A 44-year-old man with HIV infection is evaluated for persistent fevers, progressive generalized fatigue, poor appetite, and marked weight loss over the last 2 months. He has no chest pain or shortness of breath. He has been noncompliant with antiretroviral therapy, and his last CD4 count 6 months ago was 90/µL.
His temperature is 38.3 C (101 F), blood pressure is 91/53 mm Hg, pulse is 105/min, and respirations are 21/min. Examination shows a pale conjunctiva and dry mucous membranes.
Laboratory results are as follows:

A CT scan of the chest and abdomen reveals lucencies in the skeleton and bulky mediastinal and abdominal lymphadenopathy.
Bone marrow biopsy in this patient would most likely show which of the following?

Question

A 44-year-old man with HIV infection is evaluated for persistent fevers, progressive generalized fatigue, poor appetite, and marked weight loss over the last 2 months.  He has no chest pain or shortness of breath.  He has been noncompliant with antiretroviral therapy, and his last CD4 count 6 months ago was 90/µL.
His temperature is 38.3 C (101 F), blood pressure is 91/53 mm Hg, pulse is 105/min, and respirations are 21/min.  Examination shows a pale conjunctiva and dry mucous membranes.
Laboratory results are as follows:

A CT scan of the chest and abdomen reveals lucencies in the skeleton and bulky mediastinal and abdominal lymphadenopathy.
Bone marrow biopsy in this patient would most likely show which of the following?

Quizplus · Accepted Answer

With this patient's poorly controlled HIV status, marked body cavity lymphadenopathy, and bone lucency, the most likely underlying cause is non-Hodgkin lymphoma (NHL). Around 4% of HIV patients have lymphoma at the time of diagnosis with the same percentage developing lymphoma during their disease course. Factors that contribute to the incidence include direct effects of HIV, immunosuppressive state, co-infection with other oncogenic viruses (eg, Epstein-Barr), and environmental oncogenic stimuli. HAART prevents severe immunosuppression, which in turn helps to decrease the incidence of NHL. Patients with NHL tend to present with B symptoms (fever, weight loss, and night sweats), extranodal disease, and involvement of unusual locations (eg, body cavity, rectum, and soft tissue). Rarely, they may present with fever of unknown origin. Diffuse large-cell NHL and Burkitt lymphoma are the most common AIDS-related lymphomas. (Choice A) Chronic lymphocytic leukemia is not associated with HIV infection and the blood count differential shows predominantly mature-appearing lymphocytes. (Choice B) Fungal infections such as blastomycosis and histoplasmosis can involve bone. However, this patient's bulky lymphadenopathy is more suggestive of a lymphoma. (Choice C) Kaposi sarcoma usually presents with skin lesions (purplish, reddish blue, or dark brown/black) on the lower extremities, often associated with lymphedema. Lymph node involvement occurs infrequently. Kaposi sarcoma (Choice D) Although myeloma can cause bone lesions, it does not cause bulky lymphadenopathy and severe B symptoms. Educational objective: AIDS-related lymphomas are common in patients with advanced HIV, a low CD4 count (<100/µL), high HIV viral load, and a prior diagnosis of AIDS. Patients with non-Hodgkin lymphoma (NHL) tend to present with B symptoms, extranodal disease, and involvement of unusual locations. Diffuse large-cell NHL and Burkitt lymphoma are the most common AIDS-related lymphomas. __________ References: How I treat HIV-associated lymphoma. (http://www.ncbi.nlm.nih.gov/pubmed/22337719)

A 44-Year-Old Man with HIV Infection Is Evaluated for Persistent