A Life-Threatening Tracheal Localization of Lymphoma in a Patient with AIDS

arose in lung parenchyma which had been shown to be previously roentgenographically abnormal. Scar. carcinoma has been associated with several causes of focal pulmonary fibrosis including tuberculosis, organized pneumonias, cryptogenic 6brosing alveolitis, infarction, chronic abscess, his:: toplasmosis, Hamman-Rich syndrome, scleroderma, rheumatoid lung, trauma as well as foreign substances including asbestos, beryllium and silica. e.~l1 However, there has been no description of scar carcinoma associated with Lucite or Lucite ball plombage. Scar carcinoma accounts for between 16 to 30 percent of cases of peripherally located lung carcinomas.7.8.10.11 Adenocarcinoma and bronchioalveolar carcinoma are the most frequently encountered cell types in scar carcinomas. 8.10 Squamous cell carcinoma accounts for 0 to 16 percent of cases of scar carcinoma in most large series.7·10 In summary, we have presented a patient with a history of pulmonary tuberculosis and extrapleural pneumonolysis with Lucite ball plombage who developed a primary lung carcinoma in close approximation to the plombage space. The patient had no history of the usual risk factors for squamous cell lung carcinoma, which was the histologic subtype of the tumor. Lucite is not a known carcinogen in man. It has been classified as a possible carcinogen based on experimental implantation tumor studies in mice. J1 •J3 Since the plombage procedure was performed only for a limited time, and new cases such as the one described here are unlikely to surface, we can only speculate as to the possible relationship between Lucite and the development of lung carcinoma. REFERENCES 1 Wilson OA, Baker H. Experimental surgical pulmonary collapse. Surg Gynecol Obstet 1946; 82:735-42 2 'Iate CF. Intestinal obstruction in a 55-year-old man with previous thoracic surgery (extrapleural plombage). JAMA 1980; 243:1077-78 3 Trent JC, Moody JO, Hiatt JS. An evaluation of extrapleural pneumonolysis with Lucite plombage: report of fifty-one cases. J Thorac Surg 1949; 18:173-80 4 Seibert CE, 18brisky J. Lucite extraperiosteal plombage: roentgenologic review of late complications. Am J Hoentgenol Radium Ther Nucl Med 1967; 100:593-96 5 Salsali M. Late complications of Lucite ball plombage; surgical cure. Chest 1973; 64:776-78 6 Fraser RG, Pare ~ Pare PO, Fraser RS, Genereaux G~ eds. Diagnosis of diseases of the chest. 3rd ed. Philadelphia: WB Saunders, 1991:1338-39 7 Freant LJ, Joseph WL, Adkins PC. Scar carcinoma of the lung: fact or fantasy? Ann Thorac Surg 1974; 17:531-37 8 Oehs RH, Katz AS, Edmunds LH, Miller CL, Epstein OM. Prognosis of pulmonary scar carcinoma. J Thorac Cardiovasc Surg 1982; 84:359-66 9 Limas C, Japaze H, Garcia-Bunuel R. "Scar" carcinoma of the lung. Chest 1971; 59:219-22 10 Bakris GL, Mulopulos G~ Korchik R, Ezdinli EZ, Ro J, Yoon B. Pulmonary scar carcinoma: a clinicopathologic analysis. Cancer 1983; 52:493-97 11 Yoneda K. Scar carcinomas of the lung in a histoplasmosis endemic area. Cancer 1990; 65:164-68 12 Lewis RJ, ed. Carcinogenically active chemicals: a reference guide. New York: Van Nostrand Reinhold, 1991:811-12 13 Oppenheimer BS, Oppenheimer ET, Danishefsky I, Purdy Stout A, Eirich FR. Further studies of polymers as carcinogenic agents in animals. Cancer Res 1955; 15:333-40

A Life-Threatening Tracheal localization of Lymphoma In a Patient with AIDS· An Chaouat, M.D.; Philippe Frause, M.D.; Romain Kessler, M.D.; Jean-Mane lAng, M.D.; and Emmanuel Writzenblum, M.D.

Lymphoma is a frequent complication of HIV infection, but we report a rare localization in the subglottic tracheal area. A case of tracheal stenosis due to lymphoma in an HIVinfected patient is presented. The main complaint was severe dyspnea. Chemotherapy was ineffective but radiotherapy improved the patient's condition and increased the caliber of the tracheal lumen. (Chat 1993; 103:1297-99)

I

HALT = bronchus-usocialed lymphoid tissue

~

I

n HIV-infected patient had tracheal stenosis caused by

1"1 lymphoma.

CASE REPORT

A 30-year-old man was admitted to our department on June 12, 1990, because of severe dyspnea. The medical history was remarkable for the following: in April 1984 the patient had been treated for mature testicular teratoma (stage III of the Boden classification) with chemotherapy and lumboaortic lymphadenectomy. During surgery, he needed a blood transfusion. In August 1985, he was hospitalized for an immunohemolytic anemia and needed other blood transfusions. In July 1987, he was found to have positive serology tests for HIV (EUSA test and Western blot). The patient had no other risk factors. The HIV transmission was certainly from blood transfusions. Four months later, he developed Pneumocy8tls carim; pneumonia. The absolute count ofCD4-positive lymphocytes was SOIcu mm. The pneumonia was successfully treated with sulfamethoxazole-trimethoprim, and secondary prevention of Pneumocystis carinii pneumonia by nebulized pentamidine every two weeks was started. Between February 1989 and May 1990, three episodes of toxoplasma encephalitis occurred despite prophylaxis (pyrimethamine 50 mglweek); these episodes were treated with pyrimethamine and sulfadiazine that showed clinical and scan improvement. The patient was admitted to the hospital with a three-day history of cough, dyspnea, dysphonia, and fever. He was cachectic (weight, 55 kg, height, 170 cm). Temperature was ~ and pulse rate was 100 beats/min. Physical examination revealed coarse inspiratory and expiratory rales. Wheezing was audible over both lung fields. Arterial blood gases, in air, were as follows: PaO., 100 mm Hg, PaCO., 31 mm Hg. Blood cell count showed pancytopenia: hemoglobin, 9.3 gldl; hematocrit, 27.4 percent; platelet count, 54,OOOIcu mm; and leucocyte count, 1,1000cu mm with 69.5 percent polynuclear neutrophil cells. An anteroposterior chest roentgenogram showed a normal lung field, but according to clinical signs, we suspected a long stricture of the cervical tracheal area. Computed tomography (Clj showed a stenosis of the trachea at the level of the CI, C2, and C3 vertebrae. This stenosis was due to a tumor located in the right lateral wall of *From the Service de Pneumologie (Drs. Chaouat, Fraisse, Kessler, and Weitzenblum); and the Centre d'Information et de Soios de rImmuno-d~ficience Dumaine (Dr. Lang), Centre Hospitalier Universitaire, Hapital de Hautepierre, Strasbourg, France. CHEST I 103 I 4 I APRIL, 1993

1217

Thus, tracheostomy could be avoided. The patient died suddenly 14 days after radiotherapy of septic shock and pneumonia with staphylococcal empyema . Autopsy was not performed. DISCUSSION

FIGURE 1. Computed tomographic scan of the cervical trachea before radiotherapy. the trachea (Fig 1). There was no adenopathy. Injection of contrast medium emphasized the peripheral part of the tumor. Flexible tracheobronchoscopy showed a lesion filling the half part of the tracheal lumen, immediately below the vocal cords. The mucosal membrane seemed nonnal but when the bronchoscope got closer to the lesion, its contact caused bleeding. The biopsy specimens with small forceps showed only necrotic tissue. Rigid tracheobronchoscopy enabled us to take more substantial samples of tissue. Histologic examination of the biopsy specimens of the lesions disclosed a diffuse large cell immunoblastic lymphoma. Abdominal eehography and a cr scan of the brain showed no other localization oflymphoma. Intravenous corticoid therapy was started. The patient was treated with chemotherapy given every three weeks (doxorubicin [Adriamycin] bleomycin. cyclophosphamide, vincristine , and etoposide [VPI6]; methotrexate intrathecally). After two courses of this regimen, we evaluated the response to treatment: the clinical signs did not change and the cr scan of the trachea showed progression of the disease . Therefore, local radiation therapy was decided . A total dose of 20 Gy was administered in two sequences separated by 48 h. Dyspnea and cough improved markedly while the tracheal cr scan demonstrated that the tracheal narrowing was reduced (Fig 2).

FIGURE 2. Computed tomographic scan of the cervical trachea at approximately the same level, after radiotherap y.

1298

The case we report herein is, to our knowledge, the first oftrachea1 localization oflymphoma in a patient with AIDS. This localization of lymphoma seems quite infrequent even in non-AIDS patients. Nevertheless, this location of lymphoma is conceivable because of the normal presence of lymphoid tissue distributed throughout the tracheobronchial tree, constituting the "bronchus-associated lymphoid tissue (BALT)". Neoplastic diseases associated with HIV infection have been observed in about 15 percent of the patients.' Just after Kaposi's sarcoma, lymphomas are the most prevalent neoplastic complications related to HIV infection . The most frequent are high-grade lymphomas. Extralymphatic sites of lymphoma, especially central nervous system and bone marrow,' are common in patients with HIY. However, respiratory involvement is rather rare . In 648 patients with AIDS, 40 hadnon-Hodgkin'slymphoma, including only four with documented pulmonary involvement." In another reported series of 70 patients with AIDS, only two had pulmonary lymphoma.' Of 35 patients with AIDS-related lymphoma seen at the Northwestern Memorial Hospital (Chicago), 11 (31 percent) had thoracic involvement. In these cases, pleural effusions, alveolar or interstitial patterns, were the most common roentgenographic features and chest localizations were generally extranodaI, but in one patient, a paratracheal node was found and two presented with hiIar unilateral adenopathy" In our patient, the diagnosis was difficult to obtain. The cr appearance of the lesion was consistent with an abscess (peripheral enhancement after injection of contrast medium). Flexible bronchoscopy failed to provide histologic diagnosis and rigid bronchoscopy was indicated to obtain more substantial samples. Rigid bronchoscopy would have enabled us to control more easily bleeding or edema consecutive to biopsy, but we noted no complication in our patient. This observation suggests that an early chest cr or flexible bronchoscopy is indicated in HIV-positive patients who become breathless and whose posteroanterior chest roentgenogram is normal . Chemotherapy is quite effective in lymphomas occurring in patients without HIY. It seems less effective in patients with HIY. The median survival, after various treatments, is five months but it varies according to the histopathologic type (two months in the immunoblastic type).• In our patient, progression of the tracheal tumor was observed during chemotherapy and , therefore, no improvement of the symptoms was noted. Radiation therapy in contrast allowed dramatic improvement in dyspnea and wheezing. No complications could be directly related to this treatment. The right basal pneumonia and staphylococcal empyema of our patient could have been due to inhalation, but no swallowing difficulties were observed. Weconclude that radiation therapy is an effective palliative treatment of tracheal or principal bronchus sole localization of lymphoma in an HIV-positive patient. L.Jfe.IIv8atenI Traa-J L.ocaIzalIon of Lymphoma (Chaouatat aJ)

ACKNOWLEDGMENTS: We wish to thank Dr. Budor and Dr. Cuttuli for help and advice. REFERENCES

1 Kaplan MH, Susin M, Pahwa SG, Fetten J, Allen SL;Lichtman S, et al. Neoplastic complications of HTLV-III infection. Am J Med 1987; 82:389-96 2 Ziegler JL, Beckstead jA, Volberding PA, Abrams 01, Lerrine AM, Lukes RJ, et al. Non-Hodgkins lymphoma in 90 homosexual men. N Engl J Moo 1984; 311:565-70 3 Polish LB, Cohn DL, Ryder~ Myers AM, Brien RF. Pulmonary non-Hodgkins lymphoma in AIDS. Chest 1989; 96:1321-26 4 Marchewsky A, Rosen MJ, Chrytal G. Pulmonary complications of the acquired immuno-deficiency syndrome: a clinical pathologic study of 70 cases. Hum Patholl985; 16:659-70 5 Sider L, Weiss AJ, Smith MD, Von Roenn JH, Glassroth J. Varied appearance of AIDS-related lymphoma in the chest. Radiology 1989; 171:629-32 6 Knowles DM, Chamulak GA, Subar M, Burke JS, Dugan M, Wernz J, et al. Lymphoid neoplasia associated with the acquired immunode6ciency syndrome. Ann Intern Med 1988; 108:744-53

Adenosin.lnduced Torsades de Pointes* Maj Gerald R. Harrington, MC, USA; and Capt Edward G. Froelich, MC, USA

Pbysicians are 6nding increased applications for adenosine as a diagnostic and therapeutic modality for a variety of cardiac dysrbythmias. Its short halflife andlack of reported major complications make it an ideal pharmacologic agent to utilize for diagnosis and treatment. Herein we report a case of polymorphic ventricular tachycardia induced by adenosine. (Cheat 1993; 103:1299-1301)

T

he use of adenosine as a diagnostic and therapeutic agent for supraventricular dysrhythmia has increased markedly since it was introduced into clinical practice. A potential complication from the use of adenosine may be found in patients with a prolonged QT interval. The atrioventricular block induced by adenosine may allow for the development of bradycardia-induced polymorphic ventricular tachycardia. CASE REpORT

A 62-yeaM>ldman was taken to the operating room for treatment of a diverticular abscess involving the left iliopsoas muscle. Postoperatively, he demonstrated multiple episodes of atrial flutter and paroxysmal supraventricular tachycardia with heart rates up to 170 beats per minute. In order to control the recurrent episodes of supraventricular tachycardia, the patient eventually required a continuous infusion of procainamide, 2 mg/min, and esmolol, 50 ...glkglmin. Digitalis also was utilized both for rate control and

positive inotropic effect. On the 60th postoperative day, the patient again manifested a supraventricular tachycardia with ischemic ECG changes. His elevated heart rate was not responsive to increased doses of esmolol. For diagnostic purposes, 6 mg of adenosine was administered by a central venous catheter. Approximately 10 s following the bolus injection, the patient developed the expected atrioventricular block which revealed the underlying mechanism to be atrial8utter (Fig 1). A normally conducted beat returned after a 6-s pause followed by several premature ventricular depolarizations. This initiated sustained polymorphic ventricular tachycardia. Sinus rhythm was restored via defribillation with 360 J. At the time of the event, the serum potassium level measured 3.8 mEqIL; magnesium, 2.0 mg/dl, digoxin, 1.4 ng/ml, procainamide, 7.4 ~wml; and Nacetyl procainamide, 19.5 ~Wml. The patient's corrected QT interval both prior to and following the event was prolonged to nearly 500 ms (Fig 2). DISCUSSION

Adenosine recently was approved by the Food and Drug Administration for intravenous use in patients with paroxysmal supraventricular tachycardia. It is particularly effective in those patients whose supraventricular tachycardia is the result of atrioventricular reciprocating or atrioventricular nodal reentrant tachycardia. 1 In many circumstances, it has supplanted verapamil as the treatment of choice for supraventricular dysrhythmia where the underlying electrophysiologic mechanism is unclear. This is due in part to its extremely short half-life, which is reported to be 10 s.' A variety of relative contraindications to the use of verapamil have been reported. These include hypotension, congestive heart failure and prior intravenous beta blocker administration. Precipitation of cardiac arrest has been reported in patients treated with verapamil who subsequently were demonstrated to have preexcitation via an anomalous atrioventricular pathway.2 In addition, misdiagnosis of wide complex tachycardia as supraventricular in origin with aberrant conduction often leads to therapy with verapamil. ~~Ia'r ~ • : :

~'f ..." a

....... ~

t'

•

•

1 J-;" . -: .~ r +- -t -.

T'r'-

r i -;-

y-

'IJ J.

,H

~.

~r

.... I

!

i

I

,

I'JI""""

Ii:

.'1

1 1 I"

....1

~

:~Lt

H= ''1'·1-n-:r -1 • v;, .. lY'~ -,1:! I; i

I

...""

: -: .i.r

~..

.~

'j

IILl "I I - II. : ..1. .• 1.'., r 4 " , -.,;,'.];~LL.J

-i'I'11

,

I

I L,

,.

.

... .~

~

i

~

.-

1.:'

Il'-~

.'

.t

----f-M

I

I

.,.

.A

.f.:~~~

.H-

-

,.

I

,I

1"

I

I

I

r

r

AI

t~'~t+.L+-f-+ : ._~J LUI

-

I

i

TI

r;

'.r .;.. -.L W~l~·~ -.wII .....

,.1

:.

4--

1~

'T~

'"

I

II

fI 'I

• ,.. ..

I f I

..,.,..

+f

J

.I

:'"

:

.'.

! I,

~

I I

.!'

1" 'I,:;'

I

j -r

I TT~!' 1.. -1-._1J

'111

ffi~": ...... .......,

I

,-,

..

H'

1-

I I I

I.·

.......

..- ......

1 r' .r -'! r +1r"' .~

,I

~ I'M

_I

I

~

-.

...,. ft.a.-'-" .... --

I.

t

*From the Critical Care Medicine Service, Walter Reed Army Medical Center, Washington, DC. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or reOecting the views of the Department of the Army or the Department of Defense. Reprint requests: Dr. Harrington, Critical Care Medicine, Walter Reed Anny Medical Center; Washington, DC 20307

t

. riO' t -

~

.. ... '

,..

-

:

....

,~

.' ..... I-I-f-. -

,t "+-+-

i-'T"'"+-+-''t-I-.;-+.....-+

FIGURE 1. Rhythm strip 10 s after adenosine is administered. CHEST I 103 I 4 I APRIL, 1993

1299