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									45 yo man with AIDS, LE edema,
    and pulmonary nodules

          Anh Innes, M.D.
           March 4, 2003
                 History
• 45 yo man with AIDS, CD4+ of 8, admitted for
  left LE edema and groin pain.
• Pt s/p local trauma to leg 3 days PTA
• + tactile fevers and chills; denied cough,
  SOB, hemoptysis
               History,cont.
PMH                        Meds: none
• HIV dx 1992
• Crypto meningitis        Social:
• PCP                      • IVDA x 25 years
                             (speed)
• Oral thrush
                           • Occ ETOH, + tobacco
• Bacillary angiomatosis     (10 pack-years)
  x2                       • Prior homosexual
• Hepatitis C with           contacts
  cirrhosis                • Homeless
              Physical Exam
•   AFVSS 98% RA
•   HEENT: no oral thrush
•   Lungs: CTA
•   Abd: slightly distended with fluid wave
•   Ext: L groin-- edema, erythema, fluctuant
    mass
    – LLE > RLE
    – No rashes
                   Data
      9.1            LN dissection:
5.1         163      • MRSA abscess and
                       bacteremia
Na 128, K 4.2        • Warthin-Starry stain
Alk 435, AST 55,       + = BA
ALT 52               • HHV-8 + = KS
                  BA vs KS
                 Bacillary         Kaposi’s sarcoma
               angiomatosis
Cutaneous Papules, warts,         LE, oral mucosa,
            subcutaneous          genitalia; papules or
            nodules, plaques      plaques
Systemic    Brain, GI, lung,      Oral cavity, GI,
            pleura, BM, bone,     pulmonary, lymph
            liver, spleen         nodes
Imaging     Intense contrast      Septal thickening,
            enhancement of        perihilar and lower
            nodes                 lobes; nodules
Pathology   Well-formed,rounded Poorly-formed
            proliferation of BV; capillary structures;
            Warthin-Starry stain HHV-8
           Kaposi’s sarcoma
• Most common tumor in       • Clinical features:
  HIV +                         – 30-50% pulmonary
                                – 60% pleural effusion
• Classic, African, organ-
  transplant, HIV            • Palliative treatment
                             • Indications for
• Associated with HHV-8
                               chemotherapy
• Virus demonstrated in         – >25 skin lesions
  HIV+ homosexuals,             – Cutaneous KS
  HIV- homosexuals,               unresponsive to therapy
  classic KS                    – Symptomatic visceral
                                – Extensive edema
• HIV and HHV-8 interact
“Regression of AIDS-Related Pulmonary Kaposi’s
            Sarcoma after HAART”

• First report of                   • HAART initiated
  pulmonary KS                      • 2 months later:
  regression after                    symptoms resolved,
  HAART                               CXR improved
• 44 yo man with HIV,               • Protease inhibitors
  pulmonary infiltrates,              have direct antiviral
  progressive dyspnea                 effect on HHV-8?
  and hemoptysis
• Bronch with bx
  diagnostic of KS

          Aboulafia. May Clin Proc 1998;73:439-443
“Antiretroviral Therapy with Protease Inhibitors in HIV
       Type-1 and HHV-8-Coinfected Patients”

 • 6 pts coinfected with               • KS lesions regressed
   HHV-8 and HIV                         in 3 of 4
 • 4 of 6 with KS                      • Other tx used
 • Measured                            • 3 pts with rising
    • PBMC HHV-8                         CD4+ and
      DNA                                concurrent falling
    • Plasma HIV-1                       HHV-8 DNA
      RNA                              • Direct effect of PI on
    • CD4+ T cell                        HHV-8 not proven;
      counts                             temporal correlation
                                         shown

             Milito et al. J Med Virol. 1999;57:140-44
“Impact of New Antiretroviral Combination Therapies in
         HIV-infected Patients in Switzerland”

• Prospective multicenter
  study of 3785 men and
  1391 women with HIV
• 1764 homosexual men
• Pts followed 1988-1996
• Reduction in
  progression to AIDS
  and mortality during
  HAART (from 95-96)


              Egger et al. BMJ 1997;315:1194-99
“Risk of HIV-Related Kaposi’s Sarcoma and Non-
 Hodgkin’s Lymphoma with Potent Antiretroviral
                    Therapy”




          Ledergerber et al. BMJ 1999;319:23-24
          Kaposi’s Sarcoma
• Pathogenesis of HHV-8 and possible interaction with
  HIV currently being studied
• Bacillary angiomatosis should be in differential,
  especially for “unusual” KS cases
• HAART improves immune status  regression of KS
• Symptomatic pulmonary involvement: consider
  treatment with chemotherapy
                 References
Aboulafia DM. Mayo Clin     Holkova B, Takeshita K,
  Proc 1998;73:439-443.       Cheng DM, et al. J Clin
                              Oncol 2001;19:3848-51.
De Milito A, Catucci M,
  Venturi G, et al. J Med   Ledergerber B, Telenti A,
                              Egger M. BMJ
  Virol. 1999;57:140-44.      1999;319:23-24.
Egger M, Hirschel B,        Tam HK, Zhang Z,
  Francioli P, et al. BMJ     Jacobson LP, et al. Int
  1997;315:1194-99.           J Cancer 2002;98:916-
                              22.
                            Up to Date 11.1

								
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