J Formos Med Assoc 2002 • Vol 101 • No 8 585
Intussusception in AIDS-Associated Kaposi’s Sarcoma
(J Formos Med Assoc2002;101:585–7)
Key words:intussusceptionKaposi’s sarcomaAIDS
Division of Infectious Diseases and Tropical Medicine, and
Departments of 1Internal Medicine, 2Pathology and
3Surgery,Tri-Service General Hospital, National Defense Medical
Center, Taipei.Received: 15 March 2002. Revised: 15 April 2002.
Accepted: 7 May 2002.Reprint requests and correspondence to: Dr.
Yao-Chi Liu, Division of General Surgery, Department of Surgery,
Tri-ServiceGeneral Hospital, National Defense Medical Center, 325,
Section 2, Cheng-Kung Road, Nei-Hu, Taipei, Taiwan.
INTUSSUSCEPTION AS THE INITIAL MANIFESTATIONOF AIDS ASSOCIATED
WITH PRIMARYKAPOSI’S SARCOMA: A CASE REPORT
Ning-Chi Wang, Feng-Yee Chang, Yen-Yi Chou,1 Chih-Lung Chiu,1
Chih-Kung Lin,2
Yuen-Hua Ni, and Yao-Chi Liu3
Gastrointestinal symptoms usually develop in AIDSpatients at
some time during the course of illness.Kaposi’s sarcoma (KS) is the
most frequent neoplasticdisease and is a common cause of
gastrointestinal tractinvolvement in AIDS patients [1]. KS occurs
predomi-nantly in homosexual men with AIDS [1]. Patients whosuffer
from gastrointestinal KS usually have skin orlymph node involvement
[2]. However, Friedman foundthat 40% of AIDS patients with an
initial diagnosis ofcutaneous or lymph node KS also had
gastrointestinaltract involvement [3]. Most cases of enteric KS
areclinically silent and found incidentally by endoscopy
orradiologic examination [4]. We report the case of a 31-year-old
AIDS patient with homosexual behavior whodeveloped intestinal
obstruction due to intussuscep-tion of the ileum in association
with KS. Primary gas-trointestinal KS was the initial AIDS-defining
illness inthis patient.
Abstract: Kaposi’s sarcoma (KS) is the most common
AIDS-associated neoplasm. Itinvolves the gastrointestinal tract,
skin and lymph nodes with about equal frequency.However, most cases
of gastrointestinal KS are clinically silent and found
incidentally.We report the case of a 31-year-old homosexual man who
developed intussusceptionin association with a primary ileal KS. He
was admitted due to abdominal pain lasting2 hours. Flat abdominal
roentgenogram revealed small bowel ileus in the centralabdomen.
Abdominal sonography and computerized tomography revealed an
intra-luminal soft tissue mass in the small intestine with an
intussusception. Exploratorylaparotomy found an ileal tumor mass 90
cm proximal to the ileocecal valve.Pathologic examination of the
resected intestine showed KS. HIV-1 infection wasconfirmed by
Western blot. The CD4 T-cell count was 59/mm3. In
conclusion,intussusception by enteric KS may present as the initial
AIDS-associated neoplasmin patients with HIV infection.
Case ReportA 31-year-old homosexual man was admitted to our
hospitaldue to abdominal pain lasting 2 hours. There was no
historyof fever, jaundice, melena or hematochezia. There wasneither
prior history of abdominal surgery nor other systemicdisease
including HIV infection. Physical examination re-vealed an acutely
ill, febrile male with a body temperature of38.5°C. The skin and
oral cavity were normal. The abdomenwas flat and bowel sounds
increased on auscultation. Therewas diffuse tenderness and rebound
pain over the wholeabdomen. Rectal examination revealed no mass
orhemorrhoid. There was no external hernia.
Laboratory investigations disclosed a white blood cellcount of
5,000/mm3, with 56% neutrophils, 30% lympho-cytes and hematocrit
31%. Flat abdominal roentgenogramrevealed small bowel ileus in the
central abdomen. There was
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N.C. Wang, F.Y. Chang, Y.Y. Chou, et al
586
Fig. 3. Histopathologic examination of the resected ileal tumor.
Lightmicroscopy shows many spindle cells, small anastomotic
vascularchannels, and extravasation of red blood cells.
(Hematoxylin andeosin, X 400).
no pneumoperitoneum. Abdominal sonography revealed a2.5-cm
intraluminal soft tissue mass in the small intestine overthe right
lower quadrant of the abdomen (Fig. 1). Computer-ized tomography
revealed a 2-cm soft tissue mass in the smallintestine with an
intussusception over the same site (Fig. 2).No abnormalities were
seen in the liver, spleen or pancreas.There was no retroperitoneal
or pelvic lymphadenopathy.
After supportive treatment with intravenous fluid andnasogastric
tube decompression with low-pressure suction,exploratory laparotomy
was performed, revealing a 4 x 3 x3-cm tumor mass over the ileum 90
cm proximal to theileocecal valve. There were no other abnormal
findings in thevisceral organs, nor any visceral or
retroperitoneallymphadenopathy. The intussuscepted intestinal
segmentwas resected. Pathologic examination of the resected
intes-tine showed a KS lesion 3.5 x 2.5 x 0.8 cm in size that
waslocated 6.5 cm from one cut end (Fig. 3). Anti-HIV antibodytests
using enzyme immunoassay and Western blot were bothpositive. The
CD4 T-cell count was 59/mm3. The patientrecovered well and
postoperative panendoscopy was normal.
Fig. 1. Abdominal sonogram shows an intraluminal soft tissue
mass,2.5 cm in diameter, in the small intestine over the right
lowerquadrant.
Fig. 2. Axial computerized tomogram shows an intraluminal
softtissue mass, 2 cm in diameter, involving the small intestine
and adilated portion of the proximal bowel loop.
The patient refused highly active antiretroviral therapy(HAART)
and was discharged on the 13th hospital day.
DiscussionKS is a multisystem neoplastic disease. Skin
manifesta-tions are usually seen first. Visceral involvement
isfrequently seen, especially in the gastrointestinal tract(38–50%)
and lung (34%) [2, 5, 6]. The incidence ofKS with gastrointestinal
involvement has been reportedto be as high as 40 to 70% in the
presence of cutaneouslesions [2, 7]. Localization of KS is more
common inthe upper than in the lower gastrointestinal tract [2,
4].The oropharynx is the most common site of involve-ment [1]. The
frequency of lower-gastrointestinal tractKS with cutaneous or lymph
node disease is 12% [4].KS involving the gastrointestinal tract
without cutane-ous lesions is rare [8, 9]. Zoller et al found that
less than5% of AIDS patients with gastrointestinal KS had
nocutaneous lesions [7]. Lemlich et al found that the rateof
gastrointestinal involvement in AIDS patients with-out KS skin
lesions was 8% [10]. Primary gastrointesti-nal KS without cutaneous
lesion was the initial and onlyAIDS-defining illness in our
patient. Studies have re-ported no difference in CD4 cell count
between diffuseKS and KS confined only to the gastrointestinal
tract [4,11].
In the early 1980s, KS was the first AIDS-definingillness
(primary KS) in approximately 30% of AIDScases [12, 13]. The
incidence of KS as the AIDS-defining illness has decreased in the
USA [14, 15],Europe [16] and Australia [11, 17], and this
decreaseis associated with HAART [18, 19].
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Intussusception in AIDS-Associated Kaposi’s Sarcoma
Intestinal intussusception in adults is uncommonand represents
less than 15% of reported cases ofintussusception [20]. Only one
case of intussusception,occurring in the jejunum, has been
previously re-ported in a patient with KS [21]. Most patients
withgastrointestinal KS are asymptomatic. Bleeding [22],obstruction
[23], appendicitis [24], perforation withperitonitis [25], and
persistent gastrointestinal symp-toms [26] have all been reported
in gastrointestinal KS,with bleeding being the most common
complication[10, 27].
Patients with AIDS are surviving longer with HAARTand are
overcoming opportunistic infections morefrequently with antibiotic
prophylaxis. Gastrointesti-nal KS should be considered in the
differential diagno-sis of acute abdomen in AIDS patients.
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