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Int J Clin Exp Pathol 2013;6(3):536-542

Case Report
Acute kidney injury and inflammatory immune reconstitution syn-drome in mixed
genotype (A/E) hepatitis B virus co-infection in HIV-associated lymphoma

Katsushi Tajima, Kei Kohno, Yosuke Shiono, Ikuko Suzuki, Yuichi Kato, Yuki Hiroshima, Masakazu Yamamoto, Hiroya Ohtake, Aki-ko Iwaba,
Mitsunori Yamakawa, Takeo Kato

Department of Radiation Emergency Medicine, National Institute of Radiological Sciences, Chiba, Japan; Department of Pathology, Yamaga-ta
University School of Medicine, Yamagata, Japan; Department of Neurology, Hematology, Metabolism, Endocrinology, and Diabetology
(DNHMED), Yamagata University School of Medicine, Yamagata, Japan

Received Devember 4, 2012; Accepted Devember 29, 2012; Epub February 15, 2013; Published March 1, 2013

Abstract: We report a first case of HIV-associated lymphoma (HAL) presenting with acute kidney injury (AKI) and inflammatory immune
reconstitution syndrome (IRIS). A 39-year-old male, treated with nonsteroidal anti-inflammatory drugs (NSAIDs) for one month prior to
admission, developed AKI, left testicular tumor, and recurrent swelling of the right parotid gland. A resected testicular tumor exhibited features
intermediate between diffuse large B-cell lymphoma and Burkitt lymphoma. Renal biopsy showed hydro-degeneration of renal tubules,
interstitial inflammatory cells, and a small number of lymphoma cells in the sub-capsule, compatible with acute interstitial nephritis. His renal
dysfunction rapidly recovered following chemotherapy and combination antiretroviral therapy (cART). He developed pneumonia concomitantly
with a decrease in HIV-RNA level and an increase in CD4+ cells after the first cycle of chemotherapy, which spontaneously resolved after the
second cycle of chemotherapy without additional anti-infection drugs; thus, his pneumonia fulfilled the diagnostic criteria for IRIS. We suggest
that IRIS may frequently develop during chemotherapy for HAL, but may be overlooked. He was coinfected with hepatitis B virus (HBV), which
genotypes known as is associated with liver-related mortality and response to antiviral therapy; recently, an intimate interplay between HIV and
HBV in the onset of lymphoma has been reported. Therefore, we addressed the HBV ge-notype in the patient. The analysis revealed that he
exhibited a mixed genotype (A/E) not native to Japan and primarily found in Europe and North America or West Africa. These findings suggest
that universal vaccination for juveniles against HBV is warranted in Japan. (IJCEP1212004).

Keywords: Hepatitis B virus, HIV, genotype, immune reconstitution inflammatory syndrome, acute kidney injury, ptosis

Address correspondence to: Dr. Katsushi Tajima, The Department of Radiation Emergency Medicine, National Institute of Radi-ological
Sciences, 4-9-1, Anagawa, Inage-ku, Chiba-shi, Chiba, 263-8555, Japan. Phone: +81-43-379-7808; Fax: +81-43-206-4094; E-mail: