AIDS‐related Kaposi’s sarcoma (KS) is an angioproliferative malignancy that typically presents as asymptomatic, hyperpigmented, raised lesions on the skin. The disease is uncommon in individuals with CD4 counts over 200 and less often seen in women. However, KS can involve visceral tissue and present itself in much more dramatic fashion. We present a unique case of hemopytsis manifesting at Kaposi’s Sarcoma.
A 29‐year‐old female from Sierra Leone was admitted to the medical intensive care unit for fever and respiratory distress. She was diagnosed with AIDS four months prior with CD4 count of 18 and viral load over one million copies/mL. She was started on highly active antiretroviral therapy (HAART) therapy two weeks after diagnosis. At time of diagnosis, she was also found to have Hepatitis B and D co‐infection. Initial CXR was significant for new bilateral pneumonia. Blood and sputum cultures grew two different pseudomonas aeruginosa strains that appropriately responded to pipercillin/tazobactam. Despite antibiotic and HAART therapy, the patient developed septic shock, becoming progressively hypoxic and required non‐invasive positive pressure ventilation.. Follow up radiographic and CT imaging showed development of pleural effusions and diffuse infiltrates without cavitary lesions. On day 5 she because anuric and volume overloaded requiring continuous renal replacement therapy. Thereafter, liver failure evolved,, total bilirubin peaked at 54mg/dL with an INR of 4. She developed spontaneous frank hemoptysis requiring emergent intubation along with bronchoscopy. Diffuse, distinct, raised, purplish‐black, friable lesions were visualized throughout the bronchial segments. The extensive nature of the bleeding lesions would not allow for coagulating therapy or biopsy. Intravenous crystalloid and vasopressors, pack red blood cells, fresh frozen plasma and platelets were provided. Human herpesvirus‐8 (HSV8) viral load was over 10 million copies. Despite no biopsy, KS was suspected based on the appearance of the lesions, HSV8 viral load, and the patient’s CD4 count.
Pulmonary KS can present with pleural effusions and nodular infiltrates on imaging studies. Our patient had diffuse infiltrates without nodules accompanied by pleural effusions. Bronchoscopy findings were suggestive for KS and was the etiology leading to hemoptysis from the highly vascular lesions with underlying coagulopathy. With the involvement of non‐skin structures, low CD4 count, and presence of fever, weight loss, diarrhea and other systemic issues, the patient’s prognosis was poor based on criteria by the AIDS Clinical Staging Group for KS. It is important for clinicians to recognize that Kaposi’s sarcoma may manifest in many different ways, including hemopytsis as seen with our case. Its crucial to consider Kaposi’s sarcoma in your differential when hemopytsis is present in order to prevent delay in treatment and aggressively provide intervention to delay increased risked of morbidty and mortality.