A UNIQUE PRESENTATION OF PULMONARY KAPOSI SARCOMA IN A YOUNG PATIENT WITH CONCOMITANT CMV

Abstract

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Kaposi sarcoma (KS) is an AIDS-defining illness characterized by low-grade vascular tumors thought to be caused by HHV-8. Commonly described features include raised purplish skin nodules millimeters to centimeters in size on the face, groin, and lower extremities (1). Less discussed are the visceral manifestations and the co-infections which may contribute to the presentation. Our case demonstrates a young male with pulmonary KS confirmed by imaging and bronchoscopy with biopsy found to have co-infection with CMV. CASE PRESENTATION: A 29-year-old male with AIDS-related cutaneous Kaposi sarcoma (diagnosed 11/2020) presented with dyspnea, cough, hemoptysis, and lower extremity edema in 2/2021. On arrival, vitals were stable with SpO2 98% on room air. Admission labs revealed CD4 of 17, HIV viral load <30, WBC 7.4 with 1% atypical lymphocytes, AST/ALT 101/84, and negative testing for SARS-CoV-2 and influenza A/B. Chest X-ray on admission showed patchy bilateral airspace disease. CTA chest showed bilateral peribronchovascular flame-shaped ground glass opacities, bilateral pulmonary nodules, mediastinal and axillary lymphadenopathy, and moderate bilateral pleural effusions. Right thoracentesis was performed with removal of 900mL of serosanguinous fluid exudative by Light's criteria. Subsequent diagnostic bronchoscopy showed areas of thickened erythematous mucosa with predominance in the bilateral upper lobes. Bronchoalveolar lavage (BAL) revealed CMV level of 224 IU/mL without additional infectious agents. Transbronchial and endobronchial biopsy revealed neoplastic cells positive for CD31 and HHV-8, confirming pulmonary parenchymal and endobronchial KS. Patient continued with HAART and was started on liposomal doxorubicin. DISCUSSION: This case describes a young male with AIDS and cutaneous KS who presented with productive cough, dyspnea, and hemoptysis found to have pulmonary KS. An interesting aspect of this case is the possible contribution of CMV co-infection. In addition to BAL findings, imaging was consistent with aspects of both KS and CMV including flame shaped GGOs and pulmonary nodules, respectively (2,3). Also demonstrated were labs consistent with CMV, including atypical lymphocytes and moderately elevated AST/ALT (6). Interestingly, there are publications from as early as 1980 suggesting that CMV may contribute to the development of KS by working synergistically with HHV-8 (4,5). A 2009 study even went on to postulate that a particular CMV locus can activate the full KS-associated herpesvirus lytic replication cycle (7). CONCLUSIONS: Our case presents a patient with KS and CMV co-infection. CMV may directly or indirectly influence the presentation of respiratory illness in co-infected patients. Though some work has been done already, future studies should work to further elucidate the exact association between KS and CMV in AIDS patients. REFERENCE #1: Reference #1: Aboulafia D.M. The epidemiologic, pathologic, and clinical features of AIDS-associated pulmonary Kaposi's sarcoma. Chest. 2000;117(4):1128–1145.Reference #2: Restrepo C et al. Imaging manifestations of Kaposi sarcoma. Radiographics. 2006;99(4).Reference #3: McGuinness G et al. Cytomegalovirus pneumonitis: spectrum of parenchymal CT findings with pathologic correlation in 21 AIDS patients. Radiology. 1994;192(2). REFERENCE #2: Reference #4: Giraldo G, Beth E, Huang E. Kaposi's sarcoma and its relationship to cytomegalovirus (CMNV). III. CMV DNA and CMV early antigens in Kaposi's sarcoma. Int J Cancer. 1980;26(1).Reference #5: Goldman, J.M., Epstein M.A. Vaccine intervention against virus-induced tumors. Palgrave Macmillan, London;c1986. 93-103p.Reference #6: Goncalves C et al. Cytomegalovirus acute infection with pulmonary involvement in an immunocompetent patient. ID Cases. 2018;14. REFERENCE #3: Reference #7: Wells R, Stensland L, Vieira J. The human cytomegalovirus UL112-113 locus can activate the full kaposi's sarcoma-associated herpesvirus lytic replica ion cycle. Journal of Virology. Apr 2009;83(9) 4695-4699p. DISCLOSURES: No relevant relationships by Jacob Patrick, source=Web Response No relevant relationships by Yiseiry Perez-Melendez, source=Web Response