39 and 2 non-TB granulomatous lymphadenitis (Gill et al., 2007). This means that LA is a symptom that on its own should make doctors alert for a possible HIV infection. The study of Gill reports that no similar studies were conducted to compare and verify or neglect this incidence of HIV positiveness in LA patients. Our literature study confirms this since no recent publications with similar investigation were found. During my literature study it became apparent that a very low, limited amount of the information in the scientific literature is devoted to describe the features, characteristics and clinical presentation of the LA. A very restricted explanation was present describing the particular symptoms of the LN enlargement. No publication have been found with a detailed report about the features of the LA that could help a doctor to examine the LA properly and to identify crucial features of LA. Most of the authors gave only a brief description stating the presence of LA but no details were given. As a rule much more emphasis was devoted to the pathogenesis and histology of the particular disease. This lack of useful information that can be used in clinical practice raised a question why so little attention is given to a very broad symptom. No practical information is given for the general practitioners that lack the specific experience and knowledge and would only thrive from more detailed information about the various LA characteristics. It was also difficult to find information describing the clinical characteristics of the enlarged or normal LNs. All the handbooks and manuals gave a more specific data about the inner structure of the node but no details or description about the types of clinical presentations. On the whole not enough data is supplied to distinguish between the LA of different etiologies and therefore, usage of specific tests plays a crucial role in the differential diagnosis. It seems that the clinical characteristics of the LN such as consistency, size or matting are not sensitive and/or specific enough to mention them in the articles or reviews. Maybe authors feel that this information is already well known to the doctors and is not worth repeating. In the summer of 2009 a 6-week visit was made to 2 medical institutions in Moscow, Russia. The first hospital was the Hematological Scientific Center (HSC) that is a clinic that specializes only in treatment of patients with hematological disease. A number of patients with diffuse B-large cell lymphoma, HL and BL were observed however none of them were HIV positive. Nevertheless a close look on the method of treatment, the protocols and the progression of the diseases was made. A modification of the BL protocol is invented and applied in HSC, a LB-M-04 protocol. It is a modification of the Hoeltzer-protocol that is commonly used (NHL-BFM-90). The reason for the change, the intensification of the protocol is to have an effect on the tumor before the forming of 40 resistance of the tumor cells to chemotherapy. The Hoeltzer-protocol consists of 6 cycles of chemotherapy; three different types (type A, type B and type C) are administered one after another. Table 3. Types of chemotherapy in the protocol NHL-BFM-90 Type A Type B Type C Dexamethasone 20 mg, day 1-5 Doxorubicin 25 mg/m², day 3 Vincristine 2 mg, day 1 Vincristine 2 mg, day 1 Ifosfamide 800 mg/m², day 1-5 Methotrexate 1500 mg/m², day 1 Methotrexate 1500 mg/m², day 1 Dexamethasone 20 mg, day 1-5 Cytarabine 150 mg/m², day 4-5 Cyclophosphamide 200 mg/m², day 1-5 Dexamethasone 20 mg, day 1-5 Etoposide 150 mg/m², day 3-5 Vinblastine 10 mg, day 1 Cytarabine 2 g/m² 2 times per day, day 2-3 Etoposide 100 mg/m², day 4-5 In the modification of the protocol only 4 cycles are applied, but LB-M-04 protocol is intensified and the duration of the therapy is reduced. The types of the chemotherapy are altered and the combination of the drugs is changed. The interval between the cycles is 21 day and treatment takes around 3 months. They report that as a result of high chemotherapeutical sensitivity BL is completely regressing after two cycles of the therapy even when the tumor mass is considerably big, so the effect of the therapy does not depend on the size of the tumor. To reduce the agranulocytosis duration colonystimulating factor (CSF) is used (Bariakh et al.,2005). 41 Table 4. Types of chemotherapy in the protocol LB-M-04 Type A Type C Dexamethasone 20 mg, day 1-5 Dexamethasone 20 mg, day 1-5 Vincristine 2 mg, day 1 Etoposide 150 mg/m², day 3-5 Ifosfamide 800 mg/m², day 1-5 Methotrexate 1500 mg/m², day 1 Methotrexate 1500 mg/m², day 1 Vinblastine 10 mg, day 1 Cytarabine 150 mg/m², day 4-5 Cytarabine 2 g/m² 2 times per day, day 2-3 Etoposide 100 mg/m², day 4-5 Lumbar punction with an intrathecal injection of Cytarabine 30mg, Methotrexate 15mg, and Dexamethasone 4mg on the 1 day Doxorubicin 25 mg/m², day 3 Lumbar punction with an intrathecal injection of Cytarabine 30mg, Methotrexate 15mg, and Dexamethasone 4mg on the 1 day 17 (85%) of the patients got a remission after a LB-M-04 protocol. One early relapse was diagnosed and three patients died of complications of chemotherapy. The average length of the treatment was 33.5 months. 3-year survival is registered at 80%. After each cycle of the therapy a status of a myelotoxic agranulocytosis was reached (less than 100 neutrophils cells per µl). The median duration was 6.3 days with variation between 1 and 23 days. In 87% of the cycles a type of infectious complication was recorded. Fever was seen in 65% of the cases, stomatitis in 42%, necrotic enteropathy in 14%, mucositis in 6%, sepsis in 8%, pneumonia in 8%, proctitis and paraproctitis in 5% and a fever without an infection in 16%. The most amounts of complications were seen in the first cycle A that can be explained by a severe state of the patients at the moment of hospitalization. (Bariakh et al., 2005) Another hospital that was visited in Moscow was the hospital №60. A part of the hematological department is devoted to the treatment of HIV associated lymphomas. Newly developed protocol LBM-04 for the treatment of BL is already applied there. Due to the fact that this modified protocol is associated with and an intensification of the treatment more attention to the conditions of the patients along with the ‘reverse isolation’ of patient is crucial to prevent opportunistic infections and possible complications. It is sad to report that none of these conditions are provided. Patients with severe immunosuppression and myelotoxic agranulocytosis are placed in the same small rooms, sharing the infections with the neighbor. No isolation possibilities are available. A lack of funding for better conditions, which are an absolute necessity for the treatment of HIV- associated lymphoma with high dose chemotherapy, was apparent. 42 Before the beginning of the therapy of the lymphoma it is vital to have a correct diagnosis. When a lymphoma is misdiagnosed, for example a BL that was wrongly thought to be a HL and treated according to the HL protocol will afterwards react very poorly to the correct, appropriate treatment and become refractory. The tumor forms resistance for particular chemotherapeutical drugs and it reduces the chances of a successful treatment significantly. Several examples of such refractory patients that are noncompliant to the chemotherapy were observed in HSC. Therefore the lymphomas that are diagnosed in HIV positive patients should be diagnosed and evaluated correctly by a multi disciplinary team that consists of several types of doctors one of which should be an experienced hematologist. HIV associated malignancies are combinations of severe diseases and the reaction and assessment of the medical team has to be appropriate. Vigilance and high degree of suspicion for a hidden HIV infection is essential when patients with LA are encountered. 6. References Angeli V, Randolph GJ. Inflammation, lymphatic function, and dendritic cell migration. Lymphat Res Biol. 2006;4(4):217-28. Bariakh EA, Kravchenko SK, Kremenetskaia AM, Zvonkov EE, Obukhova TN, Magomedova AU, Vorob'ev AI. Clinical and epidemiological features of Burkitt's lymphoma Ter Arkh. 2009;81(7):47-53. Bariakh EA, Obukhova TN, Zvonkov EE, Kravchenko SK. Burkitt lymphoma: clinics, diagnostics, treatment. Hemat Transfus., 2005;6 : 30-36. Berger EA, Murphy PM, Farber JM. Chemokine receptors as HIV-1 coreceptors: roles in viral entry, tropism and disease. Annu Rev Immunol 1999;17:657–700. Berenguer J, Miralles P, Ribera JM, et al. Characteristics and outcome of AIDS-related Hodgkin lymphoma before and after the introduction of highly active antiretroviral therapy. J Acquir Immune Defic Syndr 2008; 47:422–428. Blinder VS, Chadburn A, Furman RR, Mathew S, Leonard JP. Improving outcomes for patients with Burkitt lymphoma and HIV. AIDS Patient Care STDS. 2008 Mar;22(3):175-87. 43 Blum KA, Lozanski G, Byrd JC. Adult Burkitt leukemia and lymphoma. Blood. 2004 Nov 15;104(10):3009-20. Boily M-C, Baggaley RF, Wang L, et al. (2009). "Heterosexual risk of HIV-1 infection per sexual act: systematic review and meta-analysis of observational studies". Lancet Infect Dis 9 (2): 118–129. Brockmeyer N, Barthel B. Clinical manifestations and therapies of AIDS associated tumors. Eur J Med Res. 1998 Mar 23;3(3):127-47. Burkitt D. A sarcoma involving the jaw in Afrikan children. Br. J. Surg., 1958.- Vol.- 46. P. 218-223. Caponetti G, Pantanowitz L. HIV-associated lymphadenopathy Ear Nose Throat J. 2008 Jul;87(7):374-5. Centers for Disease Control and Prevention. 1993 Revised classification system for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults. MMWR 1992; 41:RR17. Centers for Disease Control. Pneumocystis Pneumonia--Los Angeles. Morbidity and Mortality Weekly Report, 1981, v. 30, p. 250. Centers for Disease Control. Kaposi’s sarcoma and Pneumocystis pneumonia among homosexual men--New York City and California. Morbidity and Mortality Weekly Report, 1981, v. 30, p. 305. Chang Y, Cesarman E, Pessin MS, Lee F, Culpepper J, Knowles DM, Moore PS. Identification of herpesvirus-like DNA sequences in AIDS-associated Kaposi's sarcoma. Science. 1994 Dec 16;266(5192):1865-9. Chimienti E, Spina M, Gastaldi R, et al. Clinical characteristics and outcome of 290 patients (pts) with Hodgkin’s disease and HIV infection (HD-HIV) in pre and HAART (highly active antiretroviral therapy) era [abstract 168]. Ann Oncol 2008; 19:iv136. Chiu IM, Yaniv A, Dahlberg JE, Gazit A, Skuntz SF, Tronick SR, Aaronson SA. Nucleotide sequence evidence for relationship of AIDS retrovirus to lentiviruses. Nature 1985;317:366–8. 44 Commented Drug Repertorium. Belgian Center for Farmacotherapeutical Information. 2010 Davies MA, Meintjes G. Assessing the contribution of the immune reconstitution inflammatory syndrome to mortality in developing country antiretroviral therapy programs. Clin Infect Dis. 2009 Sep 15;49(6):973-5. de Leval L, Hasserjian RP. Diffuse large B-cell lymphomas and Burkitt lymphoma. Hematol Oncol Clin North Am. 2009 Aug;23(4):791-827. Enoch DA, Ludlam HA, Brown NM. Invasive fungal infections: a review of epidemiology and management options. J Med Microbiol. 2006 Jul;55(Pt 7):809-18. Fahey JL, Taylor JMG, Detels R, Hofmann B, Melmed R, Nishanian P, Giorgi JV. The prognostic value of cellular and serologic markers in infection with human immunodeficiency virus type 1. N Eng J Med 1990;322:166 –72. Ferrer R. Lymphadenopathy: differential diagnosis and evaluation. Am Fam Physician. 1998 Oct 15;58(6):1313-20. Fujii T, Nakamura T, Iwamoto A. Pneumocystis pneumonia in patients with HIV infection: clinical manifestations, laboratory findings, and radiological features. J Infect Chemother. 2007 Feb;13(1):1-7. Gill PS, Arora DR, Arora B, Gill M, Gautam V, Karan J, Chaudhary U, Garg N. Lymphadenopathy An Important Guiding Tool for Detecting Hidden HIV-Positive Cases: A 6-Year Study. J Int Assoc Physicians AIDS Care (Chic Ill). 2007 Dec;6(4):269-72. Gordin F, Cohn D, Sullam P, Schoenfelder J, Wynne B, Horsburgh C Jr. Early manifestations of disseminated Mycobacterium avium complex disease: a prospective evaluation. J Infect Dis 1997; 176: 126–32. Greer J, Foerster J, Lukens J, Rodgers G, Paraskevas F, Glader B. Wintrobe's Clinical Hematology, 11th edition Grogg KL, Miller RF, Dogan A. HIV infection and lymphoma. J Clin Pathol. 2007 Dec;60(12):136545 72. Hoffbrand A, Pettit J, Moss P. Essential haematology. Fourth edition 2001 Howard M, Hamilton P. Haematology: an illustrated colour text. Third edition 2007 Hsieh SM, Hung CC, Chen MY, Hsueh PR, Chang SC, Luh KT. Clinical features and outcome in disseminated mycobacterial diseases in AIDS patients in Taiwan. AIDS 1998; 12: 1301–07. Huang L, Crothers K. HIV-associated opportunistic pneumonias. Respirology. 2009 May;14(4):47485. Jones BE, Young SMM, Antoniskis D, Davidson PT, Kramer F, Barnes PF. Relationship of the manifestations of tuberculosis to CD4 cell counts in patients with human immunodeficiency virus infection. Am Rev Respir Dis 1993;148:1292-7. Jones B, Ryu R, Yang Z, Cave MD, Pogoda JM, Otaya M, Barnes PF. Chest radiographic findings in patients with tuberculosis with recent or remote infection. Am J Respir Crit CareMed 1997;156:12703. Kaposi M. Idiopathisches multiples Pigmentsarkom der Haut. Arch Dermatol Syph 1872; 4:265-73. Karakousis PC, Moore RD, Chaisson RE. Mycobacterium avium complex in patients with HIV infection in the era of highly active antiretroviral therapy. Lancet Infect Dis. 2004 Sep;4(9):557-65. Klimas N, Koneru AO, Fletcher MA. Overview of HIV. Psychosom Med. 2008 Jun;70(5):523-30. Krown SE, Metroka C, Wernz JC. Kaposi’s sarcoma in the acquired immune deficiency syndrome: a proposal for uniform evaluation, response and staging criteria. AIDS Clinical Trials Group Oncology Committee. J Clin Oncol 1989; 7: 1201–1207. Lekkerkerker AN, van Kooyk Y, Geijtenbeek TB. Viral piracy: HIV-1 targets dendritic cells for transmission. Curr HIV Res 2006;4:169 –76. Levine AM. Management of AIDS-related lymphoma. Curr Opin Oncol. 2008 Sep;20(5):522-8. 46 Levy JA. HIV pathogenesis: knowledge gained after two decades of research. Adv Dent Res 2006;19:10 –16. Lowe SM, Kocjan GI, Edwards SG, Miller RF. Diagnostic yield of fine-needle aspiration cytology in HIV-infected patients with lymphadenopathy in the era of highly active antiretroviral therapy. Int J STD AIDS. 2008 Aug;19(8):553-6. Mendelson M. Diagnosing tuberculosis in HIV-infected patients: challenges and future prospects. Br Med Bull. 2007;81-82:149-65. Mims C, Dockrell H, Goering R, Roitt I, Wakelin D, Zuckermann M. Medical Microbiology Third edition 2004 Moore RD, Chaisson RE. Natural history of opportunistic disease in an HIV-infected urban clinical cohort. Ann Intern Med 1996; 124: 633–42. Navarro WH, Kaplan LD. AIDS-related lymphoproliferative disease. Blood. 2006 Jan 1;107(1):13-20. O’Conor G.T. Malignant lymphoma in African Children. A pathology entity. Cancer, 1961.- Vol.14.- Р. 270-283. Olszewski WL. The lymphatic system in body homeostasis: physiological conditions. Lymphat Res Biol. 2003;1(1):11-21. Ong EL. Common AIDS-associated opportunistic infections.Clin Med. 2008 Oct;8(5):539-43. Pivnik AV, Korovushkin VG, Parkhomenko VN, Tonkoglaz VN, Pavlova LE, Litivinova NG, Peregudova AB, Degterev DA, Gruzdev BM. Differential diagnosis of lymphadenopathy in HIV/AIDS Ter Arkh. 2006;78(4):28-32. Potter SJ, Lacabaratz C, Lambotte O, Perez-Patrigeon S, Vingert B, Sinet M, Colle JH, Urrutia A, Scott-Algara D, Boufassa F, Delfraissy JF, The`ze J, Venet A, Chakrabarti LA. Preserved central memory and activated effector memory CD4_ T-cell subsets in human immunodeficiency virus controllers: an ANRS EP36 study. J Virol 2007;81:13904 –5. 47 Potthoff A, Brockmeyer NH HIV-associated Kaposi sarcoma: pathogenesis and therapy. J Dtsch Dermatol Ges. 2007 Dec;5(12):1091-4. Rasokat H, Haussermann L, Minnemann M. Response of AIDS-related Kaposi’s sarcoma to treatment with recombinant interferon alpha depends on the stage of underlying immunodeficiency. J Invest Dermatol 1989; 89: 444–445. Rezza G, Andreoni M, Dorrucci M, Pezzotti P, Monini P, Zerboni R, Salassa B, Colangeli V, Sarmati L, Nicastri E, Barbanera M, Pristerà R, Aiuti F, Ortona L, Ensoli B. Human herpesvirus 8 seropositivity and risk of Kaposi's sarcoma and other acquired immunodeficiency syndrome-related diseases. J Natl Cancer Inst. 1999 Sep 1;91(17):1468-74. Rolla V, Jacomet C, Salause B, et al. Clinical and laboratory findings of disseminated Mycobacterium avium complex infection (DMAC) in a pair matched case–control study. Rev Inst Med Trop Sao Paulo 1999; 41: 273–77. Salomon N, Gomez T, Perlman DC, Laya L, Eber C, Mildvan D. Clinical features and outcomes of HIV-related cytomegalovirus pneumonia. AIDS. 1997 Mar;11(3):319-24. Schmidt-Hieber M, Zweigner J, Uharek L, Blau IW, Thiel E. Central nervous system infections in immunocompromised patients: update on diagnostics and therapy. Leuk Lymphoma. 2009 Jan;50(1):24-36. Spina M, Tirelli U, Zagonel V, Gloghini A, Volpe R, Babare R, Abbruzzese L, Talamini R, Vaccher E, Carbone A. Burkitt's lymphoma in adults with and without human immunodeficiency virus infection: a single-institution clinicopathologic study of 75 patients. Cancer. 1998 Feb 15;82(4):766-74. Tebit DM, Nankya I, Arts EJ, Gao Y. HIV diversity, recombination and disease progression: how does fitness “fit” into the puzzle? AIDS Rev 2007;9:75– 87. The Henry J. Kaiser family foundation. The global HIV/AIDS epidemic, 2009 Vorkas CK, van der Horst C. HIV and tuberculosis in Russia and Eastern Europe: sounding the alarm. AIDS. 2009 Nov 27;23(18):2533-4. 48 Waites KB, Balish MF, Atkinson TP. New insights into the pathogenesis and detection of Mycoplasma pneumoniae infections. Future Microbiol. 2008 Dec;3(6):635-48. Waters L, Nelson M. Cryptococcal disease and HIV infection. Expert Opin Pharmacother. 2005 Dec;6(15):2633-44. World Health Organization, Rapid advice. Antiretroviral therapy for HIV infection in adults and adolescents 2009 49