The case of development of HIV-associated Kaposi's sarcoma with skin and lung lesions

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Introduction

The continuous improvement of methods for working with patients infected with the human immunodeficiency virus (HIV), combining timely diagnosis and administration of antiretroviral therapy (ART), has led to an increase in the length and quality of life of these patients [1]. However, the incidence rates of HIV infection in the Russian Federation and the Perm region remain high, ranging from 43.2 to 89.2 per 100,000 population, respectively[*]. Against the background of this trend, there are patients who do not seek medical help and do not receive antiretroviral therapy (ART). This leads to an increase in secondary viral and bacterial diseases recorded in this nosology, as well as the number of cancer patients among these individuals [1–3]. Disseminated Kaposi's sarcoma, a rarely recorded secondary disease in patients with HIV infection, is an indicator of oncological pathology. It is a tumorous, multi-focal disease of vascular origin that affects the skin, lymph nodes, and internal organs. It is known that the first description of this pathology was made in 1872 by the Hungarian dermatologist Moritz Kaposi. The development of sarcoma is based on immunosuppression with a pronounced violation of antitumor immunity and subsequent neoangiogenesis: the formation of spindle-shaped cells lining the walls of new vessels, capillaries, the formation of anastomoses between adjacent blood vessels. [4; 5]. Kaposi's sarcoma occurs when the number of CD₄+ T-lymphocytes in the blood is less than 500/mm³, dissemination is recorded in patients with a level of CD₄+ T-lymphocytes less than 200/mm³ [1; 6].

In view of the above, we present the clinical case of a patient with the development of Kaposi's sarcoma against the background of HIV infection.

Clinical case

Patient Ch., born in 1981, applied to the Perm Regional Center for AIDS and Infectious Diseases on December 12, 2023, complaining of skin rash on the right wing of his nose, forehead, in the right axillary and right inguinal areas, on the shins, which were not accompanied by subjective sensations.

According to his medical history, the patient first noticed changes in the skin of the right wing of his nose in December 2020. In 2021, the pathological process spread to the right frontal region and shin. In April 2022, the patient was referred to the Perm Regional Oncology Dispensary for a more accurate diagnosis. A positron emission tomography combined with X-ray computed tomography (PET/CT) was performed, and surgical excision of efflorescences on the right wing of the nose followed by histological examination was carried out. Based on the results of the studies, the diagnosis was established: Kaposi's sarcoma of the skin affecting the right wing of the nose, right frontal region, shin skin, lungs. Subsequently, in 2022, similar rashes were also noted in the right armpit and groin areas.

From the patient's life history, it was known that he had five criminal records, incomplete secondary education, was single, and had a son born in 2007.

Past medical history included chronic cytomegalovirus infection since 2005, intravenous drug use since 2007, HIV infection since 2009 (ART has been administered since March 2022), chronic viral hepatitis C since 2009, mild cytolysis syndrome, oral candidiasis.

The patient denied any occupational hazards.

Allergological anamnesis revealed a urticaria-type reaction to the administration of penicillin antibiotics.

No family history of cancer.

Objectively, the patient's condition is satisfactory, body temperature is 36.5 °C. Height is 170 cm, weight is 86 kg, BMI is 30. The musculoskeletal system is proportionally formed. The tongue is moist, there is a curdled coating on the back of the tongue and gums. Breathing through the nose is free, vesicular breathing in the lungs is carried out to all parts, no wheezing, respiratory rate is 18 per minute. Heart sounds are clear, rhythmic, heart rate is 74 beats per minute, blood pressure is 120/80 mmHg. The abdomen is soft, painless, the liver is 1.0 cm below the edge of the costal arch, the spleen is not palpable. The symptom of shaking the lumbar region is negative on both sides. Submandibular lymph nodes of 1.0 cm, anterior cervical lymph nodes of 0.5 cm, axillary and inguinal lymph nodes of 0.5 cm are palpated, elastic consistency, mobile, not soldered with surrounding tissues and among themselves, the skin above them is of physiological color.

Status localis: the skin pathological process is widespread, asymmetric, located on the face in the forehead and right wing of the nose, in the right axillary and right inguinal areas, on the shins. It is represented by polymorphic rashes in the form of purple-brown hemorrhagic spots of round and elongated shape, 2.5–3.0 cm in diameter, with clear borders and smooth surface, as well as single lenticular reddish-brown rounded papules of dense elastic consistency (Fig. 1). An atrophic scar of irregular white shape is determined in the area of the right wing of the nose (Fig. 2).

 

Fig. 1. Lesion of the nose in HIV-associated Kaposi's sarcoma

 

Fig. 2. Purple-brown spots and papules in in the right axillary area

 

Laboratory and instrumental studies were performed: the complete blood test showed an increase in hemoglobin levels – 165 g/L, eosinophils – 5.5 %, lymphocytes – 52.9 %, a decrease in segmented neutrophils to 35.6 %. The urine test was unchanged.

The biochemical blood test revealed an increase in AST – 51.7 U/L, ALT – 43.0 U/L, glucose – 6.27 mmol/L. The immunogram showed an increase in the number of T-lymphocytes – 2232/mm³ (82 %), CD₈⁺ – 2024 cells/ mm³ (74 %), a significant decrease in CD₄⁺ – 197 cells/ mm³ (7 %), a change in the ratio CD₄⁺ / CD₈⁺ = 0.10.

When examining the patient for viral hepatitis, serological markers for hepatitis B were not detected. Antibodies to HCV (IgM and IgG) and anamnestic antibodies to cytomegalovirus were found. Quantitative determination of HIV-1 RNA by PCR was 240 copies/ml.

PET/CT scans performed in dynamics revealed a neoplastic lesion of the right wing of the nose with increased metabolic activity, focal soft tissue thickening in the right frontal region with low metabolic activity (metastases?), focal changes in the lungs, the largest ones with low fixation of fluorodeoxyglucose, probably metastases, multiple foci of fluorodeoxyglucose fixation in the shin skin.

Pathohistological examination of the skin biopsy specimen from the right wing of the nose revealed the following: the epidermis is slightly thinned, in the dermis there are proliferates of round and spindle-shaped cells around the vessels, the vessels are dilated, hemorrhages, hemosiderin deposits, foci of hyalinosis, infiltration by lymphocytes and plasma cells are determined. Conclusion: the morphological picture corresponds to Kaposi's sarcoma.

Diagnosis: HIV infection, stage 4B, remission against the background of antiretroviral therapy. Chronic hepatitis C, mild cytolysis syndrome. Kaposi's sarcoma of the skin and lungs. Oral candidiasis.

Results and discussion

It should be noted that clinical types of sarcomas are divided into four varieties – classical, occurring in elderly people, immunosuppressive, endemic (African) and HIV-associated [7]. The case described by us belongs to the latter type. According to literature data, HIV-associated Kaposi's sarcoma develops at the age of 40, more often in men, and in 95 % of cases is accompanied by skin manifestations, with the clinical picture beginning with lesions of the face skin, upper extremities and mucous membranes, where small pinkish-red spots similar to insect bites form, which was also recorded in this patient [8; 9]. Foreign researchers note that as the disease progresses, the spots that have appeared increase to 3–4 cm, transforming into nodes and plaques of cherry-violet-brown color, spreading to other areas of the skin, and the elements acquire a yellow halo, which indicates tumor growth [10]. In addition to the skin, internal organs can be involved in the process, more often lymph nodes, stomach, duodenum and lungs. Visceral lesions worsen the course and prognosis of the disease [11]. Thus, the clinical picture of the disease developed in this patient according to the noted studies with a level of CD₄⁺ T-lymphocytes less than 200/mm³ of blood.

The diagnosis was established for the patient based on the characteristic clinical picture and histological examination data, which revealed proliferations of spindle-shaped cells around newly formed vessels, lymphocytic infiltration, diapedesis of red blood cells, and hemosiderin deposits [12].

Healthcare practitioners should remember that if HIV-associated Kaposi's sarcoma is suspected, a comprehensive examination of patients should be performed to assess the prevalence of the tumor process: a complete medical examination of the oral and genital mucous membranes, abdominal ultrasound, and, if necessary, computed tomography or magnetic resonance imaging [13].

It is also necessary to conduct differential diagnosis of the disease with pseudosarcomas (Mali type and Stewart–Bluefarb type), bacillary angiomatosis, pyogenic granuloma, glomus tumor, sarcoidosis, hematomas, pigmentary urticaria, lichen planus, cutaneous B-cell lymphoma [14].

It should be noted that treatment of HIV-associated Kaposi's sarcoma begins with antiretroviral therapy; if the effect is insufficient, it is advisable to add chemotherapy. At the same time, it must be remembered that all known methods of therapy do not lead to a complete cure, but only provide temporary suppression of the pathological process [15].

Conclusions

1. Long-term HIV infection without antiretroviral therapy contributes to the development of tumor processes, primarily Kaposi's sarcoma.
2. Kaposi's sarcoma against the background of HIV infection is characterized by primary facial lesions; the pathological process is widespread and rapidly progressive, affecting internal organs.
3. HIV-associated Kaposi's sarcoma is a multidisciplinary disease that requires complex therapy from infectious disease specialists, dermatologists, venereologists, and oncologists.

 

[*] Federal Service for Supervision of Consumer Rights Protection and Human Welfare, available at: https://www.rospotrebnadzor.ru/deyatelnost/epidemiological-surveillance; Federal Service for Supervision of Consumer Rights Protection and Human Welfare in the Perm Territory, available at https://59.ru/text/health/2023/07/
28/72544472.

About the authors

M. Yu. Kobernik

E.A. Vagner Perm State Medical University

Author for correspondence.
Email: margo110875@yandex.ru
ORCID iD: 0000-0002-3549-0076

PhD (Medicine), Associate Professor of the Department of Dermatovenerology

Russian Federation, Perm

V. V. Nikolenko

E.A. Vagner Perm State Medical University

Email: margo110875@yandex.ru
ORCID iD: 0000-0002-9505-1569

DSc (Medicine), Professor of the Department of Infectious Diseases

Russian Federation, Perm

O. E. Mikova

Perm Regional Center for the Prevention and Control of AIDS and Infectious Diseases

Email: margo110875@yandex.ru

PhD (Medicine), Deputy Chief Medical Officer

Russian Federation, Perm

A. A. Zavyalova

E.A. Vagner Perm State Medical University

Email: margo110875@yandex.ru

5^th-year student of the Medical Faculty

Russian Federation, Perm

M. A. Pyankova

E.A. Vagner Perm State Medical University

Email: margo110875@yandex.ru

5^th-year student of the Medical Faculty

Russian Federation, Perm

References

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