A Case of Bleeding Rectal Ulcer Caused by Kaposiʼs Sarcoma in AIDS Patient

Abstract

Introduction: AIDS-related Kaposi's sarcoma (KS) is a low-grade vascular tumor associated with human herpesvirus 8 (HHV-8) infection. We report the case of a 24 year old HIV male with rectal ulcer from disseminated KS with visceral involvement. Case: 24 year old male with AIDS/HIV (CD4 13) not on HAART, presented with rectal bleeding and weight loss. Examination revealed diffuse palpable lymphadenopathy and shiny papular, non-pruritic lesions in inguinal, scrotal and perirectal area. CT abdomen revealed lymphadenopathy and rectal inflammation. Initial infectious work up was negative for chlamydia, gonorrhea, HSV, CMV, stool for Cryptococcus, giardia, C.difficle, mycobacterium, pneumocystis smear. Colonoscopy showed large 3 cm necrotic, friable rectal ulcer and multiple focal erythematous lesions in rectum. Meanwhile, he developed epigastric pain with elevated liver tests, Ultrasound abdomen revealed new findings of splenomegaly, multiple nodules in liver concerning for abscesses vs. lymphoma. Based on findings, bone marrow and axillary lymph node biopsies were performed. Rectal ulcer and lymph node biopsies were positive for KS. The patient was diagnosed with disseminated KS involving the lung, GI tract, liver and spleen. He was started on HAART therapy. He was not a candidate for chemotherapy in view of multiorgan dysfunction. Patient eventually died. Discussion: AIDS related KS is the most common neoplasm in HIV patients, especially those with lower CD4 counts. Co-infection with HIV promotes the oncogenic capabilities of HHV-8, leading to the development of KS. KS is rare in the post HAART era. AIDS related KS preferentially affects homosexual or bisexual men. It frequently involves the skin, although extra cutaneous spread is common and may involve any organ. GI involvement is seen in 40% of untreated patients and portends a worse prognosis. Disease of the GI tract is typically asymptomatic but can present with abdominal pain, vomiting, diarrhea, weight loss, malabsorption and GI bleeding. Histopathology reveals a predominance of spindle cells. Immunohistochemical stains are positive for CD34 and CD31, which can confirm the diagnosis, although 10% of KS are CD34 negative. Treatment includes HAART therapy, chemotherapy is considered for more advanced disease using liposomal doxorubicin as the first line of treatment. KS should always be considered as a strong differential diagnosis in lesions of the gastrointestinal tract in HIV host.