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B CELL ALL IN AN ANTI‐HIV POSITIVE PATIENT: ACHIEVEMENT OF A COMPLETE RESPONSE WITH AGGRESSIVE CHEMOTHERAPY

A link between AIDS and B-cell lymphoblastic leukaemia (B-ALL) first reported by Ernberg et a1 (1986) has been supported by two recent reports by Rossi et a1 (1988) and Flanagan et a1 (1988). In the last two reports, the patients’ outcome was poor due to chemoresistance and opportunistic infection. We wish to report the following case for two reasons: firstly to bring support for the inclusion of B-ALL occurring in anti-HIV positive patients into the CDC definition of AIDS, secondly to demonstrate that achievement of complete remission (CR) with aggressive multiagent chemotherapy was possible. A previously healthy 2 7-year-old male, neither homosexual nor drug abuser, was admitted with fever, easy bruising, epistaxis. Examination revealed generalized lymphadenopathy, hepatomegaly (20 cm) and splenomegaly (2 1 cm). Blood counts showed WBC 5 1 x 1 09/1 with 5 5% blast cells, Hb 5.8 g/dl and platelets 16 x 109/l. The bone marrow smear was hypercellular with 90% blast cells of FAB L3 morphology. The blast cells bore surface immunoglobulin of both Mu heavy chain and Kappa light chain isotype. In addition they were CD9, CD24, CD20 and Y 2955 positive, and negative for T cell and myeloid markers. The karyotype of the blast cells was 46,XY. t(8;14) (q24:q32). Serum protein electrophoresis showed a monoclonal immunoglobulin of IgM kappa type. CSF was normal. The HIVl serology was positive (ELISA), confirmed by a characteristic Western Blot pattern (Fig 1, lane 10). Blast cells were negative for EpsteinBarr Nuclear antigen. Treatment using the French multiagent chemotherapy protocol LMB (Patte et al, 1986) was started. The patient was housed in a laminar air flow room and received gut decontamination with oral non-absorbable antibiotics. Severe pancytopenia lasted 15 d. During this period the patient was febrile and received broad spectrum intravenous antibiotics including trimethoprime sulfamethoxazole. On day 22 after the start of treatment peripheral blood and marrow aspiration were consistent with CR. The patient was discharged. Further treatment consisting of repeated courses of multiagent chemotherapy and CNS prophylaxis with intrathecal methotrexate was performed on an out-patient basis. At the time of this report, 5 months after the diagnosis, the patient is on maintenance therapy, in continuous CR with a Kalmofsky score of 100%: serum protein electrophoresis showed no M component. The Western Blot pattern was unchanged (Fig 1. lane 11). The level of peripheral CD4 positive T cells was low (0.08 x 109/1) (normal: 0.43-1.2). This new case of B-ALL arising in an anti-HIV positive patient emphasizes the link between the two diseases. Despite a , -