A 37-year-old male was admitted to our hospital because of his left sided hemiplegia that he had experienced for 3 months. He was known to be positive for HIV, as was determined during evaluation for idiopathic thrombocytopenic purpura in a foreign country about 6.5 years before this admission. At that time, he had been treated with zidovudine, lamivudine and saquinavir for the management of AIDS for 9 months and then he discontinued therapy of his own will. He was advised to restart treatment with zidovudine, lamivudine and indinavir at our hospital 4 years ago. He noticed weakness on the left side of his body during movement, which had slowly progressed and he finally developed left-sided hemiplegia 3 months previously. At the time of admission, he had complaints of headache and night sweats. He was diagnosed as having idiopathic thrombocytopenic purpura about 6.5 years ago and so splenectomy was done. Even after splenectomy, the thrombocytopenia continued. He was treated with steroid, vincristine, intravenous gammaglobulin, rituximab and danazole. He had also experienced liver abscess 4 years ago. He had received radiation for Kaposi sarcoma about 8 months before admission. On admission, the blood pressure was 90/60 mmHg, the pulse rate 100/min, the respiration rate 22/min and the body temperature was 38℃. Upon physical examination, the patient was in poor general condition with anemic conjunctiva. There were no signs of hemorrhagic diathesis or icterus. The laboratory finding were as follows; hemoglobin 7.4 g/dL, WBC 8,300/mm³ (neutrophila: 79.5%, lymphocytes: 14.6%, monocytes: 4.6%), platelets 10,000/mm³, erythrocyte sedimentation rate (ESR) 2 mm/h, AST 24 IU/L, ALT 9 IU/L, total bilirubin 0.7 mg/dL, LDH 473 IU/L, protein 3.9 g/dL, albumin 2.3 g/dL, BUN 9.5 mg/dL, creatinine 0.42 mg/dL, calcium 7.3 mg/dL, phosphorus 3.1 mg/dL, Na 130 mmol/L, K 3.0 mmol/L, the total number of CD4 and CD8 T lymphocytes was 46/mm³ and 621/mm³, respectively, and the ratio of CD4/CD8 was 0.07. The chest X-ray was not remarkable. Brain MRI (Figure 1A) shows 4 cm-sized round mass involving the right frontal lobe. The T1 weighted image and the T2 weighted image (Figure 1B) showed extensive areas of perilesional edema involving the right frontoparietal region and there was a mass effect upon the right lateral ventricle. Stereotactic biopsy of the brain lesion was performed, and histological examination disclosed atypical lymphoid cells with a predominant perivascular arrangement (Figure 2). Immunohistochemical examination showed positivity for CD20. The diagnosis of diffuse large B-cell lymphoma involving the CNS was made. The patient was treated with brain radiation. Sadly, he died of pneumonia 13 days after brain radiation therapy.

A 40-year-old man was hospitalized due to jaundice and lethargic fatigue that started 10 days prior to admission. The patient had complaints of weight loss and night sweats. Four months prior to this admission, he had visited to the Department of ENT at another hospital with the complaint of nasal stuffiness. At that time, the serologic testing for hepatitis B antigen and anti-HIV antibody were positive. He has been treated with zidovudine, lamivudine and efavirenz for two months until admission. He assumed that his AIDS was transmitted from heterosexual contact at abroad ten years ago. On admission, the blood pressure was 120/70 mmHg, the pulse rate 90/min, the respiratory rate 20/min and the body temperature was 36.6℃. He was icteric on the physical examination. The liver was tender and firm in consistency. It was palpated at a three-finger breadth below the right costal margin. His spleen and lymph nodes were not enlarged. The laboratory results were normal apart from an ESR of 120 mm/h; leukopenia 3,930/mm³ (neutrophils: 58.8%, lymphocytes: 31% and monocytes: 8.4%) and hemoglobin 9.4 g/dL. The liver function tests were abnormal: total bilirubin 8.9 mg/dL (direct bilirubin: 6.05 mg/dL), AST 171 IU/L, ALT 100 IU/L and LDH 1063 IU/L. The total number of CD4 and CD8 T lymphocytes was 290/mm³ and 568/mm³, respectively, and the ratio of CD4/CD8 was 0.51. Abdominal enhanced CT scanning revealed multifocal and variable sized homogenous hypodense masses in both hepatic lobes (Figure 3). A liver biopsy showed a heavy infiltration composed mainly of large lymphoid cells (Figure 4A). Immunohistochemical staining revealed the atypical cells to be CD20 positive (Figure 4B), which established a diagnosis of diffuse large B-cell lymphoma according to the WHO classification. Bone marrow biopsy demonstrated normal cellularity with normal maturation of all three cell lines. There was no malignant cell infiltration. After the patient was diagnosed as having diffuse large B-cell lymphoma, he received VAD (vincristine 0.4 mg, adriamycin 9 mg/m², dexamethasone 40 mg on days 1-4, and additional dexamethasone on days 9-12 and days 17-20). The patient seemed to show a little clinical improvement, but before starting the second chemotherapy, he developed signs of spinal cord compression (Figure 5A). Emergency radiation therapy was delivered to the spine lesion. CHOP chemotherapy (cyclophosphamide 750 mg/m², adriamycin 50 mg/m² and vincristine 1.4 mg/m² on day 1 and prednisone 100 mg/m² on days 1-5) and laminectomy induced temporary improvement (Figure 5B). Alas, the paraplegia continued and his clinical condition progressively worsened. He passed away 103 days after starting the second round of chemotherapy from complications of pressure sores, deep vein thrombosis and pulmonary thromboembolism.

A 38-year-old male with AIDS presented with a palpable mass he'd had for 5 months in the left cervical region. HIV infection was possibly through heterosexual contact and he was diagnosed two years earlier, but no particular treatments were established before admission. On physical examination, 0.8 cm-sized lymph nodes were palpable in the left cervical areas. The heart and lungs were normal, and the chest X-ray was normal. A CT scan of the head and neck (Figure 6A) showed enlarged left sided cervical lymph nodes that measured 1.6 cm × 2.4 cm in diameter. Excisional biopsy of a cervical lymph node was performed, and the histologic study suggested diffuse large B-cell lymphoma (Figure 7A). Immunohistochemical staining showed the atypical cells to be CD20 positive (Figure 7B). On admission, the patient did not declare any discomfort and the physical examination was normal. The laboratory finding were as follows; hemoglobin 14.4 g/dL, WBC 5,310/mm³ (neutrophils: 55.9%, lymphocytes: 39% and monocytes: 4.1%), platelet 178,000/mm³, ESR 9 mm/h, AST 39 IU/L, ALT 32 IU/L, total bilirubin 1.5 mg/dL, LDH 378 IU/L, protein 7.9 g/dL, albumin 4.0 g/dL, BUN 15.9 mg/dL, creatinine 0.88 mg/dL, calcium 8.5 mg/dL, phosphorus 4.2 mg/dL, Na 137 mmol/L, K 4.5 mmol/L, the percent of the CD4 and CD8 T lymphocytes was 20.5% and 70% of the total lymphocyte count, respectively, and the total number of CD4 cells was 420/mm³. The CD4/CD8 ratio was 0.36. He was treated via immunochemotherapy with Rituximab and CHOP for six cycles. After 5 cycle of R-CHOP, the CD4 cell count decreased from 420 to 95/mm³ and a regimen of zidovudine, lamivudine and didanosine were used as HAART. After 6 cycles of R-CHOP, the follow-up CT revealed marked regression in the size of the lymph nodes at both internal jugular channels (Figure 6B). He is currently under follow-up for the lymphoma.

A 67-year-old male was admitted to our hospital because of a protruding swollen chest wall mass on his right side, and he had noticed this mass for 1 month. He also had a complaint of night sweats. His past medical history included an electrical burn about 30 years ago and herpes zoster four months prior to this admission. Serological HIV positivity was detected four months ago while he was being treated for his herpes. His HIV infection was assumed to be transmitted through blood transfusion. He denied ever having homosexual contact or drug abuse. He was on zidovudine, lamivudine and lopinavir. On admission, his blood pressure was 120/80 mmHg, the pulse rate 68/min, the respiration rate 18/min and the body temperature was 36.2℃. The patient appeared generally well on physical examination. The heart and lungs sounds were normal. A chest wall mass measuring 15 cm × 18 cm in diameter was palpable on the right side of his chest. The laboratory finding were as follows: hemoglobin 12.2 g/dL, WBC 6,990/mm³ (neutrophils: 36.5%, lymphocytes: 52.5% and monocytes: 8.9%), platelets 131,000/mm³, ESR 8 mm/h, AST 37 IU/L, ALT 22 IU/L, total bilirubin 0.55 mg/dL, LDH 2,024 IU/L, protein 6.5 g/dL, albumin 3.5 g/dL, BUN 13.7 mg/dL, creatinine 1.2 mg/dL, calcium 7.6 mg/dL, phosphorus 3.4 mg/dL, Na 139 mmol/L, K 4.3 mmol/L, the total number of CD4 and CD8 T lymphocytes was 317/mm³ and 3,085/mm³, respectively, and the ratio of CD4/CD8 was 0.1. The chest X-ray was unremarkable except for marked soft tissue swelling of the right chest wall. The initial chest CT (Figure 8A) showed extensive heterogeneously infiltrative lesions that involved the right side of the chest wall musculature with accompanying edematous change of the overlying skin and subcutaneous layer. The microscopic finding of the mass showed a starry-sky pattern with diffuse proliferation of small to medium sized neoplastic cells (Figure 9A). Immunohistochemical examination showed positivity for CD20 (Figure 9B). The pathological diagnosis was Burkitt's lymphoma. The patient received 4 cycles of dose adjusted EPOCH regimen (a 4-day infusion of etoposide 50 mg/m², doxorubicin 10 mg/m² and vincristine 0.4 mg/m² with dose-adjusted cyclophosphmide 375 mg/m² on day 5 and prednisone 60 mg/m² for 5 days) every 3 weeks. Granulocyte colony-stimulating factor was used uniformly, beginning at day 6, and all HAART was withheld until day 6 of the last dose of chemotherapy. The soft tissue lesion responded very well to chemotherapy. The chest wall mass decreased in size after the first cycle of chemotherapy. After four cycles of chemotherapy, follow-up CT revealed marked regression of the lymphoma in the right chest wall (Figure 8B). He is currently alive and well in a state of complete remission of the lymphoma for more than 18 months.