Recurrent Respiratory Papillomatosis and Squamous Cell Carcinoma of the Lung in an HIV Positive Man

Abstract

INTRODUCTION: Recurrent respiratory papillomatosis (RRP) is a rare, benign neoplasm of the airway caused by human papilloma virus (HPV). Adults with RRP are often immunocompromised, and lesions tend to be aggressive. Malignant transformation has been reported to occur. We report a case of RRP in an HIV positive man with upper airway obstruction and recurrent squamous cell carcinoma (SCC) of the lung. CASE PRESENTATION: A 50 year old male former smoker with AIDS and recurrent sinonasal papillomas comes to the Emergency Department (ED) because of shortness of breath. Medical history includes: Hodgkin's Lymphoma, treated 5 years ago, and SCC of the lung, resected one year later. Papillomas have been treated since the time of diagnosis 10 years ago, with multiple debulking procedures and interferon. In the ED, patient reported progressive dyspnea over 3 months, a productive cough with white, non-bloody sputum, and a hoarse voice. On examination, inspiratory and expiratory stridor with mildly labored respirations was noted; room air oxygen saturation was 100%. MRI of the neck revealed a large tracheal mass causing near complete obstruction. PFTs were consistent with fixed airway obstruction. The patient was intubated, and underwent surgical debulking, plus treatment with a microdebrider and C02 laser, and intralesional injection of cidofavir. The patient was extubated 1 day post op with significant improvement. Five months later, he was readmitted for recurrent tracheal papillomas, and has since required 2 additional surgical interventions, and now is diagnosed with metastatic SCC lung cancer. DISCUSSION: RRP can be very resistant to medical and surgical treatment. This patient was refractory to medical treatment that included interferon and intralesional cidofovir. Response to Bleomycin has been reported, and was part of this patient's Hodgkin's disease chemotherapy, and may have been associated with slower growth during the treatment period. Mechanical debulking with surgical excision, microdebridement and C02 laser provide temporary benefit. Endobronchial stents are sometimes needed. A small percentage of patients demonstrate malignant transformation to SCC. HPV 11 and smoking are reported risk factors for this. Subtype data was not available for this patient. The HPV vaccine which targets HPV 11 offers hope in reducing the incidence of this frequently complicated disease. CONCLUSIONS: RRP from HPV infection can be refractory to treatment and may cause upper airway obstruction. Recurrence is expected, and malignant transformation may occur, especially in immunocompromised individuals.