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Burkitt lymphoma presenting as cardiac tamponade in a patient infected with HIV: a case report.

Introduction

Febrile illness has a broad differential diagnosis, particularly among persons infected with human immunodeficiency virus (HIV). Infectious complications of immunodeficiency must always be high on this differential, but clinicians must also consider HIV-associated malignancies as an explanation for fever in this population [1,2]. We present the case of a 48-year-old man infected with HIV thought to have osteomyelitis who was subsequently diagnosed with Burkitt lymphoma presenting as cardiac tamponade.

Case history

The patient was a 48-year-old man who was diagnosed with HIV in 2000 and was on highly active antiretroviral therapy with an undetectable plasma viral load and CD4 cell count at admission of 400 cells/[mm.sup.3]. He had a long history of polysubstance abuse, with complications related to intravenous use of heroin and cocaine, including remote endocarditis, right hip osteomyelitis, and hepatitis C. His past medical history included a history of chronic obstructive pulmonary disease, depression, cellulitis, and gastroesophageal reflux disease. The patient also had a 30 pack-year smoking history.

[FIGURE 1 OMITTED]

The patient was admitted to St. Paul's Hospital in Vancouver, British Columbia, in July 2009 with a 1-month history of fever, night sweats, fatigue and weight loss of 4.5 kg. His only localizing sign was hip pain in the distribution of his past right hip osteomyelitis (treated in 1996). At presentation, he had a temperature of 36.8[degrees]C, blood pressure of 118/75 mmHg, a respiratory rate of 18 breaths/min, and a heart rate of 111 beats/min. A cardiovascular examination revealed audible first and second heart sounds with no additional sounds or murmurs. His respiratory examination was unremarkable.

At presentation his complete blood count revealed a hemoglobin of 148 g/L, a white blood cell count of 7.4 x [10.sup.9] cells/L, with 5.0 x [10.sup.9] cells/L neutrophils, 4 x [10.sup.9] cells/L lymphocytes and platelet count of 233 x [10.sup.9] cells/L. Blood cultures performed on multiple occasions after admission were persistently negative. Computed tomography scan of the right hip demonstrated bony changes consistent with past or current osteomyelitis, and a radiology-guided hip biopsy revealed necrotic tissue but without any neutrophils. In the absence of any other localizing signs, the presentation was felt to be consistent with recurrent hip osteomyelitis, and the patient was initiated on empiric broad-spectrum antibiotic therapy with intravenous vancomycin and ceftriaxone. Throughout the 18-day course of antibiotic therapy, the patient was documented to have recurrent fevers, which resulted in a change and then cessation of his antibiotic regimen. The persistence of fever despite antibiotic therapy raised obvious concern of an alternative diagnosis.

After 24 days of admission, the patient experienced an acute episode of tachycardia and subsequent hypotension, and demonstrated pulsus paradoxus of 12 mmHg on physical examination. Echocardiography demonstrated a moderate pericardial effusion, unusual epicardial deposits consistent with tumor or thrombus overlying much of the right ventricle and right atrium, and diastolic collapse of the right ventricle consistent with cardiac tamponade (Fig. 1).

Clinical evidence and diagnosis

A pericardiocentesis and subsequent catheter drainage of the pericardium were performed with prompt improvement in symptoms and hemodynamics. Fluid analysis showed increased white blood cells and atypical large cells consistent with high-grade B-cell lymphoma. Flow cytometry of the pericardial fluid showed CD20 positive, CD10 negative, kappa clonal B mature B cell lymphoma. This was felt to be in keeping with Burkitt lymphoma, which was subsequently treated with chemotherapy.

Discussion

Burkitt lymphoma accounts for 30-40% of non-Hodgkin type lymphomas in patients who are HIV positive [3-5]. It often presents as extra-nodal disease, with the abdomen and pelvis frequently involved [4].

One previous report found pericardial effusion to be the presenting symptom of malignant lymphomas in 6 patients (some of whom were HIV positive) that presented over the course of 8 years [6]; none of these were cases of Burkitt lymphoma. Another report [7] described cardiac effusion as the first sign of a T-cell lymphoma. Two cases describe Burkitt lymphoma presenting as a pericardial effusion: one in an adult in remission from a large diffuse B-cell lymphoma [8] and another in a child [9], both of whom were immunocompetent. It appears rare to have Burkitt lymphoma present as cardiac tamponade in a patient infected with HIV.

In retrospect, the lack of inflammatory process on the bone biopsy was suggestive that acute osteomyelitis was an incorrect diagnosis. However, the lack of neutrophils in this specimen was believed to be due to inadequate sampling of the actively infected area rather than a result ruling out the diagnosis of osteomyelitis, and it is noteworthy that the consultant radiologist felt that repeat biopsy was inappropriate when no organisms were grown from the first biopsy specimen.

Teaching point

This case highlights the importance of maintaining a broad differential diagnosis in febrile patients infected with HIV with a presumed infectious process but who do not respond to an initial course of antibiotic therapy.

DOI: 10.1102/1470-5206.2011.0008

References

[1.] Myskowski PL, Straus DJ, Safai B. Lymphoma and other HIV-associated malignancies. J Am Acad Dermatol 1990; 22: 1253-60. doi:10.1016/0190-9622(90)70171-D. PMid:2193954.

[2.] Lyter DW, Bryant J, Thackeray R, Rinaldo CR, Kingsley LA. Incidence of human immunodeficiency virus-related and nonrelated malignancies in a large cohort of homosexual men. J Clin Oncol 1995; 13: 2540-6. PMid:7595705.

[3.] Blum KA, Lozanski G, Byrd JC. Adult Burkitt leukemia and lymphoma. Blood 2004; 104: 3009-20. doi:10.1182/blood-2004-02-0405. PMid:15265787.

[4.] Kasamon YL, Swinnen LJ. Treatment advances in adult Burkitt lymphoma and leukemia. Curr Opin Oncol 2004; 16: 429-35. doi:10.1097/00001622-200409000-00003. PMid:15314510.

[5.] Knowles DM. Etiology and pathogenesis of AIDS-related non-Hodgkin's lymphoma. Hematol/ Oncol Clin North Am 2003; 17: 785-820. doi:10.1016/S0889-8588(03)00050-9.

[6.] Gill PS, Chandraratna PA, Meyer PR, Levine AM. Malignant lymphoma: cardiac involvement at initial presentation. J Clin Oncol 1987; 5: 216-24. PMid:3543244.

[7.] Prvulovich EM, Costa DC, Bomanji J, et al. Gallium-67 imaging of pericardial lymphoma in AIDS. J Nucl Med 1996; 37: 995-6. PMid:8683331.

[8.] Kaul P, Javangula K. Burkitt Lymphoma masquerading as cardiac tamponade. J Cardiothor Surg 2007; 2: 30. doi:10.1186/1749-8090-2-30.

[9.] Graham SJ, Duval AB, Mercado TC, Trepel JB, Cotelingam JD. Burkitt's lymphoma: a pericardial presentation. Cytopathology 1990; 4: 239-42.

Goldis Chami (a), Samantha MacLean (a), Evan Wood (a), Mark W. Hull (b) and Christopher R. Thompson (c)

(a) Urban Health Research Initiative, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada; (b) Division of Infectious Diseases, Department of Medicine, University of British Columbia, Vancouver, BC, Canada; (c) Division of Cardiology, Department of Medicine, St. Paul's Hospital and the University of British Columbia, Vancouver, BC, Canada

Corresponding address: Evan Wood, MD, PhD, Urban Health Research Initiative, British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada.

Email: uhri-ew@cfenet.ubc.ca

Date accepted for publication 17 February 2011

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Author:Chami, Goldis; MacLean, Samantha; Wood, Evan; Hull, Mark W.; Thompson, Christopher R.
Publication:Grand Rounds
Article Type:Author abstract
Date:Jan 1, 2011
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