HIV-Infection, Hodgkin Lymphoma, and Pregnancy: A Case Report and Recommendations On Treatment.

Abstract 4638

According to the CDC the incidence of HIV-infection in women of child bearing age continues to increase in the era of Highly Active Anti-Retroviral Therapy (HAART). In 1992, women accounted for 14% of all adults and adolescents living with HIV/AIDS, but by the end of 2005 women accounted for 23% of all HIV/AIDS cases [1]. As Hodgkin lymphoma (HL) is the most common non-AIDS defining malignancy, we anticipate that the number of cases of HIV-associated Hodgkin lymphoma (HIV-HL) in pregnant women will increase in the near future. Herein, we describe the case of a pregnant 30-year-old HIV-infected Ethiopian woman with a CD4+ count of 254 cells/μ;L and an HIV viral load of 1200 copies/mL who presented to medical attention with progressive neck adenopathy and fatigue, but no fevers, night sweats, or significant weight loss. An incisional biopsy of a cervical lymph node revealed Reed-Sternberg cells (CD30+, CD15+, CD20-, CD3-) and an absence of sclerosis consistent with Classical Hodgkin Lymphoma, mixed cellularity subtype. A subsequent unilateral posterior iliac crest bone marrow aspirate and biopsy was unremarkable with normal trilineage hematopoiesis. Following a spontaneous miscarriage ten weeks into her pregnancy, a ¹⁸F-fluorodeoxy-D-glucose PET and fusion CT scan demonstrated disease above and below the diaphragm, establishing stage IIIA HL. The patient subsequently began HAART consisting of a co-formulation of emtricitabine and tenofovir (Truvada^®) and nevirapine, in conjunction with chemotherapy (AVD x 8 cycles). Thirty three months post-completion of chemotherapy, the patient remains disease free without evidence of recurrent HL. Through a literature search, we identified only two additional case reports describing HIV, HL, and pregnancy. One patient received three cycles of chemotherapy, refused further treatment, delivered a HIV-positive girl, and died shortly after from complications of presumed pneumocystis jiroveci pneumonia [2]. The second patient received both active antiretroviral therapy and chemotherapy, delivered a HIV-negative boy, and remained without evidence of HL at nine months follow-up [3].

The paucity of reported cases in the medical literature precludes any evidence based recommendations for the care of pregnant patients with HIV-HL. However, we recommend that medical providers use the same precautions to ensure the safety of both the mother and the child as recommended for pregnant HIV-negative patients with HL. Pregnant patients with HL should not be staged with imaging techniques that require significant radiation exposure including plain radiographs, CT, and PET scans. The extent of substantial mediastinal and pulmonary disease can be safely determined with a postero-anterior radiograph of the chest with proper shielding of the abdomen. Abdominal ultrasounds and magnetic resonance imaging may provide adequate information for the management of disease without placing the fetus at risk [4]. We also suggest controlling the underlying HIV infection when initiating HL treatment as using HAART in parallel with chemotherapy has been correlated with a dramatically improved prognosis for HIV-HL patients [5]. In the hopes of developing more specific management guidelines, we encourage other clinicians to publish their experiences with HIV-HL in pregnant patients.

1. Centers for Disease Control and Prevention. HIV/AIDS Among Youth–United States, 2008. http://www.cdc.gov/hiv/resources/Factsheets/youth.htm

2. Okechukwu CN, Ross J. Hodgkin's Lymphoma in a Pregnant Patient with Acquired Immunodeficiency Syndrome. J Clin Oncol 1998; 10:410-411.

3. Kelpfish A, Schattner A, Shtalrid M,et al. Advanced Hodgkin's Disease in a Pregnant, HIV Seropositive Woman: Favorable Mother and Baby Outcome Following Combined Anticancer and Antiretroviral Therapy. Am J Hematol 2000; 63:57-58.

4. Connors, Joseph. “Challenging Problems: Coicident Pregnancy, HIV infection, and Older Age.” In: Hematology 2008: American Society of Hematology Education Program Book. Gewirtz AM, Muchmore EA, Burns LJ, editors. Washington, D.C.: American Society of Hematology; 2008. p. 334-39.5.

5. Tirelli U, Errante D, Dolcetti R, et al. Hodgkin's Disease and Human Immunodeficiency Virus Infection: Clinicopatholgic and Virologic Features of 114 Patients From the Italian Cooperative Group on AIDS and Tumors. J Clin Oncol 1995; 13:1758-67.