Munnings_ Margie - Hospice Palliative Care Association of SA

							  Management of patients with
 Kaposi Sarcoma [KS] in a rural
  PHC setting in Mpumalanga

• Dr M G Hardman MB Ch B DCH
  MCFP M Phil Pall Med D HIV man
          Brief introduction
• This study is about treating HIV positive
  patients with Kaposi Sarcoma [KS] using
  low dosage oral etoposide combined with
  ARVs in a PHC setting.
• Many of these patients cannot be referred
  to tertiary hospitals because of long
  waiting lists and lack of resources.
                   Aim
• To show that many HIV positive patients
  with KS can have excellent results, by
  treating with a combination of etoposide
  and ARVs.
                   Method
• 33 HIV positive patients with KS were assessed
  and treated with either oral etoposide or ARVs or
  both from 1st January 2009 to 1st May 2010.
• The patients were seen monthly. At each visit a
  full clinical assessment was made. The size and
  number of lesions was recorded.
• CD4 FBC ALT, and creatinine were done at
  baseline, and a CXR if indicated
• At 6 months a VL CD4 FBC Creatinine and ALT
  were done
• Treatment with oral etoposide was started at
  50mgs 12 hourly for 7 days, followed by a 14
  day gap. FBC was done at 21 days, and if no
  sign of neutropenia was present, the etoposide
  was increased to 50mgs in the morning and
  100mgs at night for 7 days, with a 14 day break,
  and FBC. If all well etoposide was increased to
  100mgs 12 hourly.
• This cycle was repeated for as long as there was
  clinical improvement and no side effects.
• ARVs were started either prior to etoposide or
  after etoposide.
                  Results
• 9 deaths
• 17 good response
• 7 lost to follow up
              Case Study 1
• 31 year old male
• CD4 12 09/12/2008 Wt 42 kg
• Presented with chronic diarrhoea for past 3
  months
• Wheel chair bound
• Started on ARVs 14/01/2009
• Admitted to IPU 27/01/2009 started on TB
  treatment
• KS palate 1cm by 1cm
• Readmitted to the IPU 02/03/2009
• 21/04/2009 KS palate larger, and cellulites and
  KS leg
• Admitted to IPU with severe pain legs, wheel
  chair bound, and large KS palate 4cms by 2cms
  raised
• Readmitted to IPU 26/05/2009 with swollen
  painful legs, KS, large KS palate
• Started etoposide 50mgs 12 hourly in the IPU
• Second course etoposide 17/06/2009
• 05/08/2009 huge improvement, walking with a stick,
  gained 10 kg.
• Etoposide 50mgs mane 100mgs nocte
• 24/08/2009 weight 54kg etoposide
• Readmitted to IPU for D&V
• 05/10/2009 etoposide
• KS palate now smaller 3cms by 2cms
• 20/10/2009 admit IPU with D&V
• 10/11/2009 etoposide Weight 62kg
• 08/01/2010 etoposide weight 68kg. KS palate almost flat.
• 01/03/2010 etoposide CD4 314 VL <50
• 12/04/10 walking. KS palate gone. weight 70kg
             Case Study 2
• 41 year old male
• First presented 19/05/2008
• Wheel chair bound, unable to move lower
  legs, incontinent of urine, fever, stony dull
  right base, T39, KS palate, KS nodule
  tongue, KS both lower legs
• Diagnosed TB pleural effusion 30/05/2008,
  and started TB treatment
• Next visit 04/02/2009. Has completed 8 months
  TB treatment. CD4 4
• Extensive KS legs, palate and eye, rasping
  respiration, and severe SOB.
• Admitted to IPU for terminal care on morphine.
  Decided to start etoposide to relieve symptoms.
• Referred to HBC on morphine
• Second course etoposide 09/03/2009
• Readmitted to IPU 24/04/2009, still on morphine
  and etoposide.
• Continued on etoposide every 3 weeks
 Decided to start on ARVs 04/09/2009
Continued on etoposide monthly and ARVs.
Stopped morphine 30/11/2009
11/01/2010 KS eye gone, KS palate gone,
No oedema legs, still some KS legs.
12/07/2010 Able to stand briefly without
support. CD4 123, VL <50. Still on ARVs
and Etoposide.
 Has travelled to Johannesburg to visit his
family.
              Case Study 3
• 26 year old female, first presented 16/02/2010.
• Black spots on the face and body for 3 months.
• On examination, conjunctival haemorrhage, KS
  tonsils, numerous KS lesions face, body and
  limbs with severe oedema thighs
• CD4 300
• Admitted to the IPU, and started on etoposide, in
  spite of severe thrombocytopenia
• 15/03/2010, a huge improvement. Swelling
  of the face much less. Swelling of the
  thighs almost gone. Started second course
  of etoposide.
• 13/04/2010 Started third course of
  etoposide, and also started ARVs.
• 05/05/2010 developed large abscess left
  buttock, referred to hospital for I/D.
• 08/06/2010 third course etoposide
• 29/06/2010 admitted to hospital with
  severe cellulites of the arm.
• 27/07/2010 continue on etoposide and
  ARVs. All lesions much smaller.
• Admitted to hospital , as she was fainting,
  received 5 units of blood
• 17/08/2010 Feeling very well. KS tonsils
  and palate gone. Still numerous small
  lesions body, but almost unnoticeable on
  the face.
• Treated with ARVs.
              Discussion
• The majority of patients with KS
  responded well to Etoposide and ARVs
• Many of these patients had very low CD4
  counts
• Two patients had CD4 of below 50 with
  very large KS of the palate.
• Many had systemic KS.
Conclusion and Recommendations
• Treatment of patients with KS and HIV should be
  further researched, and implemented in PHC
  settings in rural areas where there is no access
  to radiotherapy and combination chemotherapy.
• The quality of life of these patients is vastly
  improved, even the patients that died had some
  relief from shortness of breath, and bulky oral
  tumours