kaposi eng

8/10/2019 Kaposi Eng

1/36

SMART TA

CASE PRESENTATION


2/36

Case presentation (1)

A - 32 - years old man

Thai ethnic people

Famer in QuChu

NghAn province

Diagnosed with HIV: 19/07/2013

Managed at OPC: 11/09/2013


3/36

Case presentation(2)

Appearance of small nodules on his chest, arms, legs

one year ago.

Nodules were initially light reddish purple and then

became darker, purple, and larger (0,51cm) overtime

No pain, no itching, no bleeding.

Denied cough, fever, fatigue, weight loss, or night

sweats, or blood in stool


4/36

Past medical history and social history

No prior ARV exposure

No history of allergies or chronic diseases

Relation with sex workers no protection and shared

needle with partners 6 year ago. He stops to useheroin now

Wife and daughter (11 year olds) are negative withHIV

Disclosed HIV status to all family members

Received psychological and economic supports fromfamily


5/36

Physical examination at 11/09/2013

Vital signs: T 36.8C, P 86 beats/min, R 18 breaths/min,

blood pressure 110/70 mmHg. Height 164 cm, weight: 58kg

Well appearing, no cachexia, thrush, or oral hairy

leukoplakia

No lymphadenopathy

Heart: no murmurs;

Lungs: clear

Abdomen: no pain, no splenomegaly, no masses Neurological examinations: normal, ambulates without

difficulty


6/36

Skin: many purple nodules on his face, chest, arms

without itching, pain, blanching, jaundice, or edema


7/36

HEENT: Eyes, nose, and mouth clear but purple plaque

noted on hard palate without bleeding


8/36

Laboratory findings

CD4: 178 cells/mm

CBC:

RBC: 5.600.000,

Hb: 127 g/L; MCV 73 (78 - 99) WBC: 7000. N: 41,4 %; L 50,3%; mono 8,3%.

PLT: 253 000

HBsAg (-); Anti HCV (-)

Chest X ray is normal

Abdominal ultrasound was normal


9/36

Question 1: What diseases do you think?

1. Bacillary Angiomatosis (Bartonella Henselae)

2. Herpes Simplex Virus (HSV)

3. Kaposis sarcoma

4. Leishmaniasis


10/36

Answer (1) = Kaposi Sarcoma (KS)

Cutaneous KS typically manifests as pigmented macules,

plaques, papules, or nodules on skin and mucous membranes

including face, ears, arms, torso, and legs

Size ranges from a few millimeters to many centimeters in

diameter and in color from red (especially in new lesions) to

purple

Lesions may be preceded by, or surrounded with, a yellow to

green "halo," probably representing extravasated erythrocyte

pigments

In black or olive-skinned people, KS lesions may appear dark

brown or black.

Color of skin lesions darkens without treatment.


11/36

Kaposis Sarcoma


12/36

Kaposis Sarcoma


13/36

Kaposi Sarcoma

Kaposi sarcoma is a malignancy and was the first and most common

AIDS-defining illness described in the U.S.

KS can affect all organs but commonly affects the skin (95%),

oropharynx (33%), GI tract (40%), and lungs (20-50%)

Can also cause lymphedema (genitals, face, legs)

Racial, genetic, and hormonal factors all have been reported to

influence the development of KS

The incidence of KS as an AIDS-defining illness has decreased withearly ART


14/36

Question 2: How common are oral

lesions with KS?

A. 10 - 15 %

B. 16 - 20%

C. 20 - 25%

D. 25 - 30%

E. 30 - 35%


15/36

Answer (2) = 33%

Lesions of the oral cavity occur in about one third (33%) of patients

with AIDS-associated KS

Hard palate lesions are most common

These flat, red or purple plaques, either focal or diffuse, may be

completely asymptomatic and easily overlooked

In other patients, however, larger nodular lesions involving the

hard or soft palate, or both, may become exophytic and ulcerated,

and may bleed.

Other oral sites of KS involvement include the gingiva, tongue,

uvula, tonsils, pharynx, and trachea. These lesions may interfere

with eating and speaking, cause tooth loss, or compromise the

airways.


16/36

Question 3: What is the cure of KS?

A. ART

B. Valgancyclovir

C. Foscarnet

D. Interferon-alpha

E. Chemotherapy

F. Radiation treatment


17/36

Answer (3) = No Cure for KS

Immediate ART is first line treatment

Chemotherapy is reserved for patients with edema, ulceration,

extensive oral and gastrointestinal diseases, and system symptoms

Intralesional chemotherapy, topical immune, and radiation

treatment for local skin disease (cosmetic)

Interferon-alpha can be used for patients with skin disease and CD4

counts>200 cells/mm3

Palliative care including regression of lesions, pain management,

and symptoms related to visceral involvement is very important


18/36

Kaposis Sarcoma

Before and after radiation treatment


19/36

Staging (TIS)

(O) (1)


20/36

Karnofsky Performance Status Score


21/36

Management (Based on T and S)

ART is 1stline therapy for ALL patients

Chemotherapy based on staging

Good prognosis is T0S0, T1S0, T0S1

Survival >80% with effective ART

Defer chemotherapy

Poor prognosis is T1S1

Survival 46-77% with effective ART

Likely rapid progression of disease

Immediate chemotherapy


22/36

Question 3: What is the T and S of this

patient?

A. T0S0

B. T1S0

C. T0S1

D. T1S1


23/36

Answer 3: T1S0

Management (Based on T and S): Patient: T1S0 Good

prognosis

Jan 24th2014 he started cotrimoxazole and immediate

ART (TDF/3TC/FEV).

BUT..


24/36

Feb 13th 2014: the purple nodules on his face, chest,

arms and in his palate appeared more and large


25/36

Feb 13th 2014: the purple nodules on his face, chest,

arms and in his palate appeared more and large


26/36

Question 4: What do you think in this condition?


27/36

f


28/36

Histopathology: Skin biopsy report from Bach

Mai Hospital diagnosis Kaposi Sarcoma

Pathology typically shows marked lymphocytic

predominance, plasma cells, angiogenesis, and spindle cells

infiltrating collagen like schools of fish

i h i i i d i h


29/36

Question 5: What virus is associated with

Kaposi sarcoma?

A) Human papilomavirus (HPV)

B) Human herpesvirus 8 (HHV8)

C) Epstein-Barr virus (EBV)

E) Herpes Simplex 2 Virus (HSV-2)


30/36

Answer (5)

Human papilomavirus: persitent infection with high risk of

Human papilomavirus (HPV) is associated with development of

cervical cancer

EBV also associated with number of malignancies: B and T cell

lymphomas, Hodgkins disease, leimyosarcoma andnosopharyngeal carcinoma. These cancers show a increased

frequency in patients with immunodeficiency.

Herpes simplex viruses:

- herpes type 1: oral herpes

- herpes type 2: genital


31/36

Answer (5) = HHV8

There are four types of KS

Classic (old men of Meditarrean descent)

Endemic (young and old in sub-saharan Africa)

Transplant associated (due to immune suppression)

AIDS associated (90% of cases in MSM in west)

HHV8 associated with all four types

HHV8 produces factors and cytokines that results in angiogenesis,

collagen proliferation, and blocking of apoptosis (cell triggered

death)

Cannot eradicate from body


32/36

Question 6: How is HHV- 8 most

commonly transmitted ?

1) Breast Milk

2) Semen

3) Pregnancy

4) Transplanted organs

5) Saliva

6) Along with sexual transmitted diseases


33/36

Answer (6) = Saliva

Saliva is most common mode of transmission

HHV 8 shed in saliva among immunocompetent and compromised

persons

Can be spread by all other means as well Contributing factor among MSM who may engage in high

frequency oral and oral-anal sex

Some evidence that transmission linked with Gonorrhea

Low rates of HHV-8 and associated KS in Southeast Asia mayreflect predominantly injection use epidemic


34/36

Case Progression

Good ART adherence

Gain weight from 58 kg to 60kg

Normal working

No more OIs Number of lesions reduced and slighter, some skin lesions

disappeared

4 /9/2014:

- CD4: 440 cells/mm- CBC, ALT, creatinine: normal


35/36

Conclusions

Kaposi's sarcoma is a malignant tumor associated with HHV-8

It primarily affects skin but may also affect mucosal linings, in

particularly the GI tract as well as the lungs

KS exists in Vietnam and will likely increase with rise in MSMepidemic

Diagnosis of KS is primarily clinical with follow-up biopsy and

histopathology as needed

First line treatment is immediate ART for all cases Chemotherapy is reserved for severe cases

There is no cure for KS


36/36

THANK YOU

kaposi eng

Documents