Cutaneous lesions in a patient with HIV: do not forget the GI tract!

Introduction

A 42-year-old man presented to the emergency department with a 1-week history of fever, abdominal pain and diarrhoea with haematochezia. A medical history was significant for untreated AIDS, which he has had for the past 9 years. The only opportunistic infection that he has had in the past was pneumocystis pneumonia. Prior upper and lower endoscopic evaluation for weight loss in 2018 was unremarkable. On examination, he had multiple purple erythematous nodules over his limbs and tongue (figure 1). Abdominal examination was unremarkable. Investigations demonstrated macrocytic anaemia, thrombocytopaenia, HIV viral load 90 900 copies/mL (4.96 log) and a CD4-count of 34 cells/µL. Cytomegalovirus (CMV) viraemia was present with a viral load of 2400 IU/mL (3.37 log). CT abdomen revealed colonic thickening with ileocolic lymphadenopathy. Stool microbiology was negative. Upper and lower endoscopies demonstrated multiple violaceous and friable lesions in the oesophagus, duodenum and colon (figures 2 and 3).

Figure 1.

Cutaneous and oral Kaposi sarcoma lesions.

Figure 2.

Kaposi sarcoma lesions found on upper GI endoscopy. GI, gastrointestinal.

Figure 3.

Kaposi sarcoma lesions found on lower GI evaluation. GI, gastrointestinal.

Diagnosis

Endoscopic biopsies showed spindle-cells staining positive for human herpesvirus-8 (HHV-8) as well as CMV inclusion bodies. HHV-8 serum virology was not available for testing at the time. The patient was started on doxorubicin and ganciclovir. He was also commenced on dolutegravir and ritonavir-boosted darunavir for HIV. Repeat endoscopy after 6 months demonstrated resolution of most of the gastrointestinal (GI) lesions.

These cutaneous and GI lesions are Kaposi sarcoma (KS). KS is an angio-proliferative disorder associated with HHV-8 and is prevalent in HIV, manifesting commonly as cutaneous lesions. It may implicate viscera, for example, lymph nodes, bone marrow, respiratory system, and more commonly, the GI tract. GI disease is usually asymptomatic or may present with weight loss, pain, diarrhoea and GI bleeding. Lesions are typically violaceous and nodular. Histological confirmation is required for diagnosis—lesional cells are positive to endothelial markers CD31 (figure 4) and HHV-8 (figure 5).¹ This patient also had coinfection with CMV GI disease given the inclusion bodies seen on colonic histology (figure 6).

Figure 4.

CD31 staining on immunohistochemistry—original magnified 200 times.

Figure 5.

HHV-8 staining on IHC—original magnified 200 times. HHV-8, human herpesvirus-8; IHC, immunohistochemistry.

Figure 6.

CMV staining on IHC—original magnified 200 times. CMV, cytomegalovirus; IHC, immunohistochemistry.

Conclusion

GI manifestations of KS are endoscopically characteristic. The majority of GI disease in HIV-related KS lesions rescind with highly antiretroviral therapy and chemotherapy.² Disseminated GI KS generally confers a poor prognosis from current literature.³ CMV/HHV-8 coinfection has not been well studied in the literature, hence outcomes compared with KS alone remain undefined.⁴

Ethics statements

Patient consent for publication

Consent obtained directly from patient(s).