HC Owen MTC 2/25: DLBCL and transgender medicine

Today our excellent R2, Dr. Kevin Wang, presented a case of a middle aged transwoman who presented with lower extremity swelling and L groin pain who was found to have new onset heart failure and also generalized lymphadenopathy. We used this case to discuss a few issues surrounding HIV patients:

a) Heart failure: patients with HIV are more likely now to suffer and pass away from chronic medical conditions such as heart failure than from complications of HIV given the success of current anti-retroviral therapies. Patients with HIV have about a 3 fold increase risk of developing CAD and also heart failure, due to the pro-inflammatory state of their HIV, their increased likelihood of co-morbid tobacco and stimulant abuse, and the side effects of older ART, specifically protease inhibitors.

b) We were able to break into groups and then go over possible differentials for generalized lymphadenopathy, using the MIAMI mnemonic (provided by the AAFP, see figure above from 2016 article on work-up of generalized lymphadenopathy) as one diagnostic schema. Our patient was ultimately diagnosed with having DLBCL and had to get modified DA-R-EPOCH regimen given she could not get doxirubicin due to her pre-existing heart failure.

c) We also spent some time discussing the nuances of caring for our transgender patients and how we can work to create a welcoming, inclusive environment that would best build a therapeutic relationship.

Special thanks to our expert discussant, Infectious Disease fellow, Dr. Stephen Rawlings for sharing his expertise on these topics!

Great case, Dr. Wang!

Clinical Pearls:

  1. The first step to avoid mis-gendering patients is to introduce yourself and your pronouns to all your patients. For additional tips consider viewing this website from UCSF: https://transcare.ucsf.edu/guidelines/clinic-environment.
  2. Transgender HIV patients are at greater risk of med nonadherence and inability to achieve viral suppression due to a number of psycho-social barriers and stigmas they face in the health care setting. To better understand their needs please read the following NEJM article: https://www.nejm.org/doi/full/10.1056/NEJMcp1903650
  3. DLBCL is one of the most prevalent malignancies in HIV patients as HIV infection can lead to chronic antigen stimulation and polyclonal B-call expansion, promoting emergence of monclonal B-cell lines. Remember to get excisional biopsies if possible (or multiple cores) in order to best preserve the lymph node architecture.

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