A Guide to Primary Care of People with HIV/AIDS - Canadian Public ...

A Guide to Primary Care of People with HIV/AIDS
Chapter 9: Management of Opportunistic Diseases
9
How do you diagnose KS?
The skin lesions are usually sufficiently characteristic
to make this diagnosis clinically based on appearance,
but a biopsy should be done when there is a need
for confirmation. The differential diagnosis includes
bacillary angiomatosis (which can be proven by biopsy
with silver stain), hematoma, nevus, hemangioma,
B-cell lymphoma, and pyogenic granuloma. When
there is visceral involvement, the usual method used
to establish the diagnosis is endoscopic examination
to show typical mucosal surface lesions. With lung
involvement, the x-ray is variable and may show
nodules, infiltrates, effusions, and/or mediastinal/
hilar nodes. Lung biopsy is often negative, but the
bronchoscopic exam often shows a characteristic
cherry-red bronchial nodule. With GI tract involvement,
the usual screening test is stool for occult blood, and
endoscopy is the usual method to make the diagnosis
by showing a hemorrhagic nodule; the biopsy is often
negative because of the submucosal location of the
tumor.
How do you treat KS?
Many patients require no therapy except possibly
makeup to cover the characteristic lesions. Topical
treatment for skin involvement includes vinblastine,
Panretin gel, liquid nitrogen, radiation, cryosurgery, or
laser. Systemic chemotherapy is preferred when there
is an extensive burden, defined as >25 skin lesions,
symptomatic visceral involvement, extensive edema,
systemic (B) symptoms, or failure to respond to local
treatment. The favored forms of chemotherapy are
liposomal anthracyclines (Doxil or DaunoXome) or, less
frequently, paclitaxel (Taxol). Immune reconstitution
with ART is associated with a substantial reduction in
the frequency of KS and a therapeutic improvement
in those who already have these lesions. It should be
noted that there is no cure for KS, and the goal of local
therapy or systemic chemotherapy is to reduce tumor
burden and relieve symptoms.
What lymphomas are associated with HIV
infection?
The subtypes of lymphomas associated with HIV
infection include B-cell large cell lymphoma, primary
body effusion lymphomas, B-cell CNS lymphoma,
Burkitt lymphoma, plasmablastic lymphoma, and
Hodgkin disease. The most common is non-Hodgkin
lymphoma.
What are the symptoms of non-Hodgkin
lymphoma (NHL)?
Compared with the general population, patients
with this complication have high rates of stage IV
disease with systemic (B) symptoms and sparse
node involvement. Common symptoms are fever of
unknown origin, liver dysfunction, marrow suppression,
lung disease (effusions, multinodular infiltrates, mass
lesions, diffuse infiltrates, and/or hilar adenopathy), GI
involvement (any level with pain and weight loss), and
CNS with mass lesions.
How do you diagnose lymphomas?
Fine needle aspirates of enlarged nodes are helpful if
positive, but false negatives are common. Biopsy is
usually necessary.
How are lymphomas treated and what should
be expected?
The usual treatment is chemotherapy with
cyclophosphamide, doxorubicin, adriamycin,
vincristine, and prednisone (CHOP); methotrexate,
bleomycin, doxorubicin, cyclophosphamide, vincristine,
and dexamethasone + G-CSF (M-BACOD); or etoposide,
prednisone, vincristine, cyclophosphamide, and
doxorubicin (EPOCH). Response rates are 50%-60%,
but the long-term prognosis is poor unless there is
immune reconstitution with ART.
How do you diagnose and treat primary CNS
lymphomas?
The typical presentation is confusion, headache,
memory loss, focal neurologic changes, usually without
fever and usually with a CD4 cell count of