A 31 y.o. male with HIV presents with swelling of the L leg. He has been treated for syphilis and gonorrhea.

the patient has hep C. What does the rash on the R leg suggest? Why is the L leg swollen?

Our patient had Kaposi’s sarcoma (KS) with metastatic disease to the inguinal lymph nodes and lymphedema of the left leg. Kaposi’s sarcoma forms masses in the skin, lymph nodes, mouth and other organs.  It is caused by a combination of immune suppression in HIV and infection by human herpesvirus 8(HHV8).the human herpes virus 8  is transmitted in saliva.  It was first described by Moritz Kaposi in 1872.  It is thought to be arising from lymphatic endothelium  rather than a true sarcoma of mesenchymal origin.

Often presenting on the face, Kaposi’s was a visible indicator of AIDS

Initially Kaposi’s affected older men in regions where the  human herpesvirus 8 was prevalent:  the Mediterranean, Eastern Europe and the Middle East.  It was slow growing and involved mostly the legs.  In those who are immune suppressed as in organ transplants, it mainly affects the skin.  In those with AIDS, it became a visible diagnostic marker of the disease. In AIDS,  multiple organs can be involved: skin, lungs,  Over 35% of people with AIDS may be affected. 

Kaposi’s of the lung

The treatment for  Kaposi’s is highly active antiretroviral therapy(HAART) ). KS can be confused with Bacillary angiomatosis.   This is caused by Bartonella species which are gram negative and treated with antibiotics. Neutrophilic inflammation is noted with bacillary angiomatosis  which is not found in Kaposi’s which has lymphoplasmacitic infiltrates.   A biopsy distinguishes between the two.

Bacillary angiomatosis

JUNE 5, 2021 MARKS THE 40th ANNIVERSARY OF THE AIDS EPIDEMIC

Much like COVID in its virulence, initially the AIDS virus  claimed the lives of 32 million people globally. 50,000 died in the US in a single year.  The first cases of AIDS were reported in Los Angeles and all had Pneumocystis carinii pneumonia. All were homosexual.  The population affected remained  predominantly homosexual males, injection drug users and their sexual partners.  It was not until 1995 that effective  antiretroviral treatment was available.

Interestingly, palliative care, as  a specialty,  grew out of the AIDS epidemic.

The treatment for  Kaposi’s is highly active antiretroviral therapy(HAART ). Our patient had a CD4 count of 19 and took his meds sporadically.  He has not returned for follow up.

Fenig E, Brenner B, Rakowsky E, et al.  Classic Kaposi sarcoma: experience at Rabin Medical Center in Israel.  American Journal of Clinical Oncology 21(5):498-500.  

Cook-Mozaffari P, Newton R, et al. The geographical distribution of Kaposi’s sarcoma and lymphomas in Africa before the AIDS epidemic. 1998 British Journal of Cancer 78(11):1521-8. 

Davis S, Henschke C, Chamides B, Westcott J.  Radiology 1987;163(2):495