Diagnosing And Treating Kaposi’s Sarcoma

Kate Johnson, DPM, and William Fishco, DPM, FACFAS

These authors present key pearls on treating a 26-year-old patient with AIDS, who presented with papules on his lower extremity, chest, back, oral mucosa and genitalia.

A 26-year-old Hispanic male presented to the Maricopa Medical Center in Phoenix with numerous well-circumscribed red to purple colored papules on his chest, back, oral mucosa, genitalia and lower extremity. Beginning below the right knee, the lesions become abundant and coalesce to form woody, indurated dark purple, brown and black plaques that cover most of the lower leg, ankle and foot.

   A large fungating nodule is visible protruding from the medial aspect of the leg. The skin on the sole of the right foot is friable and exophytic. The patient has an ulceration on the plantar forefoot. Drainage from the ulceration is clear and malodorous. There is non-pitting edema to the right lower extremity. Pedal pulses are audible via handheld Doppler. Sensation is grossly intact. The patient is unable to walk on the right foot secondary to pain.

   His past medical history is remarkable for human immunodeficiency virus and acquired immunodeficiency syndrome (HIV/AIDS) with treatment of antiretroviral therapy (ART). The right fourth toe was previously amputated following an infection. His past medical history is otherwise unremarkable. The patient has no history of illicit drug use, alcohol abuse or smoking. His family history is unremarkable.

   The patient’s vitals included blood pressure of 120/55, a pulse of 111 per minute, respirations of 20 per minute and a temperature of 100ºF. The patient was admitted to the hospital and started on broad-spectrum antibiotics. We took a multidisciplinary approach and solicited opinions from internal medicine, hematology/oncology, infectious disease, dermatology, podiatry and plastic surgery.

   The initial workup included a complete blood count with differential, chemistry panel, tuberculosis and coccidioidomycosis screens, Cryptococcus screens, rapid plasma reagin, hepatitis panel, CD4 count, viral load, blood culture, wound culture, venous duplex and X-ray of the right foot. The findings included macrocytic anemia, thrombocytopenia, a CD4 of 89 and a viral load of 119. Wound cultures were positive for Escherichia coli, Pseudomonas putida and Enterococcus faecalis. Imaging studies included chest X-ray and computed tomography scan of his chest, abdomen and pelvis, which helped rule out visceral involvement.

   A biopsy of the left shoulder and right leg lesions confirmed the diagnosis of AIDS-associated Kaposi sarcoma. The patient started on antiretroviral therapy and liposomal doxorubicin (Doxil, Janssen Products).

A Primer On The Different Varieties Of Kaposi’s Sarcoma

Kaposi sarcoma is an angioproliferative disorder of the vascular endothelium affecting mucocutaneous tissues with the potential to involve viscera. Its pathogenesis is multifactorial and hinges on immune dysfunction with simultaneous infection of the human herpes virus 8, also known as Kaposi’s sarcoma herpes virus. There are four distinct types that are grouped according to the natural history of the disease as well as the population in which the disease occurs.1

   Classic Kaposi’s sarcoma develops in individuals of Mediterranean, Eastern European or Middle Eastern heritage. It usually affects men older than 50 years who develop slow growing, purple-red lesions on the lower legs and feet. It may also spread to the arms and trunk. Disseminated disease and visceral involvement are uncommon.

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