Chlorambucil

INTRODUCTION: Lymphocytic interstitial pneumonitis (LIP) is classified under the idiopathic interstitial pneumonias. The incidence of LIP is uncommon, mainly seen in immunocompromised patients especially infection with human immunodeficiency virus (HIV), and those with connective tissue disease. We describe a young patient with H1V who developed LIP with subsequent complete clinical and radiographic resolution of the disease shortly after initiation of highly active antiretroviral therapy (HAART).

CASE PRESENTATION: A 29 year-old homosexual Hispanic male with newly diagnosed HIV infection presented with 8 months of progressive shortness of breath, nonproductive cough, 35-pound weight loss, and fevers. He grew up in southern California, denied recent travel, did not own pets, and was not taking any medications. He denied use of recreational drugs or alcohol. On presentation he was febrile, hemodynamically stable, room air pulse-oximetry was 90%. Physical exam was remarkable for thrush, bibasilar crackles, and 2cm raised violaceous lesions on chest wall and back. Laboratory values revealed a normal white blood cell count, hypoalbuminemia, lactate dehydrogenase of 365, and a CD4 count of 9. Arterial blood gas on room air revealed PaO2 of 64. Chest CT was remarkable for bilateral patchy areas of ground-glass opacities and nodularity most notable in left lower lobe. Sputum for acid-fast bacilli and fungal serologies including coccidioidomycosis, histoplasma, and cryptococcus were negative. Bronchoscopy findings revealed normal airways, no endobronchial lesions, and a bland bronchoalveolar lavage (BAL) fluid with negative findings for infection or malignancy. Antibiotics as well as empiric treatment for pneumocystis carinii pneumonia (PCP) with trimethoprim-sulfmnethoxazole and prednisone were initiated. Treatment for PCP was stopped after 5 days with negative BAL results. There was no improvement in his symptoms while on antibiotics. A repeat bronchoscopy with transbronchial biopsy revealed nonspecific interstitial pneumonitis. The patient subsequently underwent a video-assisted thoracoscopic (VATS) lung biopsy that revealed lymphocytic interstitial pneumonitis. He was started on HAART with complete resolution of his clinical and radiographic findings.

DISCUSSIONS: LIP, although common in HIV children, is rare in the adult HIV population. It is an AIDS defining illness in children < 13 years of age. LIP occurrences in HIV are more common in men, African American, Afro-Caribbean, and homosexuals. It is rare in Caucasians. There is no relationship with CD4 count. There is suggestion of an association with Epstein Barr virus (EBV) and HIV infection itself inducing LIP. Symptoms include nonproductive cough, progressive dyspnea on exertion, fevers, weight loss, and fatigue. Some patients are asymptomatic or have minimal symptoms. Duration of symptoms can range from several months to several years. Lung exam shows inspiratory crackles, wheezing, decreased breath sounds, in other cases minimal physical findings are seen. Chest radiography and chest CT show predominant interstitial pattern with bilateral reticular and ground glass opacities, and centrilobular nodules. In advanced cases CT shows bronchiectasis and fibrosis. Pulmonary function tests show restriction and loss of diffusing capacity. No clinical or laboratory findings are characteristic for LIP, tissue biopsy is ultimately required for diagnosis. Treatment is anecdotal; there are no controlled trials. Cyclophosphamide, chlorambucil, and azathioprine have been tried with varying results. Highly active antiretroviral therapy (HAART) with or without corticosteroids has been successful in very small studies. The dose of corticosteroids and duration of use are variable. HAART therapy has been used alone with success in case reports, there is no clear-cut evidence for non-nucleoside or protease inhibitor based regimens.

CONCLUSION: This case demonstrates successful treatment of lymphocytic interstitial pneumonia with HAART in an individual newly infected with HIV with complete clinical and radiographic resolution. Further studies are needed to define the role of HAART with or without steroids in the treatment of LIP for patients infected with HIV.

DISCLOSURE: Michelle Cao, None.

Michelle Cao DO * Malini Soogoor MD Janine Vintch MD Harbor/UCLA Medical Center, Torrance, CA

COPYRIGHT 2005 American College of Chest Physicians
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