Plasmablastic lymphoma of the anus: a case report

Background: Co - infection of hepatitis E virus (HEV) and hepatitis D virus (HDV) in human immunodeficiency virus (HIV) infected patients can develop and increase hepatic complications in the world, particularly in developing countries. Objectives: The purpose of this study was to assess and compare the sero - virological prevalence of HEV and HDV in patients bearing HIV infection and HIV/HCV co - infection, as well as their relation to clinical and demographic data. Methods: Cross - sectional study testing IgM/IgG anti - HEV and total antibodies HDV in serum samples belong to 73 HIV infected patients and co - infected HIV - HCV patients were evaluated. Demographic, lifestyle, and laboratory data such as CD4 counts and viral load were prospectively collected on each patient with the HIV infection. Results: There were 26 HEV infected patients IgG positive, two HEV infected patients IgM positive, two HDV infected patients total antibodies positive, and only one HDV infected patient IgM among the 73 HIV infected patients. The prevalence of HDV positive IgG and total anti - HDV among co - infected patients were 2.2% and 2.2%. In addition 18 (69.2%) and 2.2% were positive for anti - HEV IgG and IgM, respectively. Furthermore, HIV viral load among HIV co - infected patients with HEV or HDV were shown higher compared to patients solely infected with only HIV. Also, the numbers of HEV or HDV positive were high in low levels of CD4. Conclusions: According to the results, frequency of occurrence of hepatitis E was higher than hepatitis D in HIV infected patients. Severity of HIV infection and liver damage caused by HEV and HDV infections were in a direct relationship. Hence, HIV and HCV screening should be implemented in HIV - infected patients with liver damage.

Sa1515 Should We Keep HIV Infected Patients in the Average-Risk Screening Category? a Sub-Analysis of the Comp (Colonoscopy Outcomes in Minority Population) Registry Data

Lymphomas that develop in human immunodeficiency virus (HIV) infected patients are predominantly aggressive B-cells lymphomas. The most common HIV-associated lymphomas include Burkitt lymphoma, diffuse large B-cell lymphoma (that often involves the CNS), primary effusion lymphoma, and plasmablastic lymphoma (PBL). Of these, PBL is relatively uncommon and displays a distinct affinity for presentation in the oral cavity. In this manuscript we report a previously undescribed primary leptomeningeal form of PBL in a patient with acquired immunodeficiency syndrome. A 40-year-old HIV positive man presented with acute onset confusion, emesis, and altered mental status. Lumbar puncture showed numerous nucleated cells with atypical plasmocyte predominance. CSF flowcytometry showed kappa restriction with CD8 and CD38 positivity and negative lymphocyte markers, while the MRI showed diffuse leptomeningeal enhancement. As the extensive systemic work-up failed to reveal any disease outside the brain, an en bloc diagnostic brain and meningeal biopsy was performed. The biopsy specimen showed sheets of plasmacytoid cells with one or more large nuclei, prominent nuclear chromatin, scattered mitoses, and abundant cytoplasm, highly suggestive of plasmablastic lymphoma. HIV-associated malignancies have protean and often confusing presentations, which pose diagnostic difficulties posed to the practicing neurological-surgeons. Even in cases where an infectious cause is suspected for the meningeal enhancement, neoplastic involvement should be considered, and cytology and flow-cytometry should be routinely ordered on the CSF samples.

Background: In India, there is a lack of awareness and inadequate knowledge about use of Highly Active Antiretroviral Therapy (HAART) due to social stigma leading to intentional non-adherence among Human Immunodeficiency Virus (HIV) infected patients thus, Educational Intervention (EI) must be sought. Need for the study: There is a need for an EI program for HIV-infected patients for improving adherence to Antiretroviral Therapy (ART). Aim: The aim of the study was to evaluate the impact of an EI on use of HAART and its effect on adherence behavior in Intervention Care Group (ICG) in comparison with Standard Care Group (SCG) in HIV infected patients. Methods: A prospective, randomized, controlled study was conducted at Kasturba hospital Manipal from August 2009 to May 2012 in HIV infected patients. The baseline response for Knowledge, Attitude, Belief, and Practice (KABP) questionnaire was assessed. Block randomization was used to assign the patients to the SCG and ICG. In ICG group, patients are educated every 4 weeks for a total of 16 weeks with Patient Information Leaflet (PIL), adherence counseling and awareness to Adverse Drug Reactions (ADRs) to ART by a clinical pharmacist. In ISG group, patients are given standard care for ART treatment by a clinician. Post KABP response was documented in both groups at 16th week and adherence rate was measured. Repeated-measures Analysis of Variance (RANOVA) was used for the comparison of pre and post total KABP responses between ICG and SCG. Results: A total of 256 HIV positive patients were enrolled. Out of which 16 patients were excluded because they were on traditional medicines and 240 HIV-infected patients with HAART were finally included in the study, of whom 120 (89 [74.2%] men, 31[25.8%] women) were randomly assigned to the ICG and 120 (99 [82.5%] men, 21[17.5%] women) to the SCG. Pre and post KABP responses significantly increased with mean ± standard deviation (SD) (p<0.001) and greater than 95% of adherence (p<0.001) was reported in ICG after EI in comparison with SCG. Conclusion: The EI program on use of HAART in this study changed their intentional non-adherence behavior, negative beliefs and social stigma.

Screening of Hepatitis C virus (HCV) infection by molecular test is not routinely performed for the care of human immunodeficiency virus (HIV) infected patients in most countries of Sub-Saharan Africa such as Benin. The aim of this study was to assess the extent of HCV infection in patients infected with HIV in Cotonou. This study was conducted from February to June 2017 on HIV infected patients from the National Reference Center for Research and Management of HIV infection in Cotonou. &nbsp;Blood samples were collected from patients to detect anti-HCV antibody and HCV viral load. A total of 205 patients were tested, out of which 67.3% were females. Seroprevalence of anti-HCV antibody was 7.8% and HCV viral load was detectable in 3.4% of cases with a median of 2.200.000 IU/mL (6.3 Log10). Three out of seven patients (42.8%) had negative HCV serology with positive HCV RNA detection. In conclusion, the prevalence of HCV infection among HIV infected patients is not negligible in Cotonou. Universal access to molecular tests is needed in the country to detect HCV infection in these patients. &nbsp; Keywords: HCV, HIV, prevalence.

PLASMABLASTIC LYMPHOMA: ORAL VS EXTRAORAL

The recognition and the assessment of the carotid intimal thickness helps in predicting the risk of the cardiovascular events in Human Immunodeficiency Virus (HIV) infected patients who are on Antiretroviral Therapy (ART). The objective of this study was to assess and compare the carotid intimal thickness in HIV positive individuals who were on antiretroviral therapy with HIV positive individuals who were not on anti-retroviral therapy. All the HIV positive individuals who were 20 years old and above, who had been diagnosed by the National AIDS Control Organization (NACO) guidelines were included in the study. The HIV positive individuals who were diagnosed with diabetes mellitus and hypertension were excluded from the study. The study subjects were divided into 2 groups i.e. HIV patients who were on anti-retroviral therapy and HIV patients who were not on anti-retroviral therapy. The patients had to be on anti-retroviral therapy for a minimum of 6 months for them to be included in the first group. The data was collected by using a semi structured, pre-tested proforma, which included the demographic details, the duration of the HIV infection, details of the antiretroviral treatment, a history of smoking/ alcohol consumption and details on the assessments of the metabolic syndrome. A total of 42 patients were included in the study. Among them, 28 were males (66.7%) and 14 were females (33.3%). Twenty six patients were on ART and the remaining patients were treatment naive. There were significant differences with regards to their age and the duration of the HIV infection, which was longer in the patients who were on ART (p= 0.049, p=0.003 respectively). The Body Mass Index (BMI), the waist: hip ratio, the mid-arm circumference, the waist circumference, the skin fold thickness and the carotid intimal-media thickness were higher in the HIV patients who were on ART as compared to those in the treatment naive patients, though the difference was statistically insignificant. The carotid intimal thickness was higher in the HIV patients who were on ART as compared to those in the treatment naïve HIV infected patients.

HIV infection is a multiorgan disease with the kidney not spared. A variety of renal syndromes with varying clinical presentations has been reported amongst HIV infected patients. This study aims to highlight the spectrum of clinical presentations in HIV infected patients with renal disease. HIV infected patients presenting at University of Benin Teaching Hospital (UBTH) Benin City were the study population. A total of 383 patients were studied. Their biodata, clinical presentations and laboratory investigations including serum urea, creatinine and albumin, urine protein and creatinine were assessed. Their glomerular filtration rate (GFR) and protein urine excretion were calculated using six equations of modification of diet in renal disease (MDRD) and protein: creatinine ratio respectively. Patients were stratified according to their renal functions into normal, mild, moderate and severe renal function impairment. The data was analysed using statistical software program SPSS Vs 15.0. 53.3% of 383 patients screened had renal function impairment, 40.2% mild, 37.7% moderate and 22.2% severe impairment. Mean age was 35.6±8.3, 36.0±9.9 and 36.3±8.3 years for mild, moderate and severe renal function impairment (RFI) respectively. Easy fatigability was the commonest symptoms occurring in 47.5%, 30.0%, 37.5% and 22.5% of control, mild RFI, moderate RFI and severe RFI subjects respectively (p = 0.568). Oliguria, facial and body swelling occurred more in patients with RFI especially in patients with severe renal impairment. The difference is statistically significant (p = 0.046, 0.041, and 0.033 respectively). Pallor was the commonest clinical sign occurring in 32.5%, 50.0%, 35.0% and 62.5% of control and patients with mild, moderate, and severe RFI respectively; the difference was not statistically significant (p = 0.459). Ascites, facial puffiness and pedal oedema were commoner in patients with RFI especially those with severe RFI. The differences were statistically significant. (p = 0.048, 0.019, and 0.008 respectively). In conclusion spectrum of clinical presentations in HIV patients with renal impairment are many but few are specific to these patients.

Gastrointestinal parasitic infections are the major sources of diarrheal disease in developing countries and Human Immunodeficiency virus (HIV) infected patients are at the most risk. The objective of this study was to determine the prevalence of intestinal parasitic infections (IPIs) in the HIV-infected individuals visiting different care centers of Morang and Sunsari districts. The present cross-sectional study was conducted from two different HIV rehabilitation centers and one antiretroviral therapy center from eastern Nepal. A semi structured questionnaires was provided to HIV patients and 149 stool specimens were collected to analyze macroscopically and microscopically for the presence of enteric parasites. Data were analyzed by SPSS version 16. A total of 149 HIV seropositive patients with and without diarrhea were included in the study. Overall prevalence rate of enteroparasites was 19.46%. The prevalence rate of enteric parasites in HIV patients showed higher rate of protozoan infections (58.6%) than helminths (41.4%). High prevalence of parasitic infection was seen in male and also among male in the age groups of 31-40 years. The polyparasitism was not detected. A significant difference (p&lt;0.05) was observed in the level of infection of intestinal parasites between the HIV seropositive with gastrointestinal tract (GIT) symptoms and HIV seropositive without GIT symptoms. The enteric parasitic infections were detected in 19.46% among HIV seropositive patients. Early detection of enteric parasitic infections could help in the management and improvement of the quality of life for HIV-infected individuals.

The objective of the study was to determine the proportion of patients with missed lesions on plain chest radiographs compared with high-resolution computed tomography (HRCT) in 49 human immunodeficiency virus (HIV) infected patients with community-acquired pneumonia (CAP). Patients underwent plain chest radiography and HRCT scans of the chest at admission. Microbiological investigations for CAP were performed. An experienced radiologist, without knowledge of clinical or pathological data, reported the chest radiographs and HRCT scans. The study group included 26 females and 23 males, aged 18-53 years (mean age 36 years). Organisms were isolated from 26 patients (53%). In 40 patients (82%), the HRCT scans demonstrated lesions not visualized on the plain chest radiographs. There was 100% correlation between plain radiographic and HRCT scan findings in nine cases (18%). Lesions that were not visualized on the plain radiographs but elucidated on HRCT included: pleural effusion (n = 14), ground-glass opacification (n = 20), pericardial effusion (n = 8), cavitation (n = 4), cysts (n = 4), bullae (n = 4), abscess (n = 1) and pneumothorax (n = 1). In 20 of 23 cases, hilar lymphadenopathy, identified on HRCT, was not recognized on plain chest radiographs. In patients in whom an organism was isolated, a correct HRCT diagnosis of pulmonary tuberculosis, bacterial pneumonia and Pneumocystis carinii pneumonia (PCP) was made in 80%, 84% and 100% of cases, respectively. The proportion of patients with missed lesions on plain chest radiographs in HIV infected patients with CAP was high. This has important implications for management and prognosis. HRCT scans correlate well with the microbiological diagnosis when reported by an experienced radiologist.

Plasmablastic lymphoma of the oral cavity in immunocompetent patients: report of two cases

The surgical treatment and transcatheter arterial chemoembolization (TACE) rate of human immunodeficiency virus (HIV)-infected hepatocellular carcinoma (HCC) patients is relatively low in West China. For various reasons, most patients do not receive timely surgical treatment. Upon transfer to an infectious disease centralized hospital, they were already classified in the Barcelona Clinic Liver Cancer (BCLC)-B stage. A total of 2249 BCLC-B HCC patients were analyzed. The eligible population was divided into three groups for analysis of survival and prognostic factors; These were 21 HIV infected (HIV+) HCC patients treated with TACE (TACE+), 1293 non-HIV-infected (HIV−) HCC patients treated with TACE, and 150 HIV− HCC patients who only receive medication (TACE−) as a second control group. After 1:2 matching, 1- and 2-year survival of HIV+ TACE+ and HIV− TACE+ groups was 64.3% and 76.5% (P = 0.453) and 45.5% vs. 50.0% (P = 0.790) respectively. We also compared one and two-year survival between HIV+ TACE+ and HIV− TACE−. One-year overall survival was 64.3% vs. 45.7% (P = 0.097) and 2-year survival was 45.5% vs. 7.1% (P = 0.004). Multivariate analysis showed that the most important prognostic factors for survival were serum alpha-fetoprotein (AFP) and Child–Pugh score and tumor size, while HIV status had no significant effect on prognosis statistically. CD4 levels below 200 may increase the risk of opportunistic infection after surgery, but after anti-infection and systematic supportive therapy, it has no effect on survival. HIV+ patients should have the same treatment opportunities as HIV− patients. If the patient's immune status permits, we suggest that early TACE treatment should be administered to BCLC-B HCC patients, regardless of HIV infection.

The plasmablastic lymphomas (PBLs) are an aggressive group of non-Hodgkin's lymphomas occurring primarily in human immunodeficiency virus (HIV)-infected individuals with absolute CD4 counts less than 200 per microliter. It was considered to be a diffuse large B-cell lymphoma with a unique immunophenotype and occurred primarily in the oral cavity. Recent studies report that PBLs also occur in patients without HIV infection. Herein we report an unusual case of plasmablastic lymphoma presenting in nasal cavity in a 74-year-old, HIV-negative woman. Cytologic and histologic examinations demonstrated a large cell lymphoma with plasmacytic differentiation. The tumor cells were positive for CD79a, CD38, however lacked expression of leukocyte common antigen, T-cell, and B-cell markers. Epstein-Barr virus-encoded RNA transcripts were identified by in situ hybridization. To our best knowledge, this is the second case of plasmablastic lymphoma in HIV-negative patient in Korea. (

Plasmablastic lymphoma (PBL) occurs mainly in immunocompromised individuals, usually secondary to human immunodeficiency virus (HIV) infection. It classically occurs intraorally, but has been described in extraoral locations. The aim of this study was to define the immunophenotype and Epstein-Barr virus (EBV) status in a large single-centre cohort of extraoral PBL (EPBL) in South Africa, a high-prevalence HIV setting. This retrospective study of 45 EPBLs included patients' age, gender, race, HIV status, and site. Cases were reviewed histologically, and classified morphologically as pure plasmablastic or plasmablastic with plasmacytic differentiation, and assessed immunohistochemically with antibodies against CD45, CD20, CD79a, PAX5, CD138, MUM1/IRF4, BLIMP1, VS38c, Ki67, bcl-6, CD10, cyclin D1, and human herpesvirus-8, by the use of standard automated procedures. EBV was assessed by the use of chromogenic in-situ hybridisation. Tumours were assessed with a fluorescence in-situ hybridisation (FISH) MYC break-apart probe. Twenty-seven PBLs showed pure plasmablastic morphology, and 18 showed plasmacytic differentiation. The male/female ratio was 1.5:1. The anus was the favoured extraoral site (31.1%), followed by lymph nodes (15.6%). All 29 patients with known HIV status were HIV-positive. The immunohistochemical profile recapitulated that reported for oral PBLs and EPBLs in HIV-positive and HIV-negative patients. EBV was positive in 92.5% of PBLs. FISH analysis showed MYC rearrangement in 48% of cases. This study showed a strong association of EPBLs with HIV and EBV infection, similarly to the previously described oral PBL. The strong EBV association together with other clinicopathological parameters and an immunohistochemical profile that includes CD45, CD20, MUM1/IRF4, CD138 and Ki67 may be used in distinguishing PBL from diffuse large B-cell lymphoma and plasma cell myeloma.

Plasmablastic lymphoma (PBL) is a rare and recently described entity of large B-cell lymphoma. It predominantly occurs in the oral cavity of human immunodeficiency virus (HIV)-positive patients and exhibits a highly aggressive clinical behavior without effective treatment. Recently, sporadic cases describing PBL in extraoral locations of HIV-negative patients have been reported; frequently in patients with underlying immunosuppressive states. To develop the understanding of PBL, the current study reports the unusual presentation of duodenal PBL and reviews the pathogenesis, immunohistochemical features, clinical and differential diagnoses, as well as the treatment of PBL as described in previous studies. The case of a 75-year-old female with duodenal PBL without definite immunosuppression is presented in the current report. The tumor was composed of large B-cell-like cells, and was positive for cluster of differentiation 138 and melanoma ubiquitous mutated-1, with ~80% of the tumor cells positive for Ki-67. The features of the tumor were as follows: Extraoral location, HIV-negative, immunoglobulin M λ-type M protein expression, light chain restriction (monoclonal) and Epstein-Barr virus-encoded small RNA-negative, which are considered to be unusual for PBL. These unusual features complicate the differentiation of PBL from other plasma cell diseases. To the best of our knowledge, this is the first study to report a case of duodenal PBL in an immunocompetent patient. To date, the standard treatment of PBL remains elusive, however, the most commonly administered chemotherapy treatments are CHOP [intravenous cyclophosphamide (750 mg/m2, day 1), intravenous doxorubicin (50 mg/m2, day 1), intravenous vincristine (1.4 mg/m2, day 1) and prednisone (100 mg, days 1–50)]-like regimens. The patient was administered two cycles of CHOP chemotherapy for 56 days, however, ultimately succumbed as a result of disease progression. Therefore, PBL represents a diagnostic and therapeutic challenge. PBL must be considered in the differential diagnosis of gastrointestinal tumors in daily practice, even in immunocompetent patients. Furthermore, CHOP does not appear to be an optimal treatment regimen and more intensive regimens are required.