Kaposi’s Sarcoma-Associated Immune Reconstitution Inflammatory Syndrome

Abstract

Introduction: A 30-year-old African American man with a history significant for AIDS on HAART and pulmonary Kaposi’s sarcoma (KS) presented to the hospital with symptoms of decreased appetite, decreased PO intake, nausea, vomiting, fever, chills, generalized malaise, shortness of breath, and diarrhea of 1 week duration. Upon admission, he was febrile and tachycardic, and tenderness in the RUQ, LUQ, and epigastrium. His pre-hospitalization CD4 count was 55, and he had a viral load of less than 20. Labs revealed pancytopenia. A CT scan of the abdomen and pelvis with intravenous contrast enlarging speculated nodules in the right middle and lower lung lobes, worsening peripancreatic, retroperitoneal, and pelvic lymphadenopathy, and generalized mesenteric stranding. An infectious etiology for the patient’s pneumonia was ruled out, and a bronchoscopy repeated from 6 months prior was consistent with the diagnosis of KS in the lungs. Stool ova and parasite, cryptospora, enteric cultures, fecal leukocytes, occult blood, and blood cultures were all negative. An initial stool test for Clostridium difficile was indeterminate, but PCR amplification was positive. A 10 day course of metronizadole was administered and his diarrhea resolved. Meanwhile, the patient was started empirically on oral prednisone 60 mg daily for Immune Reconstitution Inflammatory Syndrome (IRIS). An EGD was performed on day 14 of his hospitalization. Lesions viewed endoscopically were classic for KS. Visceral involvement of KS is rare. It is frequently found hand-in-hand with HIV/AIDS and is thought to be associated with a poorer prognosis. Patients with KS in the GI tract may not always present with cutaneous lesions or GI symptoms. In patients with HIV and KS (HIV-KS), HAART can effectively control established KS and diminish new lesions. An exception to this is the minority of patients with HIV-KS who develop IRIS. In these patients, HAART alone is ineffective, but the addition of chemotherapy and glucocorticoids leaves the patient at risk for concurrent KS exacerbation. The prognosis for Kaposi’s sarcoma-associated IRIS is unpredictable. Kaposi’s sarcoma-associated IRIS remains a challenge for healthcare providers to diagnose and treat. Increased understanding of the disease process and alternative treatment options are needed moving forward.