AN UNUSUAL CASE REPORT OF SARCOIDOSIS IN AN HIV PATIENT

Abstract

SESSION TITLE: Fellows Diffuse Lung Disease Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Coexistence of sarcoidosis in HIV patient is a rare phenomenon and has been attributed to the impairment of immune system that may interfere with granuloma formation.(1) We present an unusual case report of sarcoidosis in HIV patient. CASE PRESENTATION: 58-year-old female with history of HIV on highly active antiretroviral therapy (HAART) (CD4 count: 746 and viral load <20/ml) presented with incidental basilar pulmonary nodules during work up for abdominal pain. Subsequent CT chest showed multiple nodular densities in all lung fields with hilar and mediastinal lymphadenopathy. She is lifetime nonsmoker and had no respiratory symptoms. PET-CT showed avid mediastinal lymph nodes and bone lesions. Bronchoscopy with EBUS guided TBNA was inconclusive with negative fungal and mycobacterial cultures. Thereafter, IR guided bone biopsy was pursued which revealed non-caseating ” naked ” granulomas. Diagnosis of sarcoidosis was established after excluding other granulomatous inflammation, infection, and malignancy. No treatment was initiated as the patient was asymptomatic. DISCUSSION: The introduction of HAART has led to sustained increase in CD4+ T lymphocyte cells, consequently leading to the development of so called “immune restoration disease”. Sarcoidosis is an immune mediated systemic disease resulting from exaggerated cellular immune response to a variety of antigens or self-antigens, in which T lymphocyte triggering, proliferation, and activation is sustained by the CD4+ type 1 (TH1) lymphocytes. TH1 cells produce IFN-?, IL-2, and TNF leading to attraction and activation of mononuclear phagocytes that induce granuloma formation. These immunological features are not clearly exhibited in coexistent sarcoidosis/HIV infection. Before HAART therapy, reports indicated a prevalence of lymphocytic alveolitis due to an increase in CD8 cells, with a very low CD4/CD8 ratio. In a retrospective cohort study, it was concluded that the development of sarcoidosis appears to depend on preservation or restoration of peripheral CD4+ lymphocyte count exceeding 200 cells/µl compared to alternative specific etiologies of granulomatous inflammation.(2) It is worth noting that in all reported clinical cases, sarcoidosis developed several months after HAART therapy compared to acute onset of other typical immune reconstitution syndromes.(1) The need to initiate steroid therapy, as in other immune reconstitution granulomatous processes, remains controversial and is based on patient’s symptoms. CONCLUSIONS: Our case highlights the importance of considering “immune restoration disease” including sarcoidosis and other granulomatous inflammation/infection in HIV patient on HAART therapy with abnormal chest imaging in addition to slow growing lymphoproliferative disorder. Reference #1: Sarcoidosis and HIV infection: a case report and a review of the literature, Postgrad Med J. 2003;79:535–38 Reference #2: Sarcoidosis Following HIV Infection, Chest 2003 Sep; 124 (3), 929–935 DISCLOSURES: No relevant relationships by Moises Cossio, source=Web Response No relevant relationships by Domingo Franco-Palacios, source=Web Response No relevant relationships by Kushagra Gupta, source=Web Response No relevant relationships by Shahzad Hussain, source=Web Response No relevant relationships by Venkateswara Kollipara, source=Web Response No relevant relationships by Toribiong Uchel, source=Web Response