Journal of the Louisiana State Medical Society
C linical C ase of the M onth
A 22-Year-Old Man With AIDS Presenting With Shortness of Breath and an Oral Lesion
Daniel Englert, MD; Paula Seal, MD; Chris Parsons, MD; Adrienne Arbour, MD; Evans Roberts III, MD; Fred A. Lopez, MD
Since the development of combination antiretroviral therapy (cART), the incidence andmortality associated with Kaposi sarcoma (KS) have been reduced, although not eliminated. Clinical presentations of KS range from simple skin involvement to disseminated disease, including involvement of the oral cavity and viscera, which portends a more ominous prognosis. Multiple case reports and data from clinical trials indicate that administration of systemic corticosteroids may aggravate KS. We present a case of disseminated KS fol- lowing administration of prednisone for presumed immune reconstitution inflammatory syndrome (IRIS) associated with fungal pneumonia in an HIV-infected individual. The discussion that follows outlines the pathophysiology and clinical presentations associated with KS and existing data for the role of corticoste- roids in promoting KS progression.
CASE PRESENTATION A 32-year-old man with a past medical history of HIV/ AIDS and remote tobacco abuse presented to our facility with a chief complaint of shortness of breath and persis- tent cough, which began three months prior to admission. He initially tried over-the-counter cough suppressants, which provided little relief. Over the next four weeks, he had progressive fatigue, decreased appetite, night sweats, shortness of breath, dry cough, and oral thrush with chest pain on swallowing. Approximately two months prior to admission, he presented with the above symptoms and was noted to be afebrile with normal values for pulse oximetry at rest. His CD4+ T-cell count was 8 cells/mm 3 (228-2,290 cells/mm 3 ). A chest radiograph revealed mild bilateral, centrally located interstitial infiltrates, and blood cultures were negative. Based on the duration of his illness, his lack of prophylaxis for Pneumocystis jirovecii pneumonia (PJP), and the appearance of his chest radiograph, he was treated presumptively for both PJP and candida esophagitis. Approximately one-and-a-half months prior to admis- sion, the patient was seen in the HIV outpatient clinic for hospital follow-up visit. He had not received cART for the previous two years. cART therapy was initiated, along with prophylactic trimethoprim-sulfamethoxazole, azithromycin, and oral fluconazole treatment for diffuse oral candidiasis. Following this outpatient clinic visit, his shortness of breath
and cough persisted, and he presented to another hospital approximately three weeks prior to admission, where he was noted to be hypoxic with multilobar infiltrates on chest radiography that were more extensive than those seen dur- ing his prior hospitalization. He received a diagnosis of multilobar community-acquired pneumonia andwas started on levofloxacin. Bronchoscopy with bronchoalveolar lavage (BAL) revealed no endobronchial lesions, a negative evalu- ation for PJP, negative Gram stain and bacterial cultures, negative AFB cultures, and negative KOH stain. He was discharged on levofloxacin, high-dose fluconazole, and a prednisone taper for presumed pneumonia in the context of an immune reconstitution inflammatory syndrome (IRIS). Fungal cultures from the BAL subsequently grew a few colonies of Paecilomyces species, and serum cryptococcal antigen was negative. One week prior to admission, he was again seen in the HIV outpatient clinic, where he was noted to have a violaceous, fungating lesion on the hard palate (Figure 1). On further questioning, the patient stated that a much smaller formof this lesion had been present for the past three months, although masked by severe overlying thrush. In addition, he had worsening shortness of breath and cough now productive of copious brown sputum. Repeat CD4+ T-cell count was 31 cells/mm3 at this time. Outpatient computed tomography (CT) of the chest revealed diffuse lung parenchymal opacities, with areas of nodularity and
224 J La State Med Soc VOL 166 September/October 2014
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