Spontaneous Regression of Epstein-Barr Virus-Positive Diffuse Large B-cell Lymphoma in an HIV-Positive Patient: A Case Report and Literature Review

Abstract

Individuals infected with human immunodeficiency virus (HIV) have a greater risk of developing malignancies, including both acquired immunodeficiency syndrome (AIDS)-defining malignancies as well as many non-AIDS-defining cancers. Several factors contribute to the increased incidence of malignancies in this population such as the direct effects of HIV itself, immune deficiency, co-infection with oncogenic viruses, environmental factors, and the effects of combination antiretroviral therapy (cART). The improvement of the immune response following the introduction of cART results in a better response to conventional therapies for malignancies, including chemotherapy, radiotherapy, and surgery. Significant disparities still exist in cancer treatment for people living with HIV and afflicted with cancers compared to those without HIV, with many in the former group not receiving any cancer treatment at all. We report a rare case whereby a newly diagnosed HIV-infected patient with Epstein-Barr virus-positive diffuse large B-cell lymphoma showed spontaneous regression of the lymphoma with the introduction of cART alone without any treatment of the cancer itself. We reviewed similar cases described in the literature and examined the possible explanations for this phenomenon.

Case Details

Disease Location

Brain, colon

Personal Characteristics

32-year-old chinese gentleman.

Clinical Characteristics

Presented with prolonged non-productive cough, shortness of breath, weight loss of 3 kg, and generalized body weakness of one-month duration. HIV testing was positive with a CD4 count of 2 cells/mm3 and an HIV viral load of 148 copies/ml. He was treated for oral candidiasis, late latent syphilis, and pneumocystis jiroveci pneumonia (pjp). Two weeks later, the patient developed bilateral lower limb weakness suspicious of spinal cord pathology. MRI of the thoracolumbar spine showed a small l2 focal intradural extramedullary lesion. Cerebrospinal fluid (csf) examination demonstrated a high cytomegalovirus (cmv) viral load of 1,684 iu/ml with positive fungal culture for sporothrix. A colonoscopy showed multiple aphthous ulcers with areas of raw bleeding from the left colon. Biopsies were taken from the mentioned lesions in the left colon while samples from the right colon were biopsied randomly and sent for histopathological examination. Intravenous amphotericin b deoxycholate and ganciclovir were initiated. His condition gradually improved and he was started on tenofovir disoproxil fumarate, emtricitabine, and efavirenz. (cart) the histopathological examination of the biopsy samples taken from the left colon showed features of high- grade b-cell lymphoma. It was concluded that the patient had ebv-positive dlbcl. CT staging demonstrated a few tiny mesorectal lymph nodes, subcentimeter para-aortic and aortocaval nodes, subcentimeter left supraclavicular nodes, and multiple lung nodules of varying sizes, with the largest measuring 5 mm. CT scan, brain biopsy, or bone marrow biopsy were done as our patient was planned for palliative care.

Remission Characteristics

During subsequent clinic visits, our patient had no gastrointestinal symptoms, b symptoms, and no new lymph nodes. CT of the brain showed resolution of the brain lesions. A colonoscopy reassessment was performed approximately a year after the initial diagnosis of his lymphoma. No luminal mass or ulcers were found on examination and the intestinal mucosa appeared healthy with no evidence of bleeding or inflammation. Biopsies were obtained from both the right and left colon, and the histopathological examination reported no evidence of malignancy.

Treatment & Mechanisms

Proposed Remission Mechanisms

Most likely due to the immune reconstitution effects of cart

Clinical Treatment

Biopsy amphotericin b tenofovir disoproxil fumarate, emtricitabine, and efavirenz.

Non-Clinical Treatment

None reported