Letter - Tropical/Infectious and parasitic dermatology
Rapidly progressive Kaposi’s sarcoma associated with human immunodeficiency syndrome
Camila Gonçalves Pinheiroa,
, Francisco de Assis Silva Paivab, Isabelle Sousa Medeiros Torres Ferreirac, Gabriela Teixeira Viana Suppa Meiraa, Antônio Carlos Evangelista de Araújo Bonfima, Luciana Cavalcante Trindadea,d
Corresponding author
a Dermatology Service, Nova Esperança Faculty of Medicine, João Pessoa, PB, Brazil
b Infectology Service, Complexo Hospitalar Clementino Fraga, João Pessoa, PB, Brazil
c Centro de Diagnóstico Anatomopatológico, João Pessoa, PB, Brazil
d Dermatology Service, Complexo Hospitalar Clementino Fraga, João Pessoa, PB, Brazil
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He reported having sex with men. On physical examination, he had a violaceous, infiltrated tumor with areas of leukoplakia, which occupied about 70% of the hard palate (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). In addition, he had non-painful purpuric lesions, violaceous papules, nodules and tumors on the face, scalp, cervical region, axillae and trunk, oval in shape and of different sizes (<a class="elsevierStyleCrossRefs" href="#fig0010">Figs. 2 and 3</a>). Serological tests confirmed HIV and syphilis infection. The CD4 lymphocyte count was 129<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">3</span> at the time of the diagnosis. Histopathology of a violaceous skin lesion showed an atypical vascular proliferation affecting the dermis and on immunohistochemistry positivity for CD31 and herpes virus 8 (HHV-8), confirming the diagnosis of KS (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). Chest radiography and upper digestive endoscopy were performed, which showed no changes suggestive of malignancy. Antiretroviral therapy (ART) and systemic chemotherapy were started during hospitalization, with initial improvement of the lesions and overall condition. In the follow up, a new CD4 cell count was requested three months after the start of ART, disclosing a value of 320 cells/mm<span class="elsevierStyleSup">3</span>, demonstrating improvement in relation to the first test. However, after approximately eight months, the patient returned to the Infectious Diseases Unit with respiratory distress and hematemesis. He was transferred to the ICU of the Oncology Unit, with rapid progression to death without due clarification of the cause of the bleeding.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">KS is an endothelial malignancy and the epidemic clinical form is associated with HIV infection. Its causes and risk factors include herpesvirus type 8 infection, immunosuppression, genetic predisposition, and the presence of HLA DR5.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">It may be the first manifestation of AIDS and indicates late diagnosis. The clinical manifestations of KS include asymptomatic violaceous, erythematous or brownish macules that progress to papules, plaques or tumors, which may bleed or ulcerate. There may be concomitant involvement of the gastrointestinal tract, lungs, lymph nodes, bones, and liver.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">On histopathology, the initial lesions show proliferation and dilation of the dermal vessels, with large endothelial cells; perivascular infiltrate of lymphocytes and plasma cells, extravasated erythrocytes and hemosiderin deposits. In the plaque and nodular stage, there is a proliferation of blood vessels and atypical spindle cells.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> There is also immunoreactivity with endothelial cell markers, such as CD34 and CD31.</p><p id="par0030" class="elsevierStylePara elsevierViewall">After the implementation of ART in AIDS, there has been a reduction in the frequency of KS.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Drugs have led to the regression of cutaneous and visceral lesions, possibly through direct anti-angiogenic effects and immune restoration.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The decrease in KS cases may also be due to the lower number of AIDS cases among homosexual/bisexual men since this neoplasm characteristically affects this population.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Treatment includes both local and systemic therapies and depends on factors such as the KS subtype, the course of the disease, its extent, and the patient's symptoms. The management of localized lesions includes radiotherapy, surgical excision, cryosurgery and laser. If there are multiple skin lesions and/or visceral involvement, chemotherapy is indicated. As for the HIV-related KS subtype, ART is the first treatment option.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The prognosis and evolution of KS are related to immunosuppression and the presence of opportunistic infections.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Despite the reduction in AIDS detection rate in Brazil in recent years,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> sexual intercourse remains the main transmission route among men. Thus, health education and ongoing debates on the topic remain relevant to encourage prevention and an early diagnosis of HIV infection.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0045" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors' contributions</span><p id="par0050" class="elsevierStylePara elsevierViewall">Camila Gonçalves Pinheiro: Collection of data, drafting of the manuscript.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Francisco de Assis Silva Paiva: Collection of data.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Isabelle Sousa Medeiros Torres Ferreira: Collection of data.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Gabriela Teixeira Viana Suppa Meira: Collection of data.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Antônio Carlos Evangelista de Araújo Bonfim: Collection of data.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Luciana Cavalcante Trindade: Critical review to obtain intellectual content, and approval of the final version of the manuscript.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0080" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Financial support" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Authors' contributions" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2021-08-31" "fechaAceptado" => "2021-12-13" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Study conducted at the Dermatology Outpatient Clinic, Dermatology Service, Nova Esperança Faculty of Medicine, João Pessoa, PB, Brazil.</p>" ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1244 "Ancho" => 1675 "Tamanyo" => 343647 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0065" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Infiltrated violaceous tumor and areas of leukoplakia on the palate.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1605 "Ancho" => 3341 "Tamanyo" => 385581 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0070" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Non-painful purpuric lesions, violaceous papules, nodules and tumors of varying sizes on the armpit, upper limb, cervical region and trunk.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1350 "Ancho" => 3341 "Tamanyo" => 608013 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0075" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Non-painful papules, nodules and violaceous tumors on the face and scalp, of varying sizes.</p>" ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1526 "Ancho" => 3341 "Tamanyo" => 909598 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0080" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">(A) Atypical vascular proliferation, with irregular vessels and endothelial atypia (Hematoxylin & eosin, low power). (B) Detail of the vascular neoplasia (Hematoxylin & eosin, ×100). (C) Immunohistochemistry of the skin fragment showing positivity for human herpes virus 8 (HHV8). (D) Immunohistochemistry of the skin fragment showing positivity for the endothelial cell marker CD31.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "HIV/AIDS e Treinamento Concorrente: a revisão sistemática" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A.R. Lazzarotto" 1 => "L.F. Deresz" 2 => "E. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 14 | 6 | 20 |
| 2024 October | 95 | 81 | 176 |
| 2024 September | 150 | 84 | 234 |
| 2024 August | 154 | 106 | 260 |
| 2024 July | 125 | 100 | 225 |
| 2024 June | 97 | 68 | 165 |
| 2024 May | 88 | 59 | 147 |
| 2024 April | 101 | 80 | 181 |
| 2024 March | 98 | 64 | 162 |
| 2024 February | 91 | 81 | 172 |
| 2024 January | 79 | 54 | 133 |
| 2023 December | 71 | 65 | 136 |
| 2023 November | 81 | 89 | 170 |
| 2023 October | 74 | 78 | 152 |
| 2023 September | 104 | 74 | 178 |
| 2023 August | 67 | 30 | 97 |
| 2023 July | 88 | 33 | 121 |
| 2023 June | 72 | 49 | 121 |
| 2023 May | 75 | 27 | 102 |
| 2023 April | 127 | 32 | 159 |
| 2023 March | 114 | 60 | 174 |
| 2023 February | 75 | 40 | 115 |
| 2023 January | 69 | 68 | 137 |
| 2022 December | 76 | 62 | 138 |
| 2022 November | 8 | 9 | 17 |
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