WHEN LOW SUSPICION COMES AT A HIGH COST: LARYNGEAL KAPOSI SARCOMA AND THE CASE FOR BROADER HIV TESTING Rithvik Vutukuri, Helen Pope; Tulane University School of Medicine, New Orleans, LA.
Introduction: Kaposi sarcoma (KS) is a serious and well-known complication of untreated HIV infection. Laryngeal involvement is very rare, with a 2023 systematic review documenting only 77 cases in the literature. Prompt identification and treatment is critical given the risk for airway obstruction. Case: A 39-year-old man with syphilis presented with a 3-week history of progressively worsening dysphagia, dysphonia, and facial edema, along with widespread violaceous skin lesions. Seven months prior, the patient had developed skin-colored forehead lesions, treated by a local dermatologist with intralesional Kenalog injections and a 3-month course of minocycline. Over that time, the painless, itchy lesions grew and spread throughout his body, slowly turning violaceous. Facial swelling over a week led to vision impairment and difficulty tolerating solid food. The physical exam revealed a hoarse voice, facial edema, and purpuric papules with silver scale on his upper face, bilateral arms, chest and bilateral upper legs. Further workup revealed a new diagnosis of HIV with CD4 48 cells/mm3 and viral load 691,000 copies/mL, and smear for pneumocystis jirovercii pneumonia (PJP) was positive. Punch biopsy of a skin
lesion confirmed Kaposi sarcoma, and laryngoscope exam found a violaceous lesion of the left epiglottis, appearing to extend into the aryepiglottic fold. The patient was admitted to the intensive care unit for airway monitoring given the extent of his facial edema. Of note, esophagogastroduodenoscopy did not show enteric Kaposi sarcoma. The patient was started on bictegravir, emtricitabine & tenofovir alafenamide for antiretroviral therapy, liposomal doxorubicin for Kaposi sarcoma, atovaquone for PJP treatment given a sulfa drug allergy, and brimonidine drops for HIV retinopathy. A percutaneous endoscopic gastrostomy (PEG) tube was placed for enteric access due to dysphagia resulting from edema induced by laryngeal Kaposi sarcoma. Discussion: Timely identification and treatment of HIV and associated opportunistic infections, such as Kaposi sarcoma, are essential for ensuring best patient outcomes. In the case of this patient, despite recent evaluations by physicians, HIV testing was not performed. As a result, the infection continued to progress, culminating in a long hospital admission with PJP infection, HIV retinopathy and widespread Kaposi sarcoma, including rare laryngeal involvement.
FROM ANTIVIRALS TO ACIDOSIS, UNMASKING A RARE CASE OF LACTIC ACIDOSIS FROM BIKTARVY Shashank Sajjan Mungasavalli Gnanesh, Nicole M Sigda, Nevin Antony Varghese, Joshua Lee Denson; Tulane University School of Medicine, New Orleans, LA.
Introduction: Bictegravir, emtricitabine & tenofovir alafenamide (Biktarvy) is a commonly used antiretroviral agent. However, in rare cases, it can lead to lactic acidosis, a potentially life-threatening condition. The incidence of lactic acidosis induced by nucleoside reverse transcriptase inhibitors (NRTIs) is reported at 1.7–25.2 cases per 1,000 person-years. Case: A 26-year-old woman with a history of mild intermittent asthma and recently diagnosed HIV presented with acute respiratory distress from an asthma exacerbation unresponsive to her home inhalers. She was intubated upon arrival for tachypnea, tachycardia, and progressive respiratory failure. Her oxygen saturation was 98% on PEEP 5 &
FiO2 30%. She had bilateral end-expiratory wheezes on examination. Labs showed leukocytosis (WBC 12.9 cells/mm3 with eosinophilia of 9%), elevated creatinine 1.2 mg/dl, and lactic acid 7.4 mmol/L that lowered to 5.1 mmol/L but later rose again to 7.3 mmol/L. An arterial blood gas showed mixed respiratory & high anion gap metabolic acidosis with a pH of 7.16, pCO2 62 mmHg, HCO3 21.5 mmol/L and anion gap of 13. Respiratory panel was negative. She was treated with steroids and bronchodilators for asthma. With the rising lactic acid, bictegravir, emtricitabine & tenofovir alafenamide was held due to suspected drug-induced type-2 lactic acidosis in absence of clear infectious etiology and other urine studies (urine pH 5.5). Her lactate 65
Made with FlippingBook Digital Publishing Software