Case Presentation:
A 50-year-old male with Human Immunodeficiency Virus (HIV) was admitted with complaints of 1-2 months of progressive dyspnea on exertion, dry cough, subjective fevers, night sweats and approximately 15 pounds of weight loss. He had previously been on antiretrovirals (ARVs) for 3 years but discontinued therapy 1 year prior due to social issues. There were no recent exposures to tuberculosis (TB), no history of incarceration, homelessness, substance use, recent travel, or sick contacts. Past medical history was notable for Pneumocystis jiroveci pneumonia (PCP), syphilis, herpes zoster, oral candidiasis and genital HSV. Initial vital signs with heart rate 106, respirations 22 and O2 saturation 96% on room air. Physical exam on admission was notable for cachexia, evidence of oral thrush, no lymphadenopathy, diminished breath sounds at the left base and no skin lesions noted. Chest x-ray showed an ill-defined opacity in the posterior left lower lobe. Empiric treatment for community-acquired pneumonia and PCP were initiated. Labs showed CD4 190 cells/mm3 and viral load 119,022 copies/mL. CT of the chest revealed diffuse subpleural ground glass opacities. Further work-up included negative induced sputum for DFA and AFB, bronchoscopy with multiple areas of flat black/dark purple discoloration throughout the airways, positive beta-D-glucan and positive quantiferon test. A more thorough mucosal exam revealed a subtle 3x3mm bluish-violet patch on the left hard palate, but still no cutaneous lesions. He was discharged with diagnoses of PCP, possible pulmonary Kaposi’s sarcoma (KS), oral candidiasis and latent TB infection (LTBI). Following discharge, biopsy of the hard palate lesion was consistent with KS. PET/CT showed hypermetabolic pelvic lymph nodes and increased activity in the lower esophagus, stomach and rectum/anus. EGD/colonoscopy were negative. He has been managed with ARVs as well as Doxil for visceral KS.
Discussion:
Kaposi’s sarcoma (KS) is the most common HIV-related malignancy and it occurs primarily in men who have sex with men. Visceral involvement as the initial manifestation of KS is relatively uncommon. The presumptive diagnosis of pulmonary KS is often clinical based on epidemiologic features, the presence of mucocutaneous lesions, the patients’ degree of immunodeficiency, radiographic features, the appearance of endobronchial lesions and the exclusion of other processes. The mainstay of treatment is ARVs; however, systemic chemotherapy is often added for symptomatic visceral involvement given poor prognosis without it.
Conclusions:
Pulmonary KS can be an elusive clinical diagnosis because the accompanying respiratory symptoms and radiographic findings can mimic a variety of other infectious and neoplastic processes seen in HIV-infected patients. However it should be included in the differential of severely immunosuppressed HIV-infected patients with respiratory symptoms, even in the absence of cutaneous lesions.