Two Patients With a Similar Non-AIDS-Defining Malignancy
The evaluation of patients who have AIDS who present with neurologic deficits and have abnormal brain scans occasionally leads to a nonAIDS-related diagnosis. Two cases of metastatic lung cancer are described here, and a discussion of lung cancer and HIV infection follows.
Hilda was a 55-year-old Hispanic woman with advanced AIDS when she presented in April 2003, noting 1 week of word-finding difficulty. She was well known to the clinic for her multiple psychiatric admissions, her substance abuse, and her nonadherence to medications. Hilda's HIV infection was diagnosed in 1995, and she had a long history of bipolar disease and schizoaffective disorder. Her medical history included mild type 2 diabetes, syphilis, and chronic low back pain with mild degenerative joint disease evident on MRI. She was a heavy smoker and frequently used benzodiazepines or painkillers that she bought on the street. She had recurrent oral candidiasis that responded to fluconazole. At this presentation, she was again admitted to the hospital.
When Hilda first presented in 2000, her CD4 cell count was 42/µL. She did not want to take antiretroviral drugs and took prophylactic medication for Pneumocystis carinii pneumonia only sporadically. In late 2001, she was on an efavirenz-based regimen for 2 months but discontinued it because of abdominal pain. During that brief time while she was receiving medication, Hilda's viral load had become undetectable and her CD4 cell count had risen to 97/µL. Following a psychiatric admission in March 2002, she was switched to a lopinavir-based regimen but took this medication only occasionally.
At the time of the present admission for word-finding difficulty 1 year later, her CD4 cell count was 13/µL and her viral load was 121,000 copies/mL. Examination revealed disorientation to time, some difficulty in naming random objects, and a diastolic murmur. A CT scan of the head demonstrated 3 ring-enhancing lesions. Her serum Toxoplasma IgG titer was negative. A chest radiographic examination was negative. Echocardiographic examination revealed aortic valve calcification and severe aortic regurgitation. Single-photon emission CT images with thallium revealed 2 foci of increased activity in the left parieto-occipital region consistent with a malignant process.
A consultant from radiation oncology requested that a lumbar puncture and brain biopsy be performed before treating empirically for CNS lymphoma. Despite Hilda's extensive psychiatric history, it was believed that she had the capacity to refuse these procedures, which she did. During her hospital stay, her word-finding difficulty became more pronounced and her mood more depressed. The addition of corticosteroids to her regimen yielded clinical improvement.
Advanced directives were discussed with Hilda; she requested that no resuscitation or intubation be performed should the need arise. A do-not-resuscitate order was placed in her chart. Hilda's major pleasure in the hospital was being allowed to go outdoors to smoke cigarettes. Preparations were begun for transfer to either a skilled nursing or a hospice facility. Before they could be completed, Hilda's condition began to destabilize, with progressively worsening renal function and development of bilateral pneumonia. Despite antibiotics and fluids, Hilda's condition deteriorated, and she died 7 weeks after admission.
An autopsy revealed a 1.8-cm poorly differentiated adenocarcinoma in the right upper lobe, associated with scarring and necrosis. Two metastatic lesions were found in the brain; these lesions were pathologically identical to the lung lesion. A right parietal hemorrhagic lesion was also noted. Enterococcus faecalis grew from the lung tissue as well.
The evaluation of patients who have AIDS who present with neurologic deficits and have abnormal brain scans occasionally leads to a nonAIDS-related diagnosis. Two cases of metastatic lung cancer are described here, and a discussion of lung cancer and HIV infection follows.
Hilda was a 55-year-old Hispanic woman with advanced AIDS when she presented in April 2003, noting 1 week of word-finding difficulty. She was well known to the clinic for her multiple psychiatric admissions, her substance abuse, and her nonadherence to medications. Hilda's HIV infection was diagnosed in 1995, and she had a long history of bipolar disease and schizoaffective disorder. Her medical history included mild type 2 diabetes, syphilis, and chronic low back pain with mild degenerative joint disease evident on MRI. She was a heavy smoker and frequently used benzodiazepines or painkillers that she bought on the street. She had recurrent oral candidiasis that responded to fluconazole. At this presentation, she was again admitted to the hospital.
When Hilda first presented in 2000, her CD4 cell count was 42/µL. She did not want to take antiretroviral drugs and took prophylactic medication for Pneumocystis carinii pneumonia only sporadically. In late 2001, she was on an efavirenz-based regimen for 2 months but discontinued it because of abdominal pain. During that brief time while she was receiving medication, Hilda's viral load had become undetectable and her CD4 cell count had risen to 97/µL. Following a psychiatric admission in March 2002, she was switched to a lopinavir-based regimen but took this medication only occasionally.
At the time of the present admission for word-finding difficulty 1 year later, her CD4 cell count was 13/µL and her viral load was 121,000 copies/mL. Examination revealed disorientation to time, some difficulty in naming random objects, and a diastolic murmur. A CT scan of the head demonstrated 3 ring-enhancing lesions. Her serum Toxoplasma IgG titer was negative. A chest radiographic examination was negative. Echocardiographic examination revealed aortic valve calcification and severe aortic regurgitation. Single-photon emission CT images with thallium revealed 2 foci of increased activity in the left parieto-occipital region consistent with a malignant process.
A consultant from radiation oncology requested that a lumbar puncture and brain biopsy be performed before treating empirically for CNS lymphoma. Despite Hilda's extensive psychiatric history, it was believed that she had the capacity to refuse these procedures, which she did. During her hospital stay, her word-finding difficulty became more pronounced and her mood more depressed. The addition of corticosteroids to her regimen yielded clinical improvement.
Advanced directives were discussed with Hilda; she requested that no resuscitation or intubation be performed should the need arise. A do-not-resuscitate order was placed in her chart. Hilda's major pleasure in the hospital was being allowed to go outdoors to smoke cigarettes. Preparations were begun for transfer to either a skilled nursing or a hospice facility. Before they could be completed, Hilda's condition began to destabilize, with progressively worsening renal function and development of bilateral pneumonia. Despite antibiotics and fluids, Hilda's condition deteriorated, and she died 7 weeks after admission.
An autopsy revealed a 1.8-cm poorly differentiated adenocarcinoma in the right upper lobe, associated with scarring and necrosis. Two metastatic lesions were found in the brain; these lesions were pathologically identical to the lung lesion. A right parietal hemorrhagic lesion was also noted. Enterococcus faecalis grew from the lung tissue as well.
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