Case Presentation:
A 26 year old man presented with 3 weeks of abdominal pain accompanied with diarrhea, nausea, and vomiting. His past medical history was significant for HIV/AIDS (CD4 170 cells/mm3) and on anti‐retroviral therapy for five months. At admission, he was febrile and oxygen saturations were 93% on room air. On exam, he had shallow inspirations, but no crackles or wheezing were auscultated. His abdomen was tender to palpation; he had axillary and inguinal lymphadenopathy. He had numerous purple lesions on his neck, chest, and back.
Laboratory evaluation of the stool was positive for occult blood. Antigen screens for CMV and C. difficile were negative. Computed tomography of the chest, abdomen, and pelvis revealed extensive lymphadenopathy. Colonoscopy and esophagogastroduodenoscopy revealed multiple erythematous nodules throughout the gastrointestinal tract consistent with Kaposi’s Sarcoma (KS). Bronchoscopy demonstrated similar lesions. Biopsied lesions all stained positive for HHV‐8.
Based on his findings, he was diagnosed with disseminated KS. Treatment was initiated with infusions of pegylated liposomal doxorubicin.
Discussion:
Diarrhea in a patient with HIV/AIDS is a common complaint. The hospitalist should develop an approach to diarrhea in this patient population. Common causes include infection, medication side effects and malignancy, as well as non‐HIV causes. A thorough history is critical to tailor the work‐up in a cost‐conscious fashion. Important questions to ask include duration, frequency and characteristics of stool, as well as weight loss. Additionally, CD4 count, history of opportunistic infections, medication history and recent medication changes can help guide clinical thinking. Labs during initial evaluation include stool studies — particularly stool cultures, ova and parasites
C.Difficile testing and acid fast staining. Endoscopy should be considered in patients with advanced immunocompromised status, persistent diarrhea or diarrhea with fever.
Kaposi’s Sarcoma (KS) is the most common tumor in HIV patients and considered an AIDS‐defining illness. Cutaneous lesions are typically the initial presentation. These elliptical papular lesions commonly occur on the lower extremities and face and can vary in color. Disseminated KS can involve the oral cavity, the gastrointestinal and respiratory tract. Symptoms of gastrointestinal KS include weight loss, abdominal pain, diarrhea and upper or lower GI bleeding. Symptoms of respiratory KS include shortness of breath, fever and hemoptysis. Diagnosis of KS is confirmed with biopsy and staining for HHV‐8, the virus that causes KS.
The goals of treatment include symptom palliation and prevention of progression. The initial step in management is to begin anti‐retroviral therapy (ART) if the patient is not already on therapy. The understanding is that ART works by immune reconstitution rather than a direct effect on the tumor. Cutaneous lesions can be treated with local symptomatic therapy. Indications for systemic chemotherapy include widespread skin involvement, extensive edema, symptomatic visceral involvement and Immune Reconstitution Inflammatory Syndrome. First‐line systemic chemotherapy is pegylated liposomal doxorubicin or liposomal daunorubicin.
Conclusions:
Hospitalists should continue to have an approach to the common complaint of diarrhea in HIV patients. Recognition of disseminated KS may lead to more aggressive therapy than initiation of anti‐retroviral therapy.