[Quiz] A man with lesions in mouth and over the trunk

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A 35-year-old white man presents at a walk-in clinic with a complaint of lesions in his mouth and over his trunk. These lesions developed over the past several months. His medical history is unremarkable.

He states that he is homosexual, that he has practiced unsafe sex in the past, and that he has had the same partner for the past 18 months. He denies having previously had any sexually transmitted diseases, but he says he has not had regular health care visits since high school.

On examination, you note numerous purple-red, oval papules distributed on the trunk and two deep-purple plaques on the soft palate and buccal mucosa. The patient also has several small, firm, nontender, palpable lymph nodes in the posterior cervical, axillary, and inguinal chains. Results of routine blood work are unremarkable except for a white blood cell count of 3,000 cells/mm3 and a differential with 5% lymphocytes.

Which of the following statements regarding our current knowledge of Kaposi sarcoma (KS) is false?
❑ A. Human herpesvirus 8 (HHV-8) plays an etiologic role exclusively in
HIV-associated KS
❑ B. Visceral organ (i.e., lung and GI tract) involvement is relatively common
in HIV-associated KS
❑ C. If HIV infection is confirmed, initiation of highly active antiretroviral
therapy (HAART) in this patient would likely lead to dramatic
improvements in the lesions during the first few months of therapy
❑ D. Male sex is a significant risk factor for the condition, especially in the
classic form of the disease
❑ E. Total CD4+ T cell count is the most important factor predictive of survival
in the form of this disease associated with HIV

Answer will be given on Sunday 4th April 2010


Answer


Answer: A—Human herpesvirus 8 [HHV-8] plays an etiologic role
exclusively in HIV-associated KS


Discussion


This patient is a homosexual man who presents with skin and oral lesions typical of KS.The additional findings of generalized lymphadenopathy and lymphopenia strongly suggest that the patient is infected with HIV.

In its classic form, KS affects elderly men, primarily
of Mediterranean descent, and manifests as violaceous plaques and nodules on the lower extremities. Among HIV-infected patients, homosexual men have by far the highest incidence of KS.

Recently, it has been shown that HHV-8 can be detected in all variants of KS, suggesting an etiologic role.

HIV-associated KS presents as oral lesions or cutaneous lesions on the upper
body. They often follow the skin lines in a pityriasis rosea-like distribution. KS can involve the pulmonary and gastrointestinal systems and can cause hemorrhage at these sites. As such, a chest x-ray and fecal occult blood test should be considered when evaluating patients newly diagnosed with HIV-associated KS.

The single most important prognostic
factor in HIV-associated KS is the CD4+ T cell count. Large tumor burdens, lymphedema, and pulmonary involvement also portend a poorer outcome.

HAART is often first-line
therapy in treating KS, especially in a patient with newly diagnosed AIDS. The improvement in viral load and CD4+ T cell counts is often accompanied by regression of KS lesions. Other therapeutic options include radiation, intralesional chemotherapy injections, and systemic chemotherapy, including liposomally encapsulated anthracyclines such as doxorubicin and daunorubicin.



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