Concomitant sarcoidosis and HIV infection. Kemp S. Gowda, MD, FRCPC; Irvin Mayers, MD, FRCPC; Stephen D. Shafran, MD, FRCPC. Sarcoidosis is a ...
Concomitant sarcoidosis and HIV infection Kemp S. Gowda, MD, FRCPC; Irvin Mayers, MD, FRCPC; Stephen D. Shafran, MD, FRCPC Sarcoidosis is a relatively common cause of asymptomatic interstitial lung disease' and is frequently associated with hilar adenopathy. Human immunodeficiency virus (HIV) infection is also frequently associated with interstitial lung disease, which may be asymptomatic.23 Although neither sarcoidosis nor HIV infection is uncommon, the concurrence of these conditions has rarely been reported.4 We describe a patient in whom the two conditions coexisted and were relatively asymptomatic.
Case report
staining was negative for acid-fast bacilli, fungi and Pneumocystis carinii. Subsequent cultures were negative for fungi, bacteria, viruses and mycobacteria. Once sarcoidosis was diagnosed, further evaluation revealed a normal serum calcium concentration; an electrocardiogram was also normal. The serum angiotensin converting enzyme level was 57 (normally less than 50) U/L. Ophthalmologic consultation did not reveal any ocular disease. As of February 1989 there have been no changes in the patient's respiratory symptoms, the findings on chest x-ray films or the spirometry results. However, the HIV infection has progressed, as demonstrated by a reduction in the circulating T4 lymphocyte count from 570 to 392 (normally 500 to 1100) x 106/L in July 1988 and to 299 x 106/L in November 1988. Since the count was below 300 x 106/L zidovudine therapy was started. As of August 1989 there had been no HIV-associated complications.
A 29-year-old homosexual man presented to his family physician in September 1987 with generalized lymphadenopathy and only minimally reduced exercise tolerance. In November 1987 a biopsy specimen of a left axillary lymph node revealed only reactive hyperplasia. The patient was found to be HIV-seropositive through enzyme-linked immunosorbent assay and the Western blot technique. A chest x-ray film revealed hilar adenopathy and a diffuse interstitial reticulonodular pattern (Fig. 1). He was referred to University Hospital, Saskatoon, for further evaluation. The findings at physical examination were normal except for generalized lymphadenopathy. The complete blood count and leukocyte differential count were normal. The T4 (helper) and the T8 (suppressor) lymphocyte counts were low normal. A chest x-ray film obtained in March 1985 revealed that the interstitial infiltrates had been present then; new films showed that there had been slight progression over the 32-month interval. The arterial blood gas values, the results of pulmonary function tests and a gallium-67 lung scan were normal. Computed tomography confirmed the presence of fine nodular interstitial infiltration as well as hilar and mediastinal lymphadenopathy (Fig. 2). Fibreoptic bronchos- Fig. 1: Chest x-ray film, showing diffuse interstitial infilcopy along with bronchoalveolar lavage and trans- trates and bilateral hilar adenopathy in patient with concurbronchial biopsy were performed; the biopsy re- rent sarcoidosis and human immunodeficiency virus (HIV) vealed noncaseating granulomas (Fig. 3). Special infection. From the Department ofMedicine, University Hospital, Saskatoon
Reprint requests to: Dr. Stephen D. Shafran, Division ofInfectious Diseases, Department of Medicine, 2E4. 11 Walter C. Mackenzie Centre, University of Alberta, Edmonton, Alta. T6G 2B7 136
CAN MED ASSOC J 1990; 142 (2)
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Comments
We believe that this is the first case of near simultaneous diagnosis of sarcoidosis and HIV infection. In a previous case sarcoidosis had existed for many years before HIV infection was diagnosed;4 in addition, there had been marked pulmonary impairment due to the sarcoidosis. The case we have described highlights the importance of obtaining a definitive diagnosis of interstitial lung disease in HIV-infected patients. Early diagnosis is particularly
Fig. 2: Computed tomogram, highlighting diffuse interstitial pattern and bilateral hilar adenopathy.
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Fig. 3: Photomicrograph of transbronchial lung biopsy specimen. showing noncaseating granulomas consistent with
important in those with P. carinii pneumonia, as treatment is highly effective if started when the symptoms are minimal.5 Alternatively, if P. carinji pneumonia is not present, diagnosis through lung biopsy may help define the prognosis, since the differential diagnosis of interstitial lung disease in HIV-infected people includes nonspecific interstitial pneumonitis, lymphoid interstitial pneumonitis, pulmonary Kaposi's sarcoma, cytomegalovirus infection, mycobacterial infection, cryptococcosis and toxoplasmosis. Sarcoidosis and HIV infection do not appear to interact with each other in either a beneficial or a detrimental manner. In the case reported here the sarcoidosis remained stable, whereas the HIV infection progressed slowly but steadily. It is impossible to generalize on the basis of one case, but it appears that concomitant sarcoidosis and HIV infection run independent courses. Hillerdal and associates' described an annual incidence of sarcoidosis of 19 cases per 100 000 population. This implies that the condition is relatively common and that in regions where HIV infection is prevalent the concurrence of these two diseases should be more common. The possible immunologic interaction between sarcoidosis and HIV infection is interesting. Sarcoidosis is characterized by increased numbers of T4 lymphocytes at the affected sites,6 whereas HIV infection is associated with global T4 lymphocyte depletion. The depletion may attenuate the inflammatory response in sarcoidosis and thus result in clinically inapparent or minimal sarcoidosis. This concept is supported by the observation that granuloma formation is frequently defective or absent in HIV-infected people with concurrent mycobacterial infection.7
References 1. Hillerdal G, Nou E, Osterman K et al: Sarcoidosis: epidemiology and prognosis. A 15-year European study. Am Rev Respir Dis 1984; 130: 29-32 2. Guillon JM, Autran B, Denis M et al: Human immunodeficiency virus-related lymphocytic alveolitis. Chest 1988; 94: 1264-1270 3. Ognibene FP, Masur H, Rogers P et al: Nonspecific interstitial pneumonitis without evidence of Pneumocvstis carinii in asymptomatic patients infected with human immunodeficiency virus (HIV). Ann Intern Med 1988; 109: 874-879 4. Wurm K, Ewert G, Lohr G: Sarcoidosis complicated by HTLV-III infection: steroid therapy in combination with thymostimulin. Sarcoidosis 1987; 4: 68-70 5. Brenner M, Ognibene FP, Lack EE et al: Prognostic factors and life expectancy of patients with acquired immunodeficiency syndrome and Pneumocvstis carinii pneumonia. Am Rev Resp Dis 1987; 136: 1199-1206 6. Hunninghake GW, Crystal RG: Pulmonary sarcoidosis. A disorder mediated by excess helper T-lymphocyte activity at sites of disease activity. N Engl J Med 1981; 305: 429-434 7. Jacobson MA: Mycobacterial diseases: tuberculosis and Mvcobacterium avium complex. Infect Dis C/in North Am 1988; 2: 465-474 CAN MED ASSOC J 1990; 142 (2)
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