The epidemiologic, pathologic, and clinical features of AIDS-associated pulmonary Kaposi's sarcoma

AIDS-related Kaposi's sarcoma (KS) occurs principally in homosexual or bisexual men infected with the newly identified human herpes virus-8, also called KS-associated herpes virus. Unlike classical forms of the disease, AIDS-associated KS is a multicentric entity that frequently involves lymph nodes and the GI tract. KS may also occur in the lung, commonly in the setting of extensive mucocutaneous disease and very rarely as an isolated event. The exact incidence of intrathoracic KS in patients with AIDS is unknown. Before the advent of highly active antiretroviral therapy (HAART), pulmonary KS had been reported in approximately 10% of patients with AIDS, 25% of patients with cutaneous KS, and in roughly 50% of postmortem examinations of patients with AIDS, KS, and respiratory infections. In the HAART era, the incidence of KS has declined precipitously in North America and Europe but not in third world countries where HAART is largely unavailable. Pulmonary KS may cause radiographic infiltrates and respiratory symptoms that mimic a variety of other infectious and neoplastic processes. An aggressive diagnostic evaluation of patients who have this condition is essential because chemotherapy and radiation therapy may provide significant palliation, particularly if used in conjunction with HAART. This review briefly explores the changing epidemiology of KS. The pathology and pathogenesis of KS is also reviewed, along with the clinical and radiographic presentation, diagnosis, and management of pulmonary KS.

Simvastatin-induced rhabdomyolysis in an HIV-infected patient with coronary artery disease

As greater numbers of human immunodeficiency virus (HIV)-infected individuals live to middle-age and beyond, there is growing concern that elevated cholesterol and lipid values will lead to cardiovascular complications in such patients. Furthermore, several of the highly active antiretroviral therapies (HAART) used to reduce levels of circulating HIV and extend acquired immunodeficiency syndrome (AIDS)-related survival are associated with a rise in plasma lipids. Anecdotal reports suggest such rises may be linked to cardiovascular complications. Herein, we review the case of a 74-year-old HIV-infected man with advanced coronary artery disease. He was prescribed simvastatin for control of hyperlipidemia and within 4 weeks developed muscle pain, proximal muscle weakness, myoglobinuria, and a markedly elevated creatinine phosphokinase (CPK). Simvastatin was discontinued, and rhabdomyolysis improved rapidly with conservative care. This report emphasizes this rare, but potentially significant, side effect of statin anticholesterol agents. Medical providers who prescribe statins must remember to check CPK levels when their HIV-infected patients complain of muscle pain. Discontinuing the offending drug will usually result in rapid diminution of muscle pain and inflammation and improve muscle strength.

Occupational exposure to human immunodeficiency virus: what healthcare providers should know

PURPOSE

The author reviews the risks of occupational exposure to HIV and provides a rationale for new postexposure guidelines for healthcare workers.

OVERVIEW

Approximately 50,000 percutaneous exposures occur yearly among healthcare workers in the United States. Of these, approximately 5000 involve exposures to blood that is known to be infected with HIV. The risk of transmission after percutaneous exposure to HIV-tainted blood has been estimated to be 0.3%, but the risk may be considerably higher to the healthcare worker if any of the following is present: a deep injury; visible blood on the sharp device; a procedure that involves a needle placed in the patient's artery or vein; and a patient with advanced AIDS. The increasing resistance of HIV strains to antiretroviral therapy continues to make treatment more difficult.

CLINICAL IMPLICATIONS

Postexposure prophylaxis with zidovudine may reduce the risk of occupational infection by 80%. Advances in the ability to ameliorate HIV transmission rates and to treat individuals with resistant disease through innovations in drug therapy, engineering of controls for injury prevention, and more focused postexposure evaluation offer the hope of reducing this infrequent, but dangerous, occupational threat.

Retinoid-induced hypercalcemia in a patient with kaposi sarcoma associated with acquired immunodeficiency syndrome

Retinoids are commonly used for the treatment of nonmalignant skin disorders and occasionally for the treatment of various neoplasms including epidemic Kaposi sarcoma (KS). Dry skin and mucus membranes, muscle and joint aches, alopecia, headaches, and liver and lipid abnormalities are the most frequent medication-related side effects. Very rarely, this class of drugs is associated with the development of hypercalcemia. The authors report the case of a man with acquired immunodeficiency syndrome (AIDS)-associated KS who, while participating in a phase II clinical trial of LGD 1057 (9-cis-retinoic acid) for treatment of epidemic KS, developed hypercalcemia, mental status changes, and renal insufficiency. The etiologic factors of retinoid-induced hypercalcemia are imperfectly understood, but with drug withdrawal his serum calcium, mental acuity, and renal function quickly normalized. Hypercalcemia occurs infrequently in the setting of AIDS and when present, is usually mediated by opportunistic infections. Clinicians should be alert to this potentially life-threatening iatrogenic complication that responds favorably to drug withdrawal.

Cost-effectiveness analysis comparing liposomal anthracyclines in the treatment of AIDS-related Kaposi's sarcoma

Liposomal formulations have been shown to alter the efficacy and toxicity profiles of anthracylines for patients with HIV-related advanced Kaposi's sarcoma (KS). Using decision-analysis models, the costs and cost-effectiveness of the two U.S. Food and Drug Administration (FDA)-approved liposomal formulations of these agents were estimated. Estimates of costs, effectiveness, and cost-effectiveness were derived from clinical trial data of separate, randomized phase III trials of pegylated liposomal doxorubicin (20 mg/m2 every 3 weeks) and liposomal daunorubicin (40 mg/m2 every 2 weeks). Clinical response rates were 59% for pegylated liposomal doxorubicin and 25% for liposomal daunorubicin. Despite higher acquisition costs for pegylated liposomal doxorubicin, total estimated costs of treatment for KS and chemotherapy-related hematologic toxicities were similar ($7,066 U.S. compared with $6,621 U.S. for liposomal daunorubicin). Cost-effectiveness profiles, defined as average costs per responder, favored pegylated liposomal doxorubicin ($11,976 U.S./responder versus $26,483 U.S./responder for liposomal daunorubicin), reflecting the higher reported response rate in the phase III trial. Sensitivity analyses suggested that the costs and cost-effectiveness results would not differ markedly when evaluated over a range of assumptions, including response rate, neutropenia rate, and dosage variations.

Extramedullary facial plasmacytomas with anaplastic features: a diagnostic dilemma with implications for treatment

Extramedullary plasmacytomas (EMPs) are rare plasma-cell tumors of the soft tissue that occur predominantly in the nasal sinuses and oropharynx. Subcutaneous and cutaneous plasmacytomas of the face are distinctly unusual. The authors report a case of rapidly expanding EMP involving the lip and contralateral nasolabial fold of a native Alaskan man with a 25-year history of recurring solitary bone plasmacytomas (SBP). An incisional biopsy revealed sheets of monotypic plasmablasts with anaplastic features. The pathologic and clinical findings were most consistent with a Richter transformation from a low-grade to a high-grade malignancy, or anaplastic myeloma (AM). With combined chemotherapy and radiation therapy, he achieved a complete response. The clinical and laboratory features of this most unusual plasma-cell dyscrasia are reviewed with an emphasis placed on diagnosis and treatment.

Malignant melanoma in an HIV-infected man: a case report and literature review

Although it is not proven by causative association, several studies indicate that patients with acquired immune deficiency syndrome (AIDS) have a high risk for developing cutaneous malignancies, especially lymphoma and Kaposi's sarcoma. Other malignant cutaneous lesions seen in this patient population include basal-cell carcinoma, squamous-cell cancer, Bowen's disease, and rarely, malignant melanoma. We review the clinical course of a human immunodeficiency virus (HIV)-infected man with a superficial spreading melanoma of the scapula treated with wide local excision. Ten years later, he was diagnosed as having metastatic and widespread disease. By placing our patient's experience in context with other case reports, we sought to determine whether malignant melanoma in the HIV-infected population presents atypically or has a more aggressive natural history. The appearance of malignant melanoma in homosexual men may be coincidental or reflective of the expanding spectrum of HIV-associated diseases. Of the 22 patients reported to have malignant melanoma and HIV, approximately one-third had metastatic disease at the time of initial examination, and those with a decreased CD4+ cell count were most likely to have systemic symptoms. Melanomas among patients with HIV infection were often atypical in appearance, being multiple or metastatic, as is the case in other well-defined immunosuppressed groups. Further epidemiological and clinical studies are required to determine whether melanoma occurs more frequently or is more likely to metastasize in persons with HIV disease. Laboratory investigators must also concentrate on those factors in the setting of HIV disease that may contribute to melanocyte activation. Our patient's fulminant clinical course should alert clinicians to carefully evaluate patients with HIV infection and unusual pigmented cutaneous lesions, or who have a prior history of malignant melanoma.

Regression of acquired immunodeficiency syndrome-related pulmonary Kaposi's sarcoma after highly active antiretroviral therapy

Kaposi's sarcoma (KS) is the most common neoplasm affecting 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 analogues with a protease inhibitor lead to increased circulating CD4+ lymphocyte counts, decreased plasma levels of HIV, and decreased mortality from AIDS-defining opportunistic infections. The effects of highly active antiretroviral therapy (HAART) on AIDS-associated KS remain largely unknown. Herein the case of an antiretroviral-naive man with advanced AIDS (CD4+ helper T-lymphocyte count, 35/mm3; HIV viral RNA quantification, more than 800,000 copies/mL), and symptomatic pulmonary KS 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 of HAART. Although this finding is preliminary, 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.

AIDS-associated secondary lymphoma of bone: a case report with review of the literature

Although musculoskeletal lesions are not reported as commonly as pulmonary or central nervous system abnormalities in human immunodeficiency virus (HIV)-positive individuals, a wide variety of osseous and soft-tissue changes are seen in these patients. We describe the case of a 35-year-old injection drug user with acquired immune deficiency syndrome (AIDS) who presented with diffuse adenopathy, lower extremity pain and swelling, subcutaneous nodules, and constitutional symptoms. Radiographic images showed bilateral lytic lesions of the tibia and accompanying soft-tissue masses. Biopsy of the bone and soft-tissue abnormalities established a diagnosis of Burkitt's-like non-Hodgkin's lymphoma (NHL). By recognizing the heterogeneity of AIDS-associated NHL presentations, and the potential clinical overlap between malignancy, infection, and other rheumatologic abnormalities, physicians may obtain appropriate diagnostic studies and offer treatment recommendations.

Use of hematopoietic hormones for bone marrow defects in AIDS

Bone marrow suppression is a substantial problem in patients infected with HIV. Contributing factors include the underlying HIV infection, alterations in the marrow microenvironment (resulting in abnormal cytokine regulation of hematopoiesis), and opportunistic infections and their associated medical treatments. Hematopoietic stimulants offer the promise of correcting peripheral blood cytopenias, augmenting host immune function, and permitting the continued use of potentially beneficial myelosuppressive therapies, which would otherwise result in dose-limiting side effects. The bone marrow abnormalities and mechanisms that contribute to alterations in hematopoiesis in HIV infection are briefly reviewed. Attention is then focused on the expanding clinical role of myeloid colony-stimulating factors (CSFs) and recombinant human erythropoietin (rHuEPO [Epogen, Procrit]) in the treatment of patients with AIDS.

Acute pancreatitis. A fatal complication of AIDS therapy

Pancreatic disease in patients with AIDS often is so mild that the diagnosis may be missed. The pancreas can be affected by systemic illness caused by opportunistic infections, Kaposi's sarcoma, or lymphoma. More commonly, drugs used to treat patients infected with human immunodeficiency virus can cause pancreatitis and result in significant morbidity and, rarely, mortality. We report one such case in a 47-year-old patient with AIDS in whom pancreatitis developed while taking 2',3'-dideoxyinosine (ddI). His condition improved on ddI withdrawal, but he suffered a fatal relapse while receiving 2',3'-dideoxycytidine and trimethoprim-sulfamethoxazole. This case gives me the opportunity to review the literature regarding the incidence, causes, and diagnosis of human immunodeficiency virus-associated pancreatitis.

Efficacy of total parenteral nutrition in a series of end-stage AIDS patients: a case-control study

The aims of this study were to document the risks and benefits of total parenteral nutrition (TPN) by comparing two groups of patients with advanced HIV disease. This case-control study took place from June 1992 through June 1994. Medical Records were the primary source of data. Bailey-Boushay House, a 24-h skilled nursing facility in Seattle, Washington was the resident location of participating patients. TPN was commonly used in this long-term care facility for persons with AIDS. Eighty patients with AIDS, 40 of whom were receiving TPN and 40 of whom were not receiving TPN but who had central venous access (control group) were chosen. No significant differences were found between the two groups in the number of positive blood cultures (10% vs. 3%), however, the number of abnormal lab values was higher in the TPN group (6 vs. 4) (p < 0.05). The TPN group also gained an average of 2.2 kg in weight compared to an average loss of 1.4 kg in the control group (p < 0.05); the control group had a higher number of patients with weight loss > 10% of admit weight (28% vs. 8%) (p < 0.05). The length of stay was similar between groups (91 vs. 77 days), as were several quality of life indicators. The conclusions of the investigators was that TPN did not appear to lead to clinically important positive or negative health effects when compared to a group not receiving TPN but with central venous access. Benefits or detriments to certain sub-groups of AIDS patients may well exist that were not apparent in this study.

Skin involvement with Pneumocystis despite dapsone prophylaxis: a rare cause of skin nodules in a patient with AIDS

Pneumocystis carinii pneumonia is among the most common life-threatening opportunistic infections that occurs in those with HIV infection and a depleted absolute CD4+ T-lymphocyte count. Fortunately, with the advent of effective prophylaxis, this AIDS-defining complication is diminishing. Rarely, Pneumocystis carinii (P carinii) occurs outside the lungs, typically in the setting of prophylaxis with aerosolized pentamidine or no prophylaxis at all. This is the case of a man with advanced AIDS and bilateral hyperpigmented axillary nodules secondary to cutaneous pneumocystosis. Unlike most other examples of extrapulmonary P carinii, dissemination occurred without documented pulmonary infection and despite prophylaxis with high-dose dapsone. A biopsy should be performed on unusual cutaneous lesions in the setting of advanced AIDS because unexpected findings may have important therapeutic implications.

Dextran syndrome. Acute hypotension, noncardiogenic pulmonary edema, anemia, and coagulopathy following hysteroscopic surgery using 32% dextran 70

Dextran solutions are favored distending media for many hysteroscopic procedures because they are easy to administer, distribute uniformly within the uterine cavity, and are relatively nontoxic. We present the case of a 26-year-old woman who developed hypotension, noncardiogenic pulmonary edema, and hemorrhagic diathesis following hysteroscopic surgery with 32% dextran 70. A medical literature review indicates that following hysteroscopic surgery in which dextran solution has been used, "dextran syndrome" has been diagnosed in some patients. This syndrome is characterized by acute hypotension, hypoxia, coagulopathy, and anemia. We speculate on the pathogenesis of this condition and offer recommendations on how to evaluate and treat this rare dextran-related complication.

Aortic aneurysm-induced disseminated intravascular coagulation

Disseminated intravascular coagulation (DIC) may result in hemorrhagic and thrombotic complications and is rarely associated with stable abdominal aortic aneurysms. In a retrospective review of our experience over the past 5 years, we identified only two instances of DIC-associated abdominal aortic aneurysms among a total of 67 patients who were operated on for asymptomatic aneurysms. In the first patient with DIC induced by abdominal aortic aneurysm, consumptive coagulopathy and a bleeding diathesis developed. The second patient's course was complicated by consumptive coagulopathy and migrating thrombophlebitis. In both instances coagulopathy resolved after surgical intervention. In this report we briefly discuss the pathogenesis and laboratory diagnosis of aneurysm-associated DIC and review current management strategies.

Carcinomatous meningitis complicating cervical cancer: a clinicopathologic study and literature review

Patients with gynecologic malignancies may develop metastases throughout the neuraxis. Cervix-related carcinomatous meningitis is a distinctly unusual clinical event with only two previous cases reported in the English medical literature. We review clinical, radiographic, and pathologic findings of a woman with advanced adenocarcinoma of the uterine cervix, whose course was complicated by leptomeningeal metastases. Carcinomatous meningitis occurs in the setting of rapidly advancing systemic disease and represents a terminal complication of cervical cancer.

Clinical presentation of minimally invasive and in situ squamous cell carcinoma of the anus in homosexual men

From January 1988 to December 1993, we identified six men with minimally invasive (stage I) squamous cell carcinoma of the anus and 10 men with anal carcinoma in situ (CIS). Of the six patients with invasive carcinoma, four were infected with human immunodeficiency virus (HIV), including one with AIDS. Of the 10 patients with CIS, eight were infected with HIV, including four with AIDS. Anal pain and bleeding were the most common symptoms of minimally invasive anal cancer and anal CIS. Anal irritation, burning, or pruritus occurred more frequently in patients with CIS, whereas anal ulcers, masses, or abscesses were more frequent in patients with minimally invasive cancer. Several patients with CIS had a discrete area of leukoplakia in the anal canal or a pigmented plaque of the anus and anal canal. These lesions were not observed in patients with minimally invasive anal cancer. The symptoms and signs of early-stage anal cancer in men at risk for developing HIV infection or men infected with HIV often resemble those of other common anorectal diseases in homosexual men. Anal cancer in HIV-infected men is not limited to those individuals with AIDS.

Fatal bone marrow necrosis following fludarabine administration in a patient with indolent lymphoma

We report the first known case of fulminant bone marrow necrosis (BMN) occurring after infusion of fludarabine monophosphate in a patient with recurrent low-grade non-Hodgkin's lymphoma (NHL). Extensive BMN is characterized by the development of fever, bony pain, a leukoerythroblastic peripheral blood film, variable degrees of pancytopenia and elevations in lactate dehydrogenase and alkaline phosphatase. The diagnosis of BMN is rarely entertained ante-mortem. Although the precise role chemotherapy may have played in triggering fatal BMN remains speculative, we alert clinicians to be aware of this entity as more patients with indolent lymphomas and leukemias are treated with this and other potent nucleoside analogs.

Cardiac tamponade due to primary pericardial lymphoma in a patient with AIDS

Cardiac tamponade due to lymphomatous involvement of the heart is a dramatic and unusual complication. Because of their nonspecific clinical presentation, these tumors are seldom diagnosed antemortem. We report the case of a patient with AIDS who presented with signs and symptoms of cardiac tamponade. Emergency pericardiocentesis followed by staging studies revealed large cell B-lymphocyte lymphoma confined to the pericardial space. With combination chemotherapy, a durable complete response was obtained. This case illustrates the potential benefit of aggressive treatment of extranodal non-Hodgkin's lymphoma in a patient with AIDS. The case is of particular interest because of the unusual development of isolated pericardial involvement as the sentinel sign of lymphoma.