THE EXPLOSIVE INFILTRATE

SESSION TITLE: Lung Cancer SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Lung Cancer and HIV present diagnostic and therapeutic difficulties in the setting of low CD4 counts. Here we report a case of AIDS and post obstructive pneumonia secondary to lung squamous cell carcinoma. CASE PRESENTATION: A 64-year-old man with HIV on Genvoya with poor adherence was brought to our hospital for cough and shortness of breath. Vital signs were stable and physical exam was significant for decreased breath sounds in the RUL field and bilateral crackles. CT chest on admission was consistent with RUL consolidation, patchy ground-glass opacity of the RML and mediastinal lymphadenopathy. He was found to have a CD4 count of 53 and RNA viral load of 214,644 copies/mL. Considering patient’s physical, radiological findings, and Alveolar arterial O2 gradient found on the ABG, he was started on treatment for CAP and presumed PJP. A BAL revealed a large endobronchial lesion in the RUL, but no biopsy obtained due to bleeding. The evening after bronchoscopy he developed significant respiratory distress. Repeat imaging showed improvement of the RUL consolidation with an underlying perihilar mass and new diffuse, symmetric bilateral ground glass opacities in mid and upper lung zones. Sputum culture, AFB, and PCP PCR were negative. He was taken for left lower lobe wedge resection for assessment of ILD and RUL endobronchial biopsy of the mass in the OR. Wedge biopsy results were consistent with diffuse alveolar damage, endobronchial biopsy showed squamous cell carcinoma. During multidisciplinary discussions for intervention vs. initiation of HAART, his respiratory status declined further and imaging confirmed worsening groundglass opacification requiring intubation. After discussion with HCP, he underwent a palliative wean and hospice care. DISCUSSION: The increased propensity of HIV infected individuals to develop lung cancer is considered to be multifactorial –including genomic instability, toxic effects of HAART, higher incidence of smoking, and oxidative stress(1). The immunosuppressive state, interaction with the HAART and concomitant comorbidities limit the use of chemotherapy and make the question of initiating treatment challenging. Surgery is limited as they are more prone to postoperative complications and decreased survival (2). The disparity between the treatments provided to HIV-infected patients with lung cancer (3) cannot be overlooked and attempts should be made for earlier diagnosis and treatment guidelines. CONCLUSIONS: HIV-infected individuals are more prone to lung cancer at a younger age, but guidelines for screening are the same as the general population. Low CD4 counts are associated with poor outcomes and there is limited data regarding chemotherapy and its interactions with HAART. Larger prospective trials are needed to assess the screening, diagnostic and treatment approaches for lung cancer in advanced HIV so as to reduce the human and financial burden. Reference #1: 1) Cadranel J, Garfield D, Lavolé A, Wislez M, Milleron B, Mayaud C. Lung cancer in HIV infected patients: facts, questions and challenges. Thorax. 2006;61(11):1000-1008. https://doi.org/10.1136/thx.2005.052373. Reference #2: 2) Hooker CM, Meguid RA, Hulbert A, et al. HIV-Infection as a Prognostic Factor in Surgical Patients with Non-Small Cell Lung Cancer. The Annals of Thoracic Surgery. 2012;93(2):405-412. https://doi.org/10.1016/j.athoracsur.2011.11.012. Reference #3: 3) Suneja G, Shiels MS, Melville SK, Williams MA, Rengan R, Engels EA. Disparities in the treatment and outcomes of lung cancer among HIV-infected individuals. AIDS (London, England). 2013;27(3):459-468. https://doi.org/10.1097/QAD.0b013e32835ad56e. DISCLOSURES: No relevant relationships by Erica Altschul, source=Web Response No relevant relationships by Bushra Mina, source=Web Response No relevant relationships by Naureen Narula, source=Web Response