Abstract
A 54-year-old male with AIDS based on a CD4 count of 48, and viral load of 71653 IU/ml was admitted to our institution for evaluation of ongoing fevers, chills, night sweats, and pancytopenia. His evaluation included a bone marrow aspiration and biopsy which showed diffuse infiltration by classical Hodgkin lymphoma. He had rapidly progressive cholestatic liver abnormalities with a bilirubin that peaked at 27.8 mg/dl. He underwent a liver biopsy which also showed involvement by classical Hodgkin lymphoma. His mental status deteriorated rapidly and he developed acute kidney injury with a peak creatinine of 2.65 mg/dl. He was not a suitable candidate for conventional chemotherapy with ABVD because of his deteriorating kidney function and abnormal hepatic profile. It was then decided to treat him with carboplatin and gemcitabine which he received on day #1, followed by another dose of gemcitabine on day #14. His total bilirubin improved but eventually plateaued at 6 mg/dl on day 28. With no good therapeutic options, he was given a dose of brentuximab 1.4 mg /m2 on day #34. Following this single dose, his bilirubin improved, his mental status changes resolved and his creatinine stabilized at 1.3 mg/dl. The patient continued to improve clinically during his hospital stay and was eventually discharged home on day #37
Because of persistent cytopenias, he had repeat bone marrow biopsy done on day #54. The bone marrow showed patchy cellularity ranging from 20 to 80%, all normal hematopoietic elements and no evidence of Hodgkin lymphoma by morphology. Eventually his cytopenias started to improve on day # 57. Since his discharge from the hospital, he has received two additional doses of brentuximab (at the dose of 1.4mg/kg) as an outpatient and now on day #150 he continues to do well with normal total bilirubin (o.3 mg/dl), creatinine (1.3 mg /dl), and normal absolute neutrophil count (2.02 k/µl). His viral load is now undetectable and his CD 4 count is 64. His only adverse event is grade 1 peripheral neuropathy involving the toes.
Based on our single case experience, we think that brentuximab vedotin could offer an option of therapy for patients with advanced stage Hodgkin lymphoma, severe hyperbilirubinemia from hepatic involvement, and acute kidney injury who cannot be treated with standard therapy due to organ dysfunction. Additionally, our patient with advanced HIV experienced no significant ill effects of Brentuximab administration in terms of response of the HIV disease to ART therapy. He rapidly achieved HIV PCR negativity and his CD 4 count is on the rise from baseline. We think that additional studies should be done to establish the safety and efficacy of this approach in this group of patients with no other good options for therapy as well as in HIV infected patients.
Off Label Use: Brentuximab Vedotin is an antibody drug conjugate directed at CD30 and is used in the treatment of refractory Hodgkin lymphoma after failure of at least 2 prior chemotherapy regimens. We describe in our presentation the use of Brentuximab Vedotin in Hodgkin lymphoma after 1 prior therapy.
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