Case Report Regression of Acquired Immunodeficiency Syndrome-Related Pulmonary Kaposi's Sarcoma After Highly Active Antiretroviral Therapy DAVID M. ABOULAFIA, M.D. Kaposi's sarcoma (KS) is the most common neoplasm af- fecting people with the human immunodeficiency virus (HIV) infection. The skin is the most common site of disease; however, KS can also involve visceral organs such as the lungs, leading to severe morbidity and contributing to death in almost 30% of patients with the acquired immunodeficiency syndrome (AIDS). New antiretroviral strategies incorporating combination nucleoside ana- logues with a protease inhibitor lead to increased circulat- ing CD4+ lymphocyte counts, decreased plasma levels of HIV, and decreased mortality from AIDS-defining oppor- tunistic infections. The effects of highly active antiretro- viral therapy (HAART) on AIDS-associated KS remain largely unknown. Herein the case of an antiretroviral- naive man with advanced AIDS (CD4+ helper T-Iympho- cyte count, 35/mm 3 ; HIV viral RNA quantification, more than 800,000 copies/mL), and symptomatic pulmonary KS I n approximately 25 to 30% of homosexual men in- fected with the human immunodeficiency virus (HIV), Kaposi's sarcoma (KS) will develop, and the number may be substantially higher among a subset with antibodies to the newly described human herpesvirus 8 (HHV_8).1-3 Tu- mors most commonly involve mucocutaneous sites; however, KS may also involve visceral organs, including the lungs, in about one-third to one-half of patients with skin involvement.P Such patients may complain of dyspnea, cough, and, rarely, hemoptysis. When left un- treated, the tumors will grow; most patients with pulmo- nary KS survive 4 to 6 months. With use of chemotherapy, median survival may increase to approximately 9 to 11 months." Recent studies indicate that patients who respond to highly active antiretroviral therapy (HAART), typically consisting of two nucleoside analogues and a protease in- hibitor, experience decreased plasma levels of HIV, de- creased incidence of opportunistic infections, increased circulating CD4+T cells, and decreased short-term mortal- ityJ.8 Brief reports further suggest that conditions pre- viously deemed intractable, such as cytomegalovirus From the Section of Hematology and Oncology, Virginia Mason Medical Center, Seattle, Washington. Address reprint requests to Dr. D. M. Aboulafia, Section of Hematol- ogy and Oncology, Virginia Mason Medical Center, 1100 9th Av- enue, P.O. Box 900 (Hl4-HEM), Seattle, WA 9811L Mayo Clin Proc 1998;73:439-443 439 is described. After HAART was initiated, his CD4+ cell count increased fourfold, his HIV-viral load decreased to nondetectable levels, and the pulmonary KS regressed dramatically. To my knowledge, this report represents the first documented case of pulmonary KS regression after the initiation ofHAART. Although this finding is prelimi- nary, if confirmed by other clinicians, the effect of potent antiretrovirals on KS growth and development will have important implications on the manner in which KS is staged and treated. Mayo Clin Proc 1998;73:439-443 AIDS = acquired immunodeficiency syndrome; HAART = highly active antiretroviral therapy; HHV-8 = human herpes- virus 8; HIV =human immunodeficiency virus; KS = Kaposi's sarcoma retinitis, progressive multifocal leukoencephalopathy, anti- biotic-resistant mucocutaneous oral candidiasis, and intes- tinal cryptosporidiosis and microsporidiosis, may stabilize or even diminish after increases in CD4 + cell counts or significant reductions in HIV plasma viral RNA loads,":" The effect that potent combination antiretroviral therapy will have in altering the clinical course of acquired immu- nodeficiency syndrome (AIDS)-related neoplasms is un- certain and necessitates long-term study." This report describes a patient with pulmonary KS in whom symptoms resolved and findings on chest radio- graphs diminished after initiation of triple antiretroviral therapy and effective suppression of plasma levels of HIV. In addition, it underscores the potential of HAART to modulate yet another AIDS-defining condition. As data mature, the influence of HAART on AIDS-related KS development and growth must be considered as newer schemas are proposed to stage and treat this most common type of HIV-associated cancer. REPORT OF CASE A 44-year-old homosexual man, infected with HIV for 10 years, sought medical assessment because of progressive dyspnea and intermittent hemoptysis of 3 months' dura- tion. He denied having recent fevers, night sweats, or purulent sputum production. He had previously declined antiretroviral therapy but was taking trimethoprim- © 1998 Mayo Foundation for Medical Education and Research For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
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