Bleeding Serpiginous Lesions in the Upper Gastrointestinal Tract: A Diagnostic Challenge

Abstract

Introduction: Gastrointestinal Kaposi's Sarcoma (KS) is an entity that is often missed as a possibly etiology of upper gastrointestinal bleeding in immunocompromised patients. We present a case of upper gastrointestinal tract bleeding from Kaposi's sarcoma lesions in the stomach. Case: A 45-year-old man with Hx of AIDS on HAART, ESRD on dialysis, HTN, CHF, chronic HBV, left internal jugular vein thrombus on warfarin presented with altered mental status. A month prior to presentation, he was evaluated for chronic diarrhea and colonoscopy at that time was grossly normal with normal mucosal biopsies. On admission, patient's labs were significant for leukocytosis with bandemia and INR of 5.1. The patient was started on broad spectrum anti-biotics. CT showed circumferential thickening of the whole colon, compatible with pancolitis. C. difficile GDH antigen was positive and he was started on metronidazole. Subsequently he developed melena with dark red clots, worsening mental status and sepsis. Hb dropped from 9 gm on admission to 3.6 gm. EGD was performed and showed serpiginous, bulging, erythematous lesions of varying size/shape throughout the entire stomach. The lesions were friable and oozing blood. Multiple biopsies were taken. Pathology showed mild chronic inflammation, negative for intestinal metaplasia or H. pylori, and no evidence of Kaposi's Sarcoma. Due to strong suspicion for KS and as the lesions were submucosal, repeat EGD with deeper biopsies was performed. The clinical case was discussed with pathology department and at this time biopsies revealed Kaposi's Sarcoma with small focus of abnormal endothelial lined spaces with atypical endothelial cells positive for HHV8, indicative of KS. Review of previous pathology specimens also revealed KS due to a strong suspicion. Discussion: Kaposi's Sarcoma is the most common tumor among HIV-infected individuals. The HIV induced damage of the mucosa associated immune system (decreased CD4 cells in lamina propria) leads to more opportunistic infections, and the development of malignant tumors. Although most cases of gastrointestinal KS are asymptomatic, advanced lesions may occasionally result in severe and life threatening hemorrhage. Due to tumor growth in the submucosa, biopsies are diagnostic in less than 25% of the time. In the setting of strong clinical suspicion for Kaposi's, this case illustrates that multiple biopsies and deeper biopsies may be needed to establish the diagnosis, as well as the importance of discussing the clinical suspicion of a lesion with the pathology team. Conclusion: KS should always be considered as a strong differential diagnosis in the lesions of the gastrointestinal tract in an immunocompromised host.