Kaposi Sarcoma of the Gastrointestinal Tract in the Era of Combination Anti-Retro Viral Therapy

Abstract

AIDS related Kaposi sarcoma (KS) is the most common tumor identified in HIV patients. Classically presents as cutaneous vascular endothelial tumors associated with HHV-8 infection. Visceral manifestation in the absence of cutaneous manifestation is uncommon. The annual incidence of Kaposi sarcoma in the United States has been steadily declining with the advent of highly potent combination anti-retroviral therapy (ART). We present an unfortunate case of a HIV positive male with extensive gastrointestinal Kaposi sarcoma. 50 year old male with prior diagnosis of HIV, non-compliant with ART presented with weight loss, abdominal pain, distention, vomiting and diarrhea for 3 months. Examination revealed a cachectic appearing male, moderate abdominal distention with mild diffuse tenderness throughout the abdomen. No cutaneous lesions identified on examination. Blood work significant for anemia, leukopenia, elevated HIV viral load >210,000 with a low CD4 count of 100. Stool studies for ova and parasites were negative. CT imaging revealed long segment mural thickening extending from the terminal ileum, descending colon to the rectum with multiple dilated fluid filled loops of small bowel with scattered large to small extensive mesenteric lymphadenopathy. EGD revealed multiple raised red to purplish nodular lesions in the oropharynx, esophagus, stomach and duodenum. Similar lesions were found on colonoscopy throughout the colon and terminal ileum associated with significant edema and narrowing in the region of the terminal ileum and sigmoid colon (Image 1). Biopsy from various sites revealed spindle cell proliferation with extravasation of red blood cells (Image2). Immunostain positive for HHV-8 consistent with the diagnosis of Kaposi's sarcoma (Image3). Patient improved on ART and was later discharged home with plans for outpatient chemotherapy. Significant advancements in the field of ART has led to a decrease in the prevalence of Kaposi sarcoma in the 21st century. Incidence of KS has shown a significant decline in United states from 47 cases per 1 million people in the 1990 to 6 cases per 1 million people because of highly effective treatments available for HIV/AIDS. Gastrointestinal manifestations commonly reported are abdominal pain, malabsorption, bleeding and rarely obstruction. GI manifestation can be easily missed in the absence of cutaneous manifestation, hence a high degree of suspicion can lead to early diagnosis and improved outcomes.2984_A Figure 1. Colonoscopy images showing multiple raised red to purple nodules throughout the colon2984_B Figure 2. H&E stain of the duodenal mucosa showing scattered bland spindle cell proliferation with extravasated red blood cells.2984_C Figure 3. Immunostain positive for HHV -8