—  SPECIALTY CONFERENCE  —

Pulmonary Pathology

Case 5 - Sarcoidosis in Association with HAART Therapy in an HIV-Infected Patient

Andrew Nicholson
Royal Brompton Hospital and Imperial College School of Medicine
London, UK





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Clinical History
HRCT shows multiple odd shaped nodules of soft tissue density, many containing air bronchograms. The CT differential includes neoplastic disease, in particular multicentric adenocarcinoma and lymphoproliferative disease. There are no CT features to narrow the wide differential.

TBBx negative, BAL negative – proceeded to surgical lung biopsy. Two firm nodules were sampled from the periphery of the lung.


Case 5 - Slide 1
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Case 5 - Figure 1
Standard section from a CT (lower lobes) shows nodules of varying size and shape, the larger of these containing an air bronchogram.
Case 5 - Figure 2
Standard section from a CT (upper lobes) shows multiple nodules of varying size and shape. The dominant lesion in the periphery has a ground-glass halo.
Case 5 - Figure 3
Areas of consolidation comprise discrete and coalescent non-necrotising granulomas filling alveoli and the interstitium.

Case 5 - Figure 4
Langhans-type giant cells are seen within areas of granulomatous inflammation.
Case 5 - Figure 5
Granulomas are seen in close apposition to a pulmonary vessel.

References

  1. Almeida FA et al. Coexistent sarcoidosis and HIV infection: an immunological paradox? J Infect. 2006 Mar;52(3):195-201.

  2. Amin DN, Sperber K, Brown LK, Chusid ED, Teirstein AS. Positive Kveim test in patients with coexisting sarcoidosis and human immunodeficiency virus infection. Chest 1992; 101:145-46.

  3. Baumer I, Zissel G, Schlaak M, Muller-Quernheim J. Th1/Th2 cell distribution in pulmonary sarcoidosis. Am J Respir Cell Mol Biol 1997; 16:171-7.

  4. Busi Rizzi E et al. Radiological patterns in HIV-associated pulmonary tuberculosis: comparison between HAART-treated and non-HAART-treated patients. Clin Radiol. 2003;58:469-73.

  5. Bonnet F et al. Malignancy-related causes of death in human immunodeficiency virus-infected patients in the era of highly active antiretroviral therapy. Cancer. 2004 Jul 15;101(2):317-24

  6. Cadranel J et al. Lung cancer in HIV infected patients: facts, questions and challenges. Thorax. 2006 Nov;61(11):1000-8

  7. Calabrese LH et al. Semin Arthritis Rheum. 2005 Dec;35:166-74.

  8. Conron M, Du Bois RM. Immunological mechanisms in sarcoidosis. Clin Exp Allergy 2001; 31:543-54.

  9. Coots LE, Lazarus AA. Sarcoidosis diagnosed in a patient with known HIV infection. Chest 1989; 96:201-2.

  10. Foulon G et al. Sarcoidosis in HIV-infected patients in the era of HAART.

  11. Clin. Infect. Dis. 2004;38:418-425

  12. Haramati LB, Lee G, Singh A, Molina PL, White CS. Newly diagnosed pulmonary sarcoidosis in HIV-infected patients. Radiology 2001; 218:24-26.

  13. Gowda KS , Mayers I, Shafran SD. Concomitant sarcoidosis and HIV infection. CMAJ 1990; 142:136-7.

  14. Kalter S, Lopez-Berestein G. Acquired immune deficiency syndrome in a patient with prior sarcoidosis: case report with monocyte function studies. Tex Med 1985 Sep;81(9):44-6.

  15. Lasalle S et al. Sarcoid-like lesions associated with the immune restoration inflammatory syndrome in AIDS: absence of polymerase chain reaction detection of Mycobacterium tuberculosis in granulomas isolated by laser capture microdissection. Virchows Archive 2006;449:689-96

  16. Ledergerber B, Egger M, Erard V, et al. AIDS-related opportunistic illnesses occurring after initiation of potent antiretroviral therapy: the Swiss HIV Cohort Study. JAMA 1999; 282:2220-6.

  17. Lenner R, Bregman Z, Teirstein AS, DePalo L. Recurrent pulmonary sarcoidosis in HIV-infected patients receiving highly active antiretroviral therapy. Chest 2001; 119:978-81

  18. Lowery WS, Whitlock WL, Dietrich RA, Fine JM. Sarcoidosis complicated by HIV infection: three case reports and a review of the literature. Am Rev Respir Dis 1990; 142:887-9.

  19. Maggi E, Mazzetti M, Ravina A, et al. Ability of HIV to promote a TH1 to TH0 shift and to replicate preferentially in TH2 and TH0 cells. Science 1994; 265:244-8.

  20. Morris DG, Jasmer RM, Huang L, Gotway MB, Nishimura S, King TE Jr. Sarcoidosis following HIV infection: evidence for CD4(+) lymphocyte dependence. Chest 2003; 124:929-35

  21. Newman TG, Minkowitz S, Hanna A, Sikand R, Fuleihan F. Coexistent sarcoidosis and HIV infection: a comparison of bronchoalveolar and peripheral blood lymphocytes. Chest 1992; 102:1899-901.

  22. Newman LS, Rose CS, Maier LA. Sarcoidosis. N Engl J Med 1997; 336:1224-34

  23. Palella FJ Jr, Delaney KM, Moorman AC, et al. Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection. HIV Outpatient Study Investigators. N Engl J Med 1998; 338:853-60.

  24. Park WB et al. Immune reconstitution inflammatory syndrome in the first year after HAART: influence on long-term clinical outcome. AIDS. 2006 Nov 28;20:2390-2.

  25. Sanchez JM et al. Impact of highly active antiretroviral therapy on the morbidity and mortality in Spanish human immunodeficiency virus-infected children. Pediatr Infect Dis J. 2003;22:863-7.

  26. Shelburne SA III et al. Immune reconstitution inflammatory syndrome: emergence of a unique syndrome during highly active antiretroviral therapy. Medicine (Baltimore) 2002; 81:21327.

  27. Wanke CA , Epidemiological and clinical aspects of the metabolic complications of HIV infection the fat redistribution syndrome, AIDS 13 1999;13: 1287-1293

  28. Whitlock WL, Lowery WS, Dietrich RA. Bronchoalveolar lavage in sarcoidosis and HIV infection. Chest 1990; 98:517. 7.