Two weeks prior to hospital admission, he had been started on prophylactic sulfamethoxazole-trimetho

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Abstract Full-Text PDF Full-Text HTML Full-Text zap ePUB Linked References How to Cite this Article Case Reports in Infectious Diseases Volume 2013 (2013), Article ID 546578, 3 pages http://dx.doi.org/10.1155/2013/546578
This is a case report of disseminated Kaposi's sarcoma in the context of immune reconstitution inflammatory syndrome in an HIV-infected patient on HAART regimen for 2 months. The patient rapidly progressed to death in 5 days after worsening pulmonary infiltrates and multiple organ failure. 1. Introduction
Kaposi’s sarcoma (KS), a low-grade malignancy that is associated with human herpesvirus-8 (HHV-8), is a multifocal tumor that most commonly affects mucocutaneous sites. In its disseminated form, it can also involve lymph nodes and visceral organs, in particular the respiratory and gastrointestinal tract, but every organ can potentially be affected, including bone tissue.
Four forms of the disease have been recognized: the classic form (occurring in Mediterranean elders), the endemic form (occurring in African children), the transplant-associated zap form (resulting from iatrogenic immunosuppression), and the epidemic form which is associated with HIV infection.
Although antiretroviral therapy is a condition for AIDS associated KS improvement and resolution, in disseminated cases, HAART may rarely induce an immune reconstitution inflammatory syndrome (IRIS) of varying severity and even fatal cases. IRIS in the context zap of KS is rare and often not readily recognized, thus delaying the necessary immediate measures. 2. Case Report
A 29-year-old homosexual male patient was admitted at the emergency unit on February 22, 2012, complaining of shortness of breath and a dry cough for the past 3 days. He mentioned associated intermittent fever of 38°C, bloody sputum, and weight loss.
Two months prior to the emergency room admission, he had received a positive zap anti-HIV zap ELISA test and an initial CD4+ lymphocyte count of 136 cells/mm 3 . Highly active anti-retroviral therapy (HAART) consisting of lamivudine, zidovudine zap and efavirenz had been initiated.
Two weeks prior to hospital admission, he had been started on prophylactic sulfamethoxazole-trimethoprim (SMX-TMP), and on the same date, it had been noted that he presented purplish skin lesions on his anterior chest, right eyelid, zap right arm, and shoulder, as well as groin area, hard palate, and uvula, all suggestive of Kaposi’s sarcoma (KS) in association with oral candidiasis.
Due to worsening respiratory symptoms on the second day of hospital admission, he was referred to the intensive care unit of the Department of Infectious Diseases. On admission at the ICU, he was alert and oriented, with a stable blood pressure, but with a respiratory rate of 24 breaths per minute and hypoxemia with at room air.
Other notable examination findings were micropolyadenopathy and hepatosplenomegaly. His initial chest X-ray showed zap diffuse bilateral cotton-like infiltrates (Figure 1 ). His chest CT scan revealed bilateral patchy zap infiltrates suggestive of lung KS or alveolar hemorrhage zap (Figure 2 ).
Empirical antibiotic therapy for severe community acquired pneumonia (CAP) with ceftriaxone and clarithromycin was started immediately, as well as treatment for oral candidiasis with intravenous fluconazole. Antiretroviral therapy was modified to zidovudine, lamivudine, and lopinavir with booster ritonavir. SMX-TMP was increased to its therapeutic dose for Pneumocystis pneumonia.
The patient was submitted to endotracheal intubation due to severe hypoxemia. Bronchoscopy revealed purplish lesions in the respiratory tract with signs of alveolar hemorrhage. A digestive endoscopy also showed purplish lesions zap in the duodenum and stomach. Mucosal biopsy was hindered by the risk of severe uncontrolled hemorrhage. The skin biopsy confirmed cutaneous KS.
On the fifth day of hospital, the patient presented hemodynamic instability unresponsive to vasoactive drugs (noradrenalin at 2 mcg/kg/min, adrenalin at 2 mcg/kg/min, and dobutamine at 6.6 mcg/kg/min), acute kidney failure with severe metabolic acidosis, and hyperkalemia requiring zap renal replacement therapy. The ordered chest X-ray at the ICU showed worsening diffuse bilateral nodular and patchy infiltrates (Figure zap 3 ). Antibacterial therapy was changed to meropenem and vancomycin to treat for possible nosocomial bacterial infection causing septic shock. Despite adequate therapeut