Presentation
A retroviral disease patient presented with a two-month history of fever, cough and loss of weight and appetite. Multiple purple-brown papules noted over head, scalp, neck, and trunk.
Patient Data
Frontal chest radiograph showed reticular opacities and multiple parenchymal lung nodules.
There is worsening reticular opacities in perihilar distributions and increasing size of the multiple lung nodules over a two month period -- initially treated as pneumocystis jiroveci pneumonia (PJP).
Thorax:
multiple scattered lung nodules in a peribronchovascular subpleural distribution, with flame shape appearance of the lung nodules
bilateral enhancing axillary lymph nodes and enhancing subcutaneous nodules
Abdomen & Pelvis:
multiple small hypoattenuating liver and splenic nodules
multiple enhancing peritoneal nodules
enhancing bilateral inguinal nodules
multiple lytic lesions of the visualised bones
Case Discussion
Histopathologic examination confirmed Kaposi Sarcoma.
This patient has disseminated Kaposi Sarcoma (skin, lung, visceral and gut). The patient developed persistent episodes of diarrhoea and a colonoscopy revealed multiple erythematous fungating lesions, extending from the rectum to caecum. After the patient started chemotherapy his condition improved, however after few months he succumbed to severe metabolic acidosis and hyperkalaemia with multiple organ dysfunction.
There are four variants of Kaposi Sarcoma:
- classic form
- endemic form (african)
- iatrogenic (organ transplant related)
- AIDS-related Kaposi Sarcoma
with the two latter form being the most common and disseminated form 1.
Kaposi Sarcoma is caused by Human Herpes Virus type 8 1.
AIDS-related Kaposi sarcoma is highly associated with patient who are male and homosexual and virus usually transmitted from the anal sexual intercourse 1.
In this disseminated form, commonly involved organs include
1) Head & neck
- cutaneous form with skin, face and neck nodules 1.
- mucosal form ( intra-oral, laryngeal and pharyngeal nodules 1.
2) Thoracic
CT has certain characteristic findings compared to chest radiograph with flame shape appearance of lung nodules (bilateral symmetrical ill defined nodules in peribronchovascular distributions 1).
These nodules may presented with "halo" sign: ground glass opacities surrounding the nodules. Other associated findings include peribronchovascular and interlobular septal thickening, fissural nodularity, mediastinal, hilar and axillary adenopathy 1.
3) Liver & Spleen
Multiple hypo-attenuating nodules. Nodules may exhibit delayed enhancement distinguishing it from multiple haemangiomas 1. Lesions should be hyperechoic on ultrasound scan.
4) Gastrointestinal tract
Can affect gastrointestinal tract from oropharynx to the rectum. Biopsy may be negative as it is a submucosal lesion 1.
In this case, with the abdominal findings, other differential diagnoses that were considered included fungal lesions in view of the liver and spleen lesions with concurrent intra-abdominal TB. He was treated for opportunistic infection with fungal (amphotericin) and challenge with TB treatment before he was subjected for anti-retroviral therapy (ART) and chemotherapy. The initial chest radiograph was confused with PJP but the CT findings were characteristic for KS with absence of pleural effusion which may be present in PJP.
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