A 34-year-old human immunodeficiency virus (HIV)-infected man, who had received highly active antiretroviral therapy (HAART) for about 3 weeks with initial low CD4 count (84 cells/μL), presented to the hospital with dyspnea. Physical examination did not reveal any significant skin lesion. The patient developed melena during hospitalization, and the hemoglobin dropped to 5.8 g/dL from 11.4 g/dL within 1 week.
The esophagogastroduodenoscopy and colonoscopy showed multiple 0.5- to 1.0-cm reddish maculopapular and polypoid lesions at the esophagus (Fig. 1a), stomach (Fig. 1b), colon (Fig. 1d), and with central ulceration at the duodenum (Fig. 1c), which were not present in his previous esophagogastroduodenoscopy 1 month ago. Biopsies revealed lamina propria-based lesion composed of a focal proliferation of spindle cells in fascicles with interstitial erythrocytes (Fig. 2a,b). Human herpesvirus 8 staining (Fig. 2c) was positive. An inclusion body was detected, and the cytomegalovirus (CMV) staining (Fig. 2d) was positive. In addition to the pathological characteristics of Kaposi's sarcoma, CMV stain showed positive-staining cells in the specimens of the stomach, duodenum, and colon, compatible with Kaposi's sarcoma with CMV coinfection.
(a) A 2-cm erythematous polypoid lesion above the esophagogastric junction. (b) Multiple 0.5- to 1.5-cm erythematous maculopapular or polypoid lesions at the prepyloric area. (c) Numerous 1- to 2-cm erythematous polypoid lesions with central ulceration at the duodenum. (d) Several 0.5- to 1-cm erythematous maculopapular or polypoid at the ascending colon.
(a, b) The hematoxylin and eosin (HE) stain showed gastric mucosal tissue with proliferation of spindle cells arranged in fascicles in association with erythrocytes interstitially. (c) The human herpesvirus 8 (HHV8) stain is positive. (d) The cytomegalovirus (CMV) stain is positive.
Kaposi's sarcoma is a low-grade tumor of the vascular endothelium, often associated with HIV. The manifestation of gastrointestinal Kaposi's sarcoma is variable, and can be asymptomatic or can cause gastrointestinal symptoms such as nausea, vomiting, malabsorption, and gastrointestinal bleeding. There are different endoscopic characteristics of Kaposi's sarcoma, such dark pink or scarlet maculopapular, polypoid lesion, or volcano-like lesions. The pathological findings include spindle cells with cytologic atypia, extravasated red blood cells, and lymphocytic and plasma cell infiltrate. Improvement in immunologic function after the initiation of HAART may unmask previous unrecognized preexisting infection, as also known as immune reconstitution inflammatory syndrome. In our case, the rapid progression of gastrointestinal Kaposi's sarcoma with CMV coinfection could be one of the manifestations of immune reconstitution inflammatory syndrome, a significant but uncommon clinical problem in the post-HAART era. Furthermore, endoscopic biopsies may still carry a risk of false-negative results, especially for the lesion in esophagus, with small size (< 1 cm) or localized in submucosa. Caution should be taken in performing endoscopy in HIV-infected patients, even for those who had received HAART.
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