A 35-year-old gay man presented with papular lesions on his elbow (Figure 217-1). Shave biopsy demonstrated Kaposi's sarcoma (KS). He subsequently tested positive for HIV and began treatment with antiretroviral combination therapy. The KS resolved with topical alitretinoin gel treatment.
Several reddish-purple papular lesions of Kaposi's sarcoma on the elbow of a man with human immunodeficiency virus/acquired immuno deficiency syndrome. (Courtesy of Heather Wickless, MD.)
In the United States, KS is most often seen in patients with AIDS and patients on immunosuppressants after organ transplantation. KS can also be classic (older Mediterranean men) or endemic (young men in sub-Saharan Africa). KS is caused by Kaposi's sarcoma-associates herpesvirus (KSHV), which promotes oncogenesis. KS cannot be cured, but treatment can result in improvement or disease stabilization. Current therapies improve the immune system or target KSHV. Therapies that modulate KSHV-mediated signaling are being studied.
- KS can be classic (older Mediterranean men), endemic (young men in sub-Saharan Africa), epidemic (AIDS patients), or posttransplantation (organ recipients).1
- In the United States, 81.6% of KS is seen in patients with AIDS2 (Figure 217-1).
- In HIV-positive patients, the prevalence is 7.2/1000 person years; 451 times higher than general population.3
- In transplant patients, the prevalence is 1.4/1000 person years; 128 times higher than general population.3
- The prevalence of classic KS in the general population of southern Italy is 2.5/100,0004 (Figure 217-2).
- The male-to-female ratio for epidemic KS in the United States is approximately 50:1 but is falling as the prevalence of AIDS increases among women.5 The male-to-female ratio has been approximately 10:1 for classic and endemic KS.
- KS is the most common malignancy seen in AIDS patients.
Classic Kaposi's sarcoma on the foot of an 88-year-old Italian man who does not have HIV/AIDS. These painful purple-red “growths” were present on his left foot for several years before diagnosis. (Courtesy of John P. Welsh, MD, and Herbert B. Allen, MD.)
- KS is caused by KSHV, also known as human herpes virus 8 (HHV-8). KSHV acts through host cell signal transduction to activate multiple oncogenic pathways.6
- KS is an angioproliferative neoplasm, with abnormal proliferation of endothelial cells, myofibroblasts, and monocyte cells.
- Lesions often begin as papules or patches and progress to plaques as proliferation continues.
- Some lesions ulcerate (nodular stage), and lymphedema can occur.
- Immunodeficiency as a consequence of AIDS.
- Immunosuppressants for solid-organ transplantation.
The diagnosis is often made clinically in a patient who has AIDS and a typical presentation of KS. In atypical presentations, diagnosis is made by biopsy.
- Cutaneous lesions are usually multifocal, papular, and reddish-purple in color (Figures 217-1...