Acute Respiratory Failure Caused by HTLV-Associated Adult T-Cell Lymphoma

Abstract

SESSION TITLE: Student/Resident Case Report Poster - Lung Pathology I SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Pulmonary manifestations are frequently seen with HTLV associated Adult T-Cell Lymphoma (ATLL), in the form of pneumonia and opportunistic infection. These patients rarely present with acute respiratory failure requiring ventilator support related to lymphadenopathy from ATLL. CASE PRESENTATION: A 75 year old Jamaican male presented with 8 months of worsening dyspnea, productive cough and weight loss. He was transferred to our tertiary care facility in hypoxic respiratory failure requiring non-invasive ventilatory support. Eight months prior to admission, he was diagnosed with chronic sinusitis requiring surgical drainage. His chronic cough persisted which prompted CT imaging, which revealed left-sided hilar lymphadenopathy and bronchiectasis. Transbronchial needle aspiration revealed necrotizing lymphadenitis and culture from an alveolar lavage revealed numerous organisms including: pseudomonas, streptococcus viridans, aspergillus flavus, and Pencillium species. Despite 2 courses of antimicrobial therapy, his symptoms progressed, and he was transferred to our hospital for further diagnosis and treatment. He denied recent travel, alcohol, or illicit drug use or high risk sexual behaviors. A repeat CT of the chest is shown in figure 1. Bronchoscopic evaluation showed purulent material in all bronchial segments of the left lung and a large mass eroding through and obstructing the left lower lobe bronchi, revealing a bronchoesophageal fistula. Transbronchial needle biopsy of a sub-carinal lymph node revealed: large atypical lymphocytes, with flow cytometry consistent with peripheral T cell lymphoma. Serum samples confirmed HTLV-1 positive serology. DISCUSSION: The prevalence of HTLV in the United States has been reported at 0.1-0.2% and only a minority of these patients will develop ATLL. Direct pulmonary manifestations from ATLL extension are rare, and almost all known cases of respiratory failure occurs from opportunistic infectious etiologies rather than direct tumor involvement. Systemic findings of HTLV-1 ATLL include hypercalcemia, hepatosplenomegaly, jaundice, and metastatic bony involvement, which were not present in our case. His initial diagnosis of sinusitis, pneumonia and necrotizing lymphadenitis along with his weight loss and dyspnea undoubtedly was related to his ATLL. A high clinical suspicion and failure of past therapy warranted new tissue diagnosis for confirmation. Initiation of chemotherapy with Etoposide, Prednisone, Vincristine, Cyclophosphamide, and Doxorubicin and placement of an esophageal stent improved his respiratory status; however, he died from respiratory failure 4 weeks later. CONCLUSIONS: This case represents a rare presentation of pulmonary HTLV-1 ATLL and highlights the need for a high clinical suspicion in patients from endemic populations presenting with lymphadenopathy and constitutional symptoms. Reference #1: Cook LB and Taylor GB. HTLV-1 and HTLV-2 prevalence in the United States. J Infect Dis. 2014 Feb; 209(4):486-7. DISCLOSURE: The following authors have nothing to disclose: Jonathan Gong, Aleksandr Melamud, Seth Koenig No Product/Research Disclosure Information