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Lymphoproliferative clonal origin of AIDS-related non-Hodgkin's lymphoma

Human immunodeficiency virus (HIV)-infected individuals have a 200-fold increased risk of developing non-Hodgkin’s lymphoma (NHL) over the general population [1]. The origin and pathogenesis of HIVassociated NHL has not yet been fully elucidated but HIV-related lymphomagenesis is believed to comprise a multistep process of chronic B-cell stimulation starting with HIV-induced immunosuppression. In many cases, Epstein-Barr virus (EBV) coinfection contributes to HIV-related transformation [2 – 4], complemented with genetic aberrations, and cytokine deregulation that contribute to the development of lymphoma. A small percentage of patients develop an HIVrelated benign hyperproliferative disorder that precedes NHL by several years with clonal B cell populations in both [2,5 – 7]; however, the clonal relationship between the two pathologies has not been clearly defined. We describe an HIV-positive patient who presented with a benign hyperplastic lymph node, harbored EBV, and was diagnosed with NHL three years later. We show a direct clonal link between the benign lymphoproliferative disorder and lymphoma in this patient. The data suggests that the natural history of HIV-related lymphomagenesis can be extended for up to three years. A 40-year-old African American female, who used intravenous drugs, was diagnosed with HIV infection in 1989. She was continually noncompliant with antiretroviral therapy. In September 2000, enlargements of the cervical, axillary, supraclavicular, and inguinal lymph nodes were observed. A left axillary lymph node biopsy performed in December 2000 showed a polymorphic lymphoid population [Figure 1(a)] with no evidence of lymphoma. Flow cytometry showed that the B-cells were polytypic, and the T-cells showed no loss of pan T-antigens. The CD4:CD8 ratio was reversed at 1:3. Computerized tomographic (CT) scan in October 2000 showed hepatosplenomegaly with lymphadenopathy in the peripancreatic, portocaval, retroperitoneal, and inguinal areas. In January 2003, the patient experienced a weight loss of 18 kg and was hospitalized because of abdominal pain, nausea, and constipation of 2 weeks in duration. Physical examination revealed icteric sclera and lymph node enlargement in the occipital, cervical, axillary and inguinal regions. Laboratory testing showed a hemoglobin level of 7.8 g/dl, a white blood cell count of 8,900/ml, a platelet count of 89,000/ml, a total bilirubin level of 3.9 mg/dl, an alkaline phosphatase level of 1,174 U/l, a gamma glutamyl transferase level of 917 U/l, and an alanine aminotransferase level of 26 U/l. CT scan showed massive splenomegaly, and extensive bulky lymphadenopathy at the hilar, paratracheal, subcarinal, retrocrural, periaortic, pericaval, and gastrohepatic ligament regions, with compression on the inferior vena cava, bilateral pleural effusions, moderate ascites, and gall bladder sludge.