title: Fulminant anaplastic large cell lymphoma (ALCL) concomitant with primary cytomegalovirus (CMV) infection, and human herpes virus 8 (HHV-8) infection together with Epstein-Barr-virus (EBV) reactivation in a patient with asymptomatic HIV-infection.
abstract: BACKGROUND
  Most malignant lymphomas in HIV-patients are caused by reactivation of EBV-infection. Some lymphomas have a very rapid fulminant course. HHV-8 has also been reported to be a cause of lymphoma. The role of CMV in the development of lymphoma is not clear, though both CMV and HHV-8 have been reported in tissues adjacent to the tumour in Burkitt lymphoma patients. Here we present a patient with asymptomatic HIV infection, that contracted a primary cytomegalovirus (CMV) infection and human herpes virus 8 (HHV-8) infection. Three weeks before onset of symptoms the patient had unprotected sex which could be possible source of his CMV and also HHV-8 infection He deteriorated rapidly and died with a generalized anaplastic large cell lymphoma (ALCL).
  
  
  METHODS
  A Caucasian homosexual male with asymptomatic human immunodeficiency virus (HIV) infection contracted a primary cytomegalovirus (CMV) infection and human herpes virus 8 (HHV-8) infection. He deteriorated rapidly and died with a generalized anaplastic large cell lymphoma (ALCL). Clinical and laboratory records were compiled. Immunohistochemistry was performed on lymphoid tissues, a liver biopsy, a bone marrow aspirate and the spleen during the illness and at autopsy. Serology and PCR for HIV, CMV, EBV, HHV-1-3 and 6-8 was performed on blood drawn during the course of disease.
  
  
  RESULTS
  The patient presented with an acute primary CMV infection. Biopsies taken 2 weeks before death showed a small focus of ALCL in one lymph node of the neck. Autopsy demonstrated a massive infiltration of ALCL in lymph nodes, liver, spleen and bone marrow. Blood samples confirmed primary CMV- infection, a HHV-8 infection together with reactivation of Epstein- Barr-virus (EBV).
  
  
  CONCLUSIONS
  Primary CMV-infection and concomitant HHV-8 infection correlated with reactivation of EBV. We propose that these two viruses influenced the development and progression of the lymphoma. Quantitative PCR blood analysis for EBV, CMV and HHV-8 could be valuable in diagnosis and treatment of this type of very rapidly developing lymphoma. It is also a reminder of the importance of prevention and prophylaxis of several infections by having protected sex.
authors.affiliation: Department of Microbiology, Tumor and Cell Biology (MTC), Karolinska Institute, Box 280, Stockholm, SE- 17177 Sweden ; Department of Infectious diseases/Venhälsan, Stockholm South General Hospital, Sjukhusbacken 14, SE-11883 Stockholm, Sweden.
authors.forename: Sven
authors.identifier: 0000-0002-1387-7042
authors.initials: S
authors.lastname: Grützmeier
authors.affiliation: Department of Oncology/Pathology, Karolinska Institutet, SE- 17177 Stockholm, Sweden ; Present address: Department of Laboratory Hematology, Laboratory Medicine Program, University Health Network, Toronto, ON Canada.
authors.forename: Anna
authors.initials: A
authors.lastname: Porwit
authors.affiliation: Institute of Virology, Hannover Medical School, Hannover, Germany.
authors.forename: Corinna
authors.initials: C
authors.lastname: Schmitt
authors.affiliation: Department of Infectious diseases/Venhälsan, Stockholm South General Hospital, Sjukhusbacken 14, SE-11883 Stockholm, Sweden.
authors.forename: Eric
authors.initials: E
authors.lastname: Sandström
authors.affiliation: Department of Infectious Diseases, Karolinska University Hospital, Huddinge, Sweden.
authors.forename: Börje
authors.initials: B
authors.lastname: Åkerlund
authors.affiliation: Department of Microbiology, Tumor and Cell Biology (MTC), Karolinska Institute, Box 280, Stockholm, SE- 17177 Sweden.
authors.forename: Ingemar
authors.initials: I
authors.lastname: Ernberg
keywords: ALCL; CMV-DNA; EBV latency; EBV-DNA; HHV-8 DNA; HHV-8 infection; Malignant lymphoma; Primary CMV-infection; Unprotected sex