Commentary: Chylothorax in an HIV-infected Patient

Pablo Tebas, MD, Associate Professor of Medicine, University of Pennsylvania, Philadelphia, Pa

Pneumocystis carinii

In 1981, clinicians in Los Angeles and other parts of the United States started to see an unusual cluster of homosexual men with 2 infrequent diseases, pneumonia¹ and Kaposi's sarcoma (KS).²Anew, devastating epidemic had just been recognized. Since then, we have learned more about HIV infection and AIDS than most other diseases in the history of humankind. In 3 years, the causative agent was identified and, in 15 years, thanks to the discovery of combination highly active antiretroviral therapy (HAART), what once was a fatal disease has become a manageable disease for patients who live in countries that provide access to these life-saving medications.³

HIV infection or AIDS was, and still is, a stigmatizing disease. In the 1980s, having cutaneous KS was the equivalent of carrying a sign that said, "I have AIDS." It is difficult for young physicians who did not live those days to realize how devastating it was, both physically and psychologically, for a patient to have this complication. Things have changed for the better, but physical stigma still exist for many patients. Indeed, currently the most stigmatizing physical finding for HIV-infected patients is related to the treatment of this disease rather than the disease itself, namely, the lipoatrophy associated with antiretroviral therapy.

Mycobacterium avium-intracellulare

Dr Margolis and colleagues describe a patient with an unusual complication of his HIV-associated KS, chylothorax. Everything seems to fit, and, although unusual, it appears that his chylothorax might be secondary to his KS. However, HAART has taught us that things are not that simple anymore. Successful antiretroviral treatment results in immune reconstitution. Infections that were previously impossible or difficult to treat, such as cryptosporidiosis, azole-resistant thrush, cytomegalovirus retinitis, , or progressive multifocal leukoencephalopathy, have changed their naturally inexorable courses. KS has not been exempted from this change, and HAART has simultaneously decreased its perceived incidence and improved its prognosis.⁴ However, this has not been the result of a decreased transmission of KS herpesvirus (also known as herpesvirus type 8), the causative agent of KS, but probably the result of the improved immune system of coinfected patients.⁵

The patient described in this case has a well-controlled HIV RNA viral load and an elevated CD4⁺ cell count. We should take a second look at our assumptions. Maybe what looks clear is not so clear. That is what Dr Margolis and colleagues want us to do. They make a strong case that the patient's problem is likely related to a previous surgery and not to KS or HIV infection. As they try to convince us, they do a superb review of the causes of chylothorax in HIV infection. And as often happens in clinical medicine, we cannot be absolutely certain that the new explanation is the truth, but it certainly makes more sense than the alternatives.

The main lesson from this case is that patients with well-controlled HIV infection can have other complications that are completely unrelated to their disease. It is necessary to see patients in their clinical context, specifically their degree of immune suppression if they have not started therapy, and their degree of immune reconstitution after starting therapy.

Remember to keep an open mind and consider all possibilities (HIV related or not) when you see the next unusual complication in an HIV-infected patient. Today, it is more true than ever that AIDS and HIV infection have replaced syphilis in the old aphorism of Sir William Osler: "Know syphilis in all its manifestations and relations, and all other things clinical will be added unto you."⁶

Pneumocystis carinii

N Engl J Med

1. Gottlieb MS, Schroff R, Schanker HM, et al. pneumonia and mucosal candidiasis in previously healthy homosexual men: evidence of a new acquired cellular immunodeficiency. . 1981;305:1425-1431.

Ann Intern Med

2. Fauci AS. The syndrome of Kaposi's sarcoma and opportunistic infections: an epidemiologically restricted disorder of immunoregulation. . 1982;96:777-779.

N Engl J Med

3. Palella FJ Jr, Delaney KM, Moorman AC, et al, for the HIV Outpatient Study Investigators. Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection. . 1998;338:853-860.

J Acquir Immune Defic Syndr

4. Jones JL, Hanson DL, Dworkin MS, et al. Effect of antiretroviral therapy on recent trends in selected cancers among HIV-infected persons. Adult/Adolescent Spectrum of HIV Disease Project Group. . 1999;21(suppl 1):S11-S17.

JAMA

5. Osmond DH, Buchbinder S, Cheng A, et al. Prevalence of Kaposi's sarcoma-associated herpesvirus infection in homosexual men at beginning of and during the HIV epidemic. . 2002;287:221-225.

Sir William Osler: Aphorisms from His Bedside Teachings

and Writings.

6. Bean RB. Collected by Robert Bennett Bean, M.D. (1874-1944). Springfield, Ill: Charles C. Thomas, 1968.