Clinica Case 8:  KAPOSI’S SARCOMA

 

A 36 years-old male, smoker of one packet of cigarettes per day, reporting personal antecedents of arterial hypertension treated with Lovibonâ and Micardis 80â.

The patient arrived at the hospital’s emergency unit, directed by his dentist on observing a purplish erythema, exophytic, pediculated lesion, soft to the touch and occasionally bleeding, with a diameter of approximately 1.5 cm, located on the gingiva on third quadrant, level 3.2-3.3.

We detected another purplish erythema lesions on the right posterior lower gingiva and in palate, near to the third upper left molar, as well as nodular lesions on the gingiva near to the left upper incisors and canine.

A laboratory tests were requested.

The results of the tests were positive for the human immunodeficiency virus (HIV), with a CD4 T LYMPHOCYTES count of + 187 cells/uL 11%, CD8 T LYMPHOCYTES + 1262 celLs/uL 76.2%, QUOTIENT CD4/CD8= 0.1. viral load HIV 376000 C/ml.

 

Histopathology study confirmed the existence of highly vascularized tissue with abnormal blood vessels and abundant extravasated erythrocytes with dense inflammatory infiltration. They are compatible with Kaposi Sarcoma (KS) in the gingival area, and for that reason the patient was sent to the department of internal - infectious medicine for assessment and treatment.

 

The patient was finally diagnosis as HIV+ C3 phase (KS) patient, he did not present any other disease, or chronic or infectious illnesses, (STDs, hepatitis B, hepatitis C, Toxoplasm, CMV). He began with anti-retroviral treatment and with chemotherapy, consisting of 10 cycles of CAELYX 20 mg., with a interval of 21 days between them, with a very positive tolerance.

After the completion of the cycles, we observed the complete remission of the patient’s lesions.

 

The patient is currently asymptomatic, and does not present lesions on intraoral exploration. He maintains a CD4 count + >400 and a viral load of HIV <50. Chemotherapy was then interrupted and the treatment was reduced to anti-retrovirals with periodical control.

 

DISCUSSION

 

Kaposi Sarcoma (KS) is defined as a multicentric vascular neoplasic process, presenting a high number of pinkish, reddish or purplish lesions and blotches or nodules on the skin and membrane mucosas.

KS is the malignant neoplasic manifestation most frequently associated with infection by the Human Immunodefficiency Virus (HIV), its appearance is considered as a criterion for AIDS and it is not infrequent for it to be the first manifestation of that condition.(1,2)

 

One of the fist known manifestations of AIDS was the unusual epidemic appearance of KS. It emerged in 79% of cases diagnosed in 1981. However, in 1989 it was diagnosed in just 25% of cases; in 1992 in 9%; and in 1997 it did not reach 1%, a figure maintained to the present. Many studies prove that the reduction in the incidence of KS coincides with the beginning of the use of powerful antiretroviral treatments, and of their increasingly earlier protocolization (3).

 

Those treatments have substantially improved the immunity system, resulting in:

·         An increase in survival rate.

·         A decrease in the rate of progression towards AIDS

·         A decrease of opportunistic infections and of the oral manifestations of the illness. Among them, oral and esophageal candidiasis continue being the most prevalent and significant. (2,4,5)

 

At present, notwithstanding the reduction of the incidence of oral KS to rates below 1% due to Antiretroviral Therapy (ART) and to Highly Active Antiretroviral Therapy (HAART), recent investigations have demonstrated no alteration in either the epidemiology or the clinical or histological characteristics of this lesion (2,4,5,6,7).

 

KS oral lesions develop in 10% to 20% of male HIV+ 30-40 years old patients, and are more frequent in those acquiring the virus by sexual transmission in opposition to those being infected through parenteral infection by drug use. Oral lesions may be the first manifestations of the AIDS disesase. (8)

 

References:

 

1.      Harrison ed. Principios de Medicina Interna.
Madrid: Interamericana Editores; 2001.p.2165-218

2.       Aguirre JM,Echevarria MA, Eguia Del Valle A.
Síndrome de inmunodeficiencia adquirida : manifestaciones en la cavidad bucal.
Med Oral Patol Oral Cir Bucal 2004;9:148-57

3.      Arno A, Ruiz L, Clotet B.
Carga Viral: tecnicas de cuantificacion, valor pronostico y utilidad clinica para el seguimiento del paciente VIH-I positivo.
Jano 1997:7;18-24

4.      Coogan M.M, Greenspan J, Bull World Health Organ vol.83 no.9 Geneva Sept. 2005

5.      Reichart PA.
Oral manifestations in HIV infection: Funga and bacterial infections, Kaposi’s sarcoma. Med Microbiol Immunol (Berl).2003 Aug;192(3):165-9.

6.      Regel-I JA, Jordan R C K.
Oral Kaposi´s sarcoma: Biopsy accessions as an indication of declining incidence.
Oral surg oral med oral pathol. October 2002 :339.(letters to the editor)

7.      Bravo IM, Correnti M, Escalona L, Perrone M, Brito A, Tovar V, Rivera H.
Prevalencia de lesiones bucales en pacientes VIH+, relación con contaje de células CD4+ y carga viral en una población Venezolana.
Med Oral Patol Oral Cir Bucal 2006;11:25-31.

8.      Sapp JP, Eversole LR, Wysocki GP, eds. Patologia oral y maxilofacial contemporanea. Madrid: Harcourt Brace Editores;1998.p.214-21.