The CD4 lymphocyte plays a pivotal role in both sarcoid and HIV infection. Sarcoidosis is CD4 mediated and symptomatic HIV is CD4 depleted. Concurrent HIV infection and sarcoidosis has rarely been reported. The management of a patient with both conditions represents a diagnostic and therapeutic challenge. We describe a patient in whom these two conditions coexist and review the literature.
A 41-year-old African American female was diagnosed with biopsy proven cutaneous sarcoidosis in 1992. She did not have pulmonary symptoms but the chest radiograph revealed mild bilateral interstitial infiltrates. During 1996 she was started on highly active anti-retroviral therapy (HAART) for newly diagnosed HIV disease with poor medical compliance (CD4/CD8 228/804, ratio 0.28). In 2000 she presented with a 4-week history of exertional dyspnea, dry cough and orthopnea. Physical examination revealed small submandibular lymph nodes and clear lungs on auscultation. Chest radiograph revealed worsening bilateral infiltrates. Serum CD4/CD8 ratio was 0.83 (435/524). The angotensin-1-converting enzyme was slightly elevated at 56U/L. The broncho-alveolar lavage (BAL) fluid had a CD4/CD8 ratio of 1.4. Transbronchial biopsies showed non-caseating granulomas. All cultures were negative. The patient was treated with corticosteroids with marked clinical and radiographic improvement.DISCUSSION: To our knowledge, only 3 cases of sarcoidosis and HIV infection with CD4/CD8 ratio more than 1.0 in the BAL have been reported. This patient was found to have a relatively elevated CD4/CD8 ratio in the BAL compared to her serum, suggesting that active sarcoid rather than HIV disease was the etiology for her pulmonary disease. This raises the possibility of “immune reconstitution syndrome” which may have worsened her sarcoidosis as a result of treatment of HIV disease with HAART. The well-defined non-caseating granulomas on lung biopsy suggest sarcoidosis as CD4 lymphocyte depletion may attenuate granuloma formation.
Sarcoidosis should be considered in the differential diagnosis of HIV patients with pulmonary symptoms while on HAART. In patients with coexisting sarcoidosis and HIV, the CD4/CD8 ratio in the BAL fluid may be diagnostically helpful.
F.A. Almeida, None.