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*Corresponding author: E-mail: lyntumwine@gmail.com;
International Journal of Medical and Pharmaceutical
Case Reports
2(5): 110-116, 2015
EBV-Positive Grey Zone Lymphoma in an HIVInfected Man from Kampala, Uganda: Case Report
;
Article no.IJMPCR.2015.022
SCIENCEDOMAIN international
www. sciencedomain.org
L. K. Tumwine1,2*, J. Orem3
and L. W. Ayers2,4
1
Department of Pathology, School of Biomedical Sciences, College of Health Sciences, Makerere
University, P.O.Box 7072, Kampala, Uganda.
2Sub-Saharan Africa Lymphoma Consortium (NCI/SSALC), USA.
3Uganda Cancer Institute, P.O.Box 3955, Kampala, Uganda.
4Department of Pathology, Ohio State University Wexner Medical Center, 2001 Polaris Parkway,
Columbus, OH, USA.
Authors’ contributions
This work was carried out in collaboration with all authors. Author LKT provided the case and wrote
the draft manuscript. Author JO provided the detailed patient case notes and managed the literature
searches and author LWA designed the figures, managed the literature searches and contributed to
correction of the draft. All authors read and approved the final version of the manuscript.
Article Information
DOI: 10.9734/IJMPCR/2015/13625
Editor(s):
(1) Syed A. A. Rizvi, Department of Pharmaceutical Sciences, College of Pharmacy, Nova Southeastern University, USA.
Reviewers:
(1) Anonymous, University of Texas MD Anderson, USA.
(2)
Pranab Kumar Bhattacharya, Department of Pathology, School of Tropical Medicine ,Kolkata, 108 CR Avenue Kolkata-700073 West Bengal, India.
Complete Peer review History: http://www.sciencedomain.org/review-history.php?iid=786&id=38&aid=6950
Received 26th August 2014
Accepted 7th October 2014
Published 15th November 2014
ABSTRACT
Aim: We describe the clinical, histopathological and immunophenotypic characteristics of an HIVinfected
adult man on antiretroviral therapy who presented with an EBV-positive grey zone
lymphoma.
Case Presentation: A 56-year-old HIV infected man from Uganda presented with a four month
history of progressive abdominal swelling and B-symptoms. He was on highly active antiretroviral
therapy (HAART) and cotrimoxazole. He was afebrile (36.9°C), severely wasted (BMI 14.8), and
mildly anaemic. On physical examination, he had a 15 by 8 cm mass in the hypogastrium and
umbilical region.
The total white cell count was 8.3X103
/µL; neutrophils, 5.72X103
/µL; haemoglobin 11.1g/dL, platelets 528X103
/µL, LDH 197 IU/L and CD4 367/µL. Abdominal ultrasound and CT scan showed
a tumour involving the mesentery, jejunum and mid ileum. At laparotomy, a biopsy was taken,
fixed, processed and stained with Haematoxylin & Eosin (H & E). Histopathology demonstrated
large pleomorphic cells admixed with inflammatory smaller cells, Reed-Sternberg-like cell variants
and frequent abnormal mitoses. Biomarkers CD20, PAX5, CD30 were positive but ALK negative
(immunohistochemistry and strong EBER positivity in situ hybridization. The patient improved on
modified CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisolone) therapy.
Discussion: The tumour had features intermediate between mediastinal large B cell lymphoma
and classical Hodgkin lymphoma.
Conclusion: We present a case of EBV-positive grey zone lymphoma in an HIV-infected man on
HAART therapy diagnosed and treated in a resource constrained medical setting. The histological
features are unusual and represent a low incidence lymphoma that is recognized by mixed
features reminiscent of Hodgkin’s lymphoma and mediastinal large B-cell lymphoma.
Keywords: HIV/AIDS; EBV; grey zone lymphoma; Uganda.
1
. INTRODUCTION
In most low income countries of Africa, especially
sub Saharan Africa, lymphomas are diagnosed
using morphology alone
[1]. The diagnosis of
lymphoma in developed countries is currently
based on morphology, the patient’s clinical data,
immmunophenotype and molecular studies.
The 2008 WHO classification recognizes a group
of lymphomas that do not fit in any of the clearly
defined categories: “the grey zone lymphomas”
[2]. These present a diagnostic dilemma due to
the presence of overlapping clinical,
morphologic, immunophenotypic and molecular
features of two well defined groups
[2,3].
Most common of the grey zone lymphomas are
the “B cell lymphoma unclassifiable between
diffuse large B cell lymphomas (DLBCL) and
classical Hodgkin lymphoma (cHL)”. They are
mainly mediastinal although several recent
studies have shown that they may present in
extramediastinal locations as well. These tumors
are usually clinically aggressive
[4-6].
Primary mediastinal B-cell lymphomas (PMBL)
display morphologic and immunophenotypic
features similar to those of classic Hodgkin
lymphoma (cHL). For this reason they are called
“mediastinal grey zone lymphoma” or “large B
cell lymphoma with Hodgkin features” [4,7,8].
Accurate diagnosis and characterization of these
tumors is essential to enable specific treatment
and prognosis
[9]. EBV positive grey zone
lymphomas in HIV infected patients have been
rarely reported
[10]. Grey zone lymphomas
display features similar to primary mediastinal B
cell lymphoma and classic Hodgkin lymphoma
[2]. In particular, there is a diffuse pattern of
large round, oval or polygonal cells, with bizarre
pleomorphic nuclei: some resembling Hodgkin
and/or Reed-Sternberg cells and tumor cells of
anaplastic large cell lymphoma (ALCL)
[11].
Most large B cell lymphomas presenting in
immunocompromised patients are EBV positive.
EBV is thought to contribute to lymphomagenesis
through promotion of B cell proliferation. On the
other hand, the contribution of HIV to
lymphomagenesis is complex but it is thought to
be through immunodeficiency and molecular
lesions
[12]. Co-infection with oncogenic viruses
such as HHV8 and Epstein-Barr virus (EBV)
might also contribute [13]. A distinct category of
DLBCL that occurs in the elderly patients, that is
‘EBV-positive diffuse large B cell lymphoma of
the elderly’ has also been rarely identified
[14].
We report a case of EBV-positive grey zone
lymphoma in an HIV infected adult male from
Kampala, Uganda.
2.
CASE PRESENTATION
A 56-year-old HIV infected African man from
Kampala, Uganda presented to our hospital with
a four months history of progressive abdominal
distension, drenching night sweats, evening
fevers, poor appetite and weight loss. He did not
vomit; have constipation, abdominal pain or
diarrhoea. He had been receiving highly active
antiretroviral therapy (HAART) and cotrimoxazole
prophylaxis for Pneumocystis
jiroveci.
This was his second admission to hospital. He
had been hospitalised for the same condition a
month earlier, before being referred for further
management. During the previous admission in a Tumwine et al.; IJMPCR, 2(5): 110-116, 2015; Article no.IJMPCR.2015.022
112
secondary health care setting, an exploratory
laparotomy was done and the colon was found
nested together forming a mass anterior to the
aorta. The abdomen was closed and the mass
left intact. He was then referred to our hospital.
He was married with two children. He was a
retired soldier and a peasant farmer. There was
no history of diabetes, hypertension or sickle cell
disease in the family. He did not take alcohol
neither smoke tobacco nor cigarettes.
On examination, he was a middle aged man, with
an axillary temperature of 36.9°C. He was
severely wasted (weight: 46kgs, height 176.5
cms and BMI of 14.8) had mild anaemia and no
jaundice. He had lipodystrophy of the face and
dark patches on his finger nails.
He had a midline sub umbilical surgical scar on
his abdominal wall with a tender pulsatile mass in
the hypogastrium and umbilical region extending
4 cms to the epigastrium. It measured 15 cms by
8 cms, the overlying skin was irregular and
attached to the base. There was no bruit,
however, and the bowel sounds were increased.
Rectal examination was normal. The respiratory,
cardiovascular, musculoskeletal and the central
nervous systems were essentially normal.
Results of laboratory tests included: total white
cell count (WBC) of 8.3X103
/µL. Neutrophils,
5.72X103
/µL. Haemoglobin 11.1g/dL and platelet
count 528X103
/µL. Liver and renal function tests
were normal. Lactate dehydrogenase was 197
IU/L. The chest X-ray and echocardiography
(ECHO) were normal, but the electrocardiogram
(ECG) revealed sinus bradycardia. The nadir
CD4 T cell count was 0.26/µL five years prior to
admission in our hospital when he was started on
HAART. On admission, he had last had his CD4
T cell count done two years prior and it was 351/
µL. At admission, the CD4 T cell count was
367/µL.
Ultrasound examination of the abdomen
confirmed the presence of a mass and at CT
scan, there was a midline intra-abdominal mass
lesion that arose from above the aortic
bifurcation and slightly below the origin of the
inferior mesenteric artery and extended to the
pelvic cavity. It was anterior to the aorta and did
not involve it as well as the lower portion of the
superior mesenteric artery. It involved the
mesentery. It was heavily vascularised. These
features were suggestive of a neoplastic
mesenteric tumour with small bowel involvement.
A laparotomy revealed a mesenteric tumour
involving the mesentery at the level of the mid
ileum.
Cytopathological examination done during the
operation was suggestive of lymphoma. A biopsy
was taken for further histopathological work up.
Histopathology of prepared tissues stained by (H
& E) revealed a population of very large
pleomorphic cells suggestive of Reed-Sternberg
cells and admixed with smaller inflammatory
cells. These Reed-Sternberg like variants, with
abnormal mitoses. A provisional diagnosis of
anaplastic large cell lymphoma was made.
Immunohistochemistry was carried out at the
Department of Pathology, Ohio State University,
Columbus, Ohio revealed that the large
pleomorphic cells were CD20+, PAX5+ and
CD30+ but ALK negative. The tumor cells were
large or medium and were strongly EBER+. The
small background cells were CD3 positive. All
these features were suggestive of an EBV
positive large B cell lymphoma, with Hodgkin
features.
The patient was initially rehydrated with normal
saline and 5% dextrose. He later received
allopurinol and the first course of chemotherapy
after stabilisation. This included modified CHOP:
cyclophosphamide 750 mg/m2
, Doxorubicin
50mg/m2 and Vincristine 1.4 mg/m2 on day one
and prednisolone 100 mg on days one to five,
repeated every 21 days. He registered
satisfactory progress, and is alive and well.
3.
DISCUSSION
This patient’s tumor had clinical,
histopathological features and immunophenotype
intermediate between mediastinal large B cell
lymphoma and classical Hodgkin lymphoma. It
was located in the mesentery at the level of the
mid ileum.
Histomorphologically, there was a diffuse pattern
of very large pleomorphic and anaplastic cells
admixed with smaller mature lymphocytes, ReedSternberg-like
variants, with plenty of abnormal
mitoses and an inflammatory cell background.
These features are similar to those of mediastinal
large B cell lymphoma which presents with
features of medium sized to large cells with
abundant pale cytoplasm and more or less round
or ovoid nuclei. In some cases, lymphoma cells
had pleomorphic and/or multilobated nuclei
which resembled Reed-Sternberg cells hence Tumwine et al.; IJMPCR, 2(5): 110-116, 2015; Article no.IJMPCR.2015.022
113
raising the suspicion of Hodgkin lymphoma or
Anaplastic large cell lymphoma (see Fig. 1) [15].
The majority of the tumors reported in the
literature are located in the mediastinum,
however there are a few that are
extramediastinal like in our patient who had a
mesenteric tumor [4,5].
Immunohistochemically, the tumor expressed
mature B-cell markers; positive for CD20,
CD79a, PAX-5 (see Fig. 1). This is similar to the
immunophenotype of mediastinal large B cell
lymphoma with expression of B-cell antigens
and lack of surface Immunoglobulins [16].
CD30 was expressed especially by the Hodgkinlike,
Reed-Sternberg cells. This has been seen
in similar cases where the expression of CD30 is
heterogeneous with weak to strong intensity [5].
These features are similar to those of classical
Hodgkin lymphoma.
CD15 and CD10 were weakly expressed, but
ALK was negative. Activated B-cell markers like
MUM-1 were strongly expressed as well, and
EBER was strongly positive. EBV is usually
associated with classic Hodgkin lymphoma (cHL)
but not primary mediastinal large B cell
lymphoma (PMBL). However, most AIDS related
lymphomas are strongly associated with EBV.
The presence of EBV and Hodgkin-like cells also
raised the possibility of an EBV positive large B
cell lymphoma in the elderly. Most of the reported
gray zone lymphomas are not EBV positive
[17].
Fig. 1. At light microscopy, under Haematoxylin and Eosin staining (H&E) a population of very
large bi-nucleated and multinucleated cells admixed with smaller cells, Reed-Sternberg- like
variants and plenty of abnormal mitoses which turned out to be CD20+, CD79a+, CD30+, MUM-
1 positive, CD15-, CD10-, EBER+, Ki-67>80%, ALK- and P53+. Based on these findings we
made a diagnosis of grey zone lymphoma Tumwine et al.; IJMPCR, 2(5): 110-116, 2015; Article no.IJMPCR.2015.022
114
In the current literature, there is only one report
of an EBV positive gray zone lymphoma in an
elderly female who was not HIV infected[8].
Although our patient was above 50 years, the
diagnosis of EBV positive large B cell lymphoma
in the elderly was excluded because there was a
known cause of immunodeficiency which was
HIV/AIDS infection. EBV+ DLBCL in the elderly
has been described in patients who are more
than 50 years of age with no known cause of
immunodeficiency. Bhattacharya has also
described cases of Hodgkin lymphoma in
patients on combined antiretroviral therapy
(cART), and an increased prevalence of Hodgkin
lymphoma in the cART era as compared the precART
era. This prevalence increased with CD T
cell count
[18]. However, in our patient the
clinical, morphological and immunophenotype
was not specific to any of the distinct groups,
classic Hodgkin lymphoma and mediastinal large
B cell lymphoma, hence the diagnosis of gray
zone lymphoma. Our patient’s immunophenotype
was (strong B-cell immunophenotype CD20+,
CD79a+, PAX-5, CD30+, CD15+/-, CD10+/-,
ALK- and EBER+) which does not fit in the
description for Nodular sclerosis Classic
Hodgkin lymphoma with weak B-cell antigen
expression (CD20- is weakly or variably
expressed and PAX-5 and CD79a are weak or
negative, CD30+, CD15+, CD10-, ALK- and
EBER+) and primary mediastinal B cell
lymphoma (CD20-, CD15+….
The most recent 2008 WHO classification
recognizes a group of lymphomas that do not fit
in any of the clearly defined categories: “the grey
zone lymphomas” which present a diagnostic
dilemma because of the presence of overlapping
clinical, morphologic, immunophenotypic and
molecular features of two well defined groups
[2,19]. This classification gives the
histopathologist ‘the opportunity, to assign these
lymphomas to a designated group’ that has
features of large B cell lymphomas and Hodgkin
disease.
Our patient was treated with the regimen for
aggressive B-cell non Hodgkin lymphoma and
highly active antiretroviral therapy (HAART). He
did very well on this treatment and completed all
the six cycles of therapy. This is in line with what
most recent studies have recommended that
these tumors are treated using therapy for
aggressive B-cell non Hodgkin lymphomas.
Clinical trials have not been realized due to the
rarity of this type of tumor and the lack of uniform
diagnostic criteria for the Mediastinal grey zone
lymphomas. The recommended treatment for
grey zone lymphomas is CHOP-like regimens
[20,21]. The patient described in this report
hence presents with features suggestive of grey
zone lymphoma in an HIV positive patient. It
remains to be seen whether such patients should
be classified solely as grey zone lymphomas or
whether they should be assigned to their own
category.
4.
CONCLUSION
This was a case of HIV/AIDS-related EBVpositive
grey zone lymphoma in an adult male
from Kampala, Uganda. It was a malignant
lymphoma with histological features and
immunophenotype intermediate between
mediastinal large B cell lymphoma and classical
Hodgkin lymphoma. Use of
immunohistochemistry in the classification of
NHL is vital, without which the specific subtypes
are very difficult to classify.
CONSENT
All authors declare that written informed consent
was obtained from the patient for publication of
this case report and its accompanying images.
ETHICAL ISSUES
This case study was part of a larger study of the
Mid- Region Aids and Cancer Specimen
Resource and Sub Saharan Lymphoma
Consortium (SSALC) Uganda study NIH Grant
number U01 CA 06652. Ethical approval was
sought from the Institutional Review Board
protocol number REC REF 2009-093.
Further written informed consent was obtained
from the patient for publication of this case report
and any accompanying images. A copy of the
written consent is available for review by the
Editor-in-Chief of this journal.
COMPETING INTERESTS
Authors have declared that no competing
interests exist.
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