Kaposi's sarcoma: etiology and pathogenesis, inducing factors, causal associations, and treatments: facts and controversies

An exophytic red-purple nodule on the hip

A 35-year-old man with Fitzpatrick skin type IV, born in Brazil, presented to the dermatology clinic with a 3-month history of an asymptomatic growth on the left hip. He reported no prior history of trauma.

Prognostic factors in Kaposi sarcoma, single centre experience

BACKGROUND

Kaposi sarcoma (KS) is a multicentric vascular and lymphatic neoplasm caused by human herpesvirus 8 (HHV-8). It generally concerns the elderly and immunosuppressed population. Four major clinical types of KS have been described. The most common subtype is Classical KS (CKS).

OBJECTIVES

Our retrospective study aimed to better define prognostic subgroups among patients with CKS, which is the most common in our country.

METHOD

Between 2014 and 2020, 43 patients with CKS were treated with local excision, radiotherapy and chemotherapy. Reviewed information included demographics, clinical features, laboratory findings, treatment responses and overall survival.

RESULTS

During the follow-up, eight patients (18.6%) died of CKS. The complete response rate was 46.5%, partial response and stable disease 51.2%, and progressive disease 2.3% of all patients. Gender, haemoglobin level at diagnosis, and disseminated involvement were prognostic factors affecting survival in all patients.

CONCLUSION

We confirmed that male gender, low haemoglobin levels, and disseminated involvement are associated with poor prognosis in CKS patients. It is the only Turkish study in which prognostic analysis was performed for this rare cancer.

Guinea pig herpes like virus is a gamma herpesvirus

Guinea Pig Herpes-Like Virus (GPHLV) is a virus isolated from leukemic guinea pigs with herpes virus-like morphology described by Hsiung and Kaplow in 1969. GPHLV transformed embryonic cells from Syrian hamsters or rats, which were tumorigenic in adult animals. Herein, we present the genomic sequence of GPHLV strain LK40 as a reference for future molecular analysis. GPHLV has a broad host tropism and replicates efficiently in Guinea pig, Cat, and Green African Monkey-derived cell lines. GPHLV has a GC content of 35.45%. The genome is predicted to encode at least 75 open-reading frames (ORFs) with 84% (63 ORFs) sharing homology to human Kaposi Sarcoma Associated Herpes Virus (KSHV). Importantly, GPHLV encodes homologues of the KSHV oncogenes, vBCL2 (ORF16), vPK (ORF36), viral cyclin (v-cyclin, ORF72), the latency associated nuclear antigen (LANA, ORF73), and vGPCR (ORF74). GPHLV is a Rhadinovirus of Cavia porcellus, and we propose the formal name of Caviid gamma herpesvirus 1 (CaGHV-1). GPHLV can be a novel small animal model of Rhadinovirus pathogenesis with broad host tropism.

Exploring Applications of Flexible Vesicular Systems as Transdermal Drug Delivery

Deformable lipidic-nano carriers are a category of advanced liposomal formulations. Deformable lipidic-nano carriers have a specific character to transform by rearranging the lipidic backbone to squeeze themself through a pore opening ten times smaller than their diameter when exposed to a variable condition like hydration gradient as these have potentially been used as a non-invasive delivery system to transdermally migrate various therapeutic agents for over three decades. Despite their vast application in transdermal drug delivery system, non-uniformity to express their chemical nature still exist and authors use various terms synonymously and interchangeably with each other. The present study delineates the terminologies used to express different derived deformable vesicular carriers to harmonize the terminological use. It also includes the effectiveness of deformable nanocarriers like Transferosomes, Ethosomes, Menthosomes, Invasomes, and Glycerosomes in skin conditions like basal cell carcinoma, fungal and viral infections, and hyperpigmentation disorders, along with others. Various review and research articles were selected from the 'Pubmed' database. The keywords like Transferosomes, Flexi-vesicular system, ultra-deformable vesicles, and nano-vesicular systems were used to extract the data. The data was reviewed and compiled to categorically classify different flexible vesicular systems. The composition of the different vesicular systems is identified and a report of various pathological conditions where the use of flexible lipid nanocarrier systems was implemented is compiled. The review also offers suggestive approaches where the applicability of these systems can be explored further.

Prognostic analysis of cutaneous Kaposi sarcoma based on a competing risk model

The data regarding the prognosis of cutaneous Kaposi sarcoma (KS) was limited. The current study aimed to explore the risk factors and develop a predictive model for the prognosis of cutaneous KS patients. Data were extracted from Surveillance, Epidemiology, and End Results database from 2000 to 2018 and randomly divided into training and validation cohort. The Kaplan-Meier analysis, cumulative incidence function based on the competing risk model and Fine-Gray multivariable regression model was used to identify the prognostic factors and then construct a 5-, 10-, and 15-year KS-specific death (KSSD) nomogram for patients. The concordance index (C-index), area under the curve (AUC) of operating characteristics and calibration plots were used to evaluate the performance of the model. The clinical utility of the model was measured by decision curve analysis (DCA). In 2257 cutaneous KS patients identified from database, the overall median survival time was about 13 years. Radiotherapy (p = 0.013) and surgery (p < 0.001) could lower the KSSD, while chemotherapy (p = 0.042) and surgery (p < 0.001) could increase the overall survival (OS) of patients with metastatic and localized lesions, respectively. Race, number of lesions, surgery, extent of disease, year of diagnosis and age were identified as risk factors associated with cutaneous KS-specific survival. Performance of the nomogram was validated by calibration and discrimination, with C-index values of 0.709 and AUC for 5-, 10-, and 15-year-KSSD of 0.739, 0.728 and 0.725 respectively. DCA indicated that the nomogram had good net benefits in clinical scenarios. Using a competing-risk model, this study firstly identified the prognostic factors, and constructed a validated nomogram to provide individualized assessment and reliable prognostic prediction for cutaneous KS patients.

Koebner Phenomenon in Kaposi's Sarcoma: A Large Single-Center Case Series and Review of Current Knowledge

BACKGROUND

occasional case reports have described the appearance of Kaposi's sarcoma (KS) on previously unaffected skin after incidental or accidental injury, but the association is probably under-reported.

OBJECTIVES

to present a large case series of patients suffering from Koebner phenomenon (KP) in KS and describe their main epidemiological, clinical, and therapeutic features.

METHODS

we have retrospectively analyzed our clinical and photographic records of 524 patients who had been diagnosed with KS between 2009 and 2021.

RESULTS

31 of 524 (6%) KS patients developed KP. Among these 31 patients, 24 (77%) had KS lesions after surgery, 4 (13%) after electrochemotherapy, laser therapy and cryotherapy, and 3 (10%) on areas affected by bullous diseases.

CONCLUSIONS

trauma, including surgery or other medical procedures, can trigger KS, underlying the importance of treatment options which cause the least injury to the skin.

Oral-visceral iatrogenic Kaposi sarcoma following treatment for acute lymphoblastic leukemia: a case report and review of the literature

Background

There have hardly been any reported cases of children presenting with Kaposi sarcoma as a second malignancy following treatment for acute lymphoblastic leukemia outside a transplant setting.

Case presentation

We report a case of a 5-year-old boy of Bantu origin, which, to our knowledge, could be only the second reported case of oral–visceral Kaposi sarcoma after acute lymphoblastic leukemia treatment. The patient presented with a 1-month history of progressive, non-painful, soft tissue oral mass, 1 month after completing treatment for high-risk acute lymphoblastic leukemia. He was successfully treated for Kaposi sarcoma on a two-drug regimen (bleomycin and vincristine) with good clinical response.

Conclusion

Visceral Kaposi sarcoma as a second malignancy may occur after pediatric acute lymphoblastic leukemia treatment, but its rarity makes it unlikely to raise suspicion among clinicians, thus precluding early diagnosis and treatment. We recommend routine evaluation for Kaposi sarcoma lesions in children undergoing long-term surveillance following treatment for childhood acute leukemia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13256-022-03620-3.

The Molecular Interplay between Human Oncoviruses and Telomerase in Cancer Development

Human oncoviruses are able to subvert telomerase function in cancer cells through multiple strategies. The activity of the catalytic subunit of telomerase (TERT) is universally enhanced in virus-related cancers. Viral oncoproteins, such as high-risk human papillomavirus (HPV) E6, Epstein-Barr virus (EBV) LMP1, Kaposi's sarcoma-associated herpesvirus (HHV-8) LANA, hepatitis B virus (HBV) HBVx, hepatitis C virus (HCV) core protein and human T-cell leukemia virus-1 (HTLV-1) Tax protein, interact with regulatory elements in the infected cells and contribute to the transcriptional activation of TERT gene. Specifically, viral oncoproteins have been shown to bind TERT promoter, to induce post-transcriptional alterations of TERT mRNA and to cause epigenetic modifications, which have important effects on the regulation of telomeric and extra-telomeric functions of the telomerase. Other viruses, such as herpesviruses, operate by integrating their genomes within the telomeres or by inducing alternative lengthening of telomeres (ALT) in non-ALT cells. In this review, we recapitulate on recent findings on virus-telomerase/telomeres interplay and the importance of TERT-related oncogenic pathways activated by cancer-causing viruses.

Kaposi’s sarcoma associated with chronic myeloid leukemia and imatinib mesylate therapy

Kaposi's sarcoma is associated with immunosuppression and human herpesvirus 8 infection, while rarely described in myeloid malignancies. Here, we illustrate a rare case of chronic myeloid leukemia treated with imatinib, a tyrosine kinase inhibitor, who developed a human herpesvirus 8‐related Kaposi's sarcoma.

Pulmonary Kaposi Sarcoma without Respiratory Symptoms and Skin Lesions in an HIV-Naïve Patient: A Case Report and Literature Review

Kaposi sarcoma (KS) is a multifocal lympho-angioproliferative, mesenchymal low-grade tumor associated with a γ2-herpesvirus, named Kaposi sarcoma-associated virus or human herpesvirus (KSHV/HHV8). The lung is considered a usual anatomical location of KS, despite being infrequent, often in association with extensive mucocutaneous lesions and very uncommonly as an isolated event. We report a case of a pulmonary KS (pKS) in a human immunodeficiency virus (HIV) naïve patient, which was atypical due to a lack of cutaneous involvement and an absence of respiratory symptoms. The pKS was initially identified as a tumoral suspected nodular lesion and only after immunohistochemical analysis was it characterized as KS. Furthermore, the diagnosis of pKS led to the discovery of the HIV-seropositive status of the patient, previously unknown. Our report underlines the importance of considering pKS even without skin lesions and as a first manifestation of HIV infection. We also reviewed literature on the current knowledge about pKS in people living with HIV (PLWH) to underline how one of the most common HIV/acquired immunodeficiency syndrome (AIDS) associated tumors can have a challenging localization and be difficult to recognize.

Visceral Kaposi’s Sarcoma as a Presentation in a Newly Diagnosed HIV-Infected Man: A Case Report

Kaposi’s sarcoma is an angioproliferative malignancy due to human herpesvirus-8 and is associated with immunosuppression. Although most cases are cutaneous and resolve with treatment of the underlying condition, few cases present with organ involvement and have a fulminant course. We present a case of a 24-year-old sexually active man who presented with fulminant visceral Kaposi’s sarcoma, without cutaneous involvement. He presented with anasarca, high fever, hypoalbuminemia, and anemia on day five of antiretroviral therapy (ART). There was clinical improvement after the first dose of liposomal doxorubicin. However, given that he developed refractory pancytopenia, with disease relapse by the third week, he received a second dose of doxorubicin, with no clinical improvement, and the patient died with multi-organ dysfunction on day 22 of presentation. The main treatment is liposomal doxorubicin with ART, and the disease is typically associated with a poor prognosis.

Angiotensin converting enzyme and angiotensin converting enzyme inhibitors in dermatology: a narrative review

INTRODUCTION

Angiotensin converting enzyme inhibitors (ACEI) are commonly used for cardiovascular diseases. The evidence supporting the use of ACEI in dermatology is limited.

AREAS COVERED

This review article was divided into three parts. The first part discusses ACEI in clinical use in dermatology. The second part reveals the relationship between angiotensin converting enzyme (ACE) and immune diseases, and further discusses the possible relationship between ACEI in clinical use in these diseases and ACE. The third part focuses on cutaneous adverse reactions of ACEI.

EXPERT OPINION

The use of ACEI in dermatology is mainly based on its properties as regulation of renin angiotensin system (RAS), but currently, with limited clinical use. The association of ACE and several diseases are well discussed, including COVID-19, psoriasis, sarcoidosis, systemic lupus erythematosus and vitiligo. The main cutaneous adverse effects of ACEI include angioedema, psoriasis and pemphigus. Plausible factors for these adverse reactions include accumulation of vasoactive mediators, preventing angiotension from binding to AT₁ receptor and AT₂ receptor and presence of circulating antibodies.

Foot Wounds and the Reconstructive Ladder

Background:

Foot soft tissue coverage represents a challenge to reconstructive surgeons due to a lack of donor sites for this specialized skin. This glabrous tethered thick skin is designed to withstand weight bearing stress and is hard to replace. The limited arch of rotation of foot local flaps contributes to further difficulties. In this study, we share our experience in foot soft tissue loss coverage using techniques tailored to each wound presentation.

Methods:

This case series presents eight patients with wounds of the plantar and dorsal surfaces of the foot, heel, and ankle. Closure techniques were selected and planned based on wound presentation and comorbidity status.

Results:

Patients’ mean age at surgery was 61 years. Etiologies of wounds include trauma, frostbite, diabetic ulceration, malignancy, pressure ulcer with osteomyelitis, and necrotizing infection. Coverage techniques included split and full-thickness skin graft, medial plantar arch pinch graft, cultured epithelial autograft, Hyalomatrix wound device, EpiFix tissue matrix, pedicle flap, and free rectus flap. Complete soft tissue coverage was achieved in each case within reasonable postoperative periods, and ambulation was preserved and/or restored.

Conclusions:

Foot soft tissue reconstruction is challenging and should be planned carefully due to the required specialized skin replacement. Primary closure should be considered first and attempted if possible. Technique escalation in accordance with the reconstructive ladder should be undertaken based on wound etiology, presentation, amount and nature of tissue loss, available resources, and surgeon experience.

Tofacitinib-Associated Iatrogenic Kaposi Sarcoma in a Patient With Ulcerative Colitis

Tofacitinib is an oral Janus kinase inhibitor. Although it contributes to the induction and maintenance of clinical remission of patients with moderate-to-severe ulcerative colitis, various malignancies have been reported after the use of this small molecule. We report a rare case of biopsy-proven Kaposi sarcoma in a patient with complex biological-resistant ulcerative colitis after 2 years of treatment with tofacitinib. Kaposi sarcoma lesions spontaneously regressed after tofacitinib was discontinued. Given the concern of potential risk of malignancy associated with this agent, we believe that specialists should be aware of this rare but serious possible adverse event.

Reflections on quinine and its importance in dermatology today

Quinine and its D-isomer quinidine have been used medically in Europe since the 1600s. They were originally found within the bark of the cinchona tree in the jungle of the Andes. They were recognized to have multiple beneficial medical properties, ranging from a combined antipyretic and analgesic effect to the first effective treatment for malaria and later atrial fibrillation. With the development of other medications and the recognition of the potential life-threatening toxic reactions to these drugs, their medical use declined. Quinine is available without a prescription in many countries and is present in tonic water. Quinine has an extensive following of users who believe it is salutary and harmless, considering it a food supplement. In the past, dermatologists were frequently the first to recognize disease caused by these drugs owing to early findings of dermatitis or petechiae. Even though the medical use of these drugs has markedly decreased, drug eruptions may still be due to quinine, and patients may even be unaware they are taking this medication.

Disseminated violaceous plaques in a HIV-1-positive patient from eastern India: A manifestation of Kaposi's sarcoma

Kaposi's sarcoma (KS) is an angioproliferative disorder primarily of viral etiology, though multiple cofactors are also responsible. Human herpes virus-8, a gamma herpes virus, is considered to be the causative agent. Acquired immunodeficiency syndrome-associated KS has different clinical pictures than those seen in other types of KS. As it progresses rapidly, early institution of highly active antiretroviral therapy (HAART) after proper diagnosis is expected. Though HAART has reduced the prevalence of KS in HIV disease, HAART has not eliminated the disease. Here, we report a case who is HIV 1 and hepatitis B surface antigen positive with numerous violaceous plaques over the face, upper extremities, and trunk along with oral mucosal involvement. He had received ten sessions of electron beam radiotherapy on the face, and the facial lesions have healed with residual hyperpigmentation.

Electrochemotherapy in Kaposi sarcoma: A systematic review

Kaposi sarcoma (KS) is a rare angioproliferative disorder, which is usually associated with human herpesvirus-8 infection. Electrochemotherapy (ECT) may be an option in the treatment of KS skin lesions due to the high response rate noted in neoplastic lesions of different histological types. The aim of the present systematic review was to analyse the available evidence on using ECT in the treatment of KS skin lesions. Tumor response, local control and toxicity were analyzed. In the three included studies, the complete response rate was 65-100% and the overall response rate in all studies was 100%. The treatment was well tolerated with mild and transient toxicity. However, further studies are required to fully analyze long-term disease control and to compare ECT with other local therapies used for KS.

A comparative study of classic and HIV-viremic and aviremic AIDS Kaposi sarcoma

BACKGROUND

Kaposi sarcoma in people living with HIV (PLHIV) is the most common AIDS-associated malignancy. There is increased interest in Kaposi sarcoma in PLHIV with controlled HIV viremia.

OBJECTIVES

To describe Kaposi sarcoma occurring in PLHIV despite virological control and to compare their clinical presentations with viremic AIDS-Kaposi sarcoma (AIDS-KS) and classic Kaposi sarcoma (CKS).

METHODS

This was a monocentric retrospective study, including all Kaposi sarcoma patients registered between the 1 January of 2000 and 31 December 2017 in a comprehensive data bank for all cancers in the Hérault region, South of France. AIDS-KS were also described using chart reviews from the Infectious diseases Department, which followed more than 90% of PLHIV from the same region. We defined aviremic AIDS-KS as Kaposi sarcoma occurring in persons taking HAART with a HIV viral load less than 50 copies for more than 12 months. We compared clinical characteristics of persons with aviremic AIDS-KS, viremic AIDS-KS and CKS, using the Kriegel score and number and topography of skin lesions, and presence of lymphedema.

RESULTS

We retrieved 187 Kaposi sarcoma cases, of which 12 occurred in PLHIV with aviremic AIDS-KS. Kriegel score stage I was found in 10 (83%) of the aviremic AIDS-KS, 34 (68%) of CKS and 38 (58.4%) of viremic AIDS-KS cases, with similar clinical presentations between aviremic AIDS-KS and CKS groups, and viremic AIDS-KS persons having more aggressive presentations. One person with aviremic AIDS-KS had visceral involvement.

CONCLUSION

We showed that Kaposi sarcoma in PLHIV with controlled viremia were generally indolent, similarly to CKS. Visceral involvement is, however, possible.

Diagnosis and treatment of classic and iatrogenic Kaposi's sarcoma: Italian recommendations

Kaposi's sarcoma (KS) is a lymphangioproliferative disorder associated with Human herpesvirus 8 (HHV8) infection. Four clinical subtypes are recognized: classic, endemic, epidemic (HIV-related) and iatrogenic. KS diagnosis is based on clinical features, histopathological assessment, and HHV8 serology. Classic KS is usually skin-limited and has a chronic course, while the iatrogenic variant may show mucosal, nodal or visceral involvement. Clinical staging is fundamental to guide the management. Localized disease may be treated with different local therapies, even if there are no randomized trials comparing these different modalities. Aggressive, disseminated KS and cases with visceral involvement usually require systemic chemotherapy, most commonly vinblastine, bleomycin or paclitaxel. Iatrogenic KS needs immunosuppression tapering/withdrawal and, if possible, switch to m-TOR inhibitors in post-transplant KS. The present work by a panel of Italian experts provides guidelines on KS diagnosis and management based on a critical review of the literature and a long and extensive personal experience.

Kaposi's Sarcoma-Associated Herpesvirus Fine-Tunes the Temporal Expression of Late Genes by Manipulating a Host RNA Quality Control Pathway

Kaposi's sarcoma-associated herpesvirus (KSHV) is a human oncogenic nuclear DNA virus that expresses its genes using the host cell transcription and RNA processing machinery. As a result, KSHV transcripts are subject to degradation by at least two host-mediated nuclear RNA decay pathways, the PABPN1- and poly(A) polymerase α/γ (PAPα/γ)-mediated RNA decay (PPD) pathway and an ARS2-dependent decay pathway. Here, we present global analyses of viral transcript levels to further understand the roles of these decay pathways in KSHV gene expression. Consistent with our recent report that the KSHV ORF57 protein increases viral transcript stability by impeding ARS2-dependent decay, ARS2 knockdown has only modest effects on viral gene expression 24 h after lytic reactivation of wild-type virus. In contrast, inactivation of PPD has more widespread effects, including premature accumulation of late transcripts. The upregulation of late transcripts does not require the primary late-gene-specific viral transactivation factor, suggesting that cryptic transcription produces the transcripts that then succumb to PPD. Remarkably, PPD inactivation has no effect on late transcripts at their proper time of expression. We show that this time-dependent PPD evasion by late transcripts requires the host factor nuclear RNAi-defective 2 (NRDE2), which has previously been reported to protect cellular RNAs by sequestering decay factors. From these studies, we conclude that KSHV uses PPD to fine-tune the temporal expression of its genes by preventing their premature accumulation.IMPORTANCE Kaposi's sarcoma-associated herpesvirus (KSHV) is an oncogenic gammaherpesvirus that causes Kaposi's sarcoma and other lymphoproliferative disorders. Nuclear expression of KSHV genes results in exposure to at least two host-mediated nuclear RNA decay pathways, the PABPN1- and PAPα/γ-mediated RNA decay (PPD) pathway and an ARS2-mediated decay pathway. Perhaps unsurprisingly, we previously found that KSHV uses specific mechanisms to protect its transcripts from ARS2-mediated decay. In contrast, here we show that PPD is required to dampen the expression of viral late transcripts that are prematurely transcribed, presumably due to cryptic transcription early in infection. At the proper time for their expression, KSHV late transcripts evade PPD through the activity of the host factor NRDE2. We conclude that KSHV fine-tunes the temporal expression of its genes by modulating PPD activity. Thus, the virus both protects from and exploits the host nuclear RNA decay machinery for proper expression of its genes.

Epidemic, Endemic, or Stewart-Bluefarb? When Several Forms of Kaposi Seem to Dispute Paternity

The role of human herpes virus 8 (HHV8) is demonstrated in the occurrence of Kaposi's disease, but the role of cofactors is still hardly known. We report a case of Kaposi's disease which occurred 10 years after a local trauma in an HIV-positive patient from Central Africa. A 38-year-old female, from and living in Central Africa, consulted for angiomatous papulo-nodules associated with purple-colored macules and painful lymphoedema of the right leg and foot that had been developing for 6 months. She reported a history of posttraumatic lymphoedema of the affected limb as a result of a road accident that occurred ten years earlier. The mucous were healthy. There was no sign of systemic lesions. The diagnosis of Kaposi's disease was evoked with, in differential, a Stewart–Bluefarb syndrome-type of pseudo-Kaposi and an epidemic Kaposi disease. Retroviral serology was positive to HIV1 with a CD4 count of 600 cells/mm³. Histopathology of the lesions and duplex ultrasonography could not be performed. The rest of the biological assessment was without particularity. The diagnosis of epidemic Kaposi's disease associated with cofactors involved in endemic Kaposi's disease and Stewart–Bluefarb syndrome was retained. An antiretroviral treatment (emtricitabine, tenofovir, and efavirenz) allowed to obtain after 6 months a noticeable improvement of the lesions and a disappearance of the pain with however the persistence of a residual lymphoedema. This is a special case of Kaposi's disease that seems to involve several factors. The role of cofactors in Kaposi's disease remains to be elucidated.

Human herpesvirus 8-associated colonic Kaposi's sarcoma during vedolizumab treatment in ulcerative colitis: a case report and review of the literature

Background

Kaposi’s sarcoma (KS) is a rare vascular tumor associated with human herpesvirus (HHV)-8 infection. One of the variants of KS is defined iatrogenic and is overall reported in transplanted patient but also, although less frequently, in patients treated with long-standing immunosuppressive therapy, such as in inflammatory bowel disease including ulcerative colitis and Crohn’s disease.

Case presentation

Herein, we report the first case of KS in a human immunodeficiency virus (HIV)-negative 47-year old male with UC after treatment with the α4-β7 integrin inhibitor vedolizumab (VDZ). The patient underwent to colectomy for a medical refractory disease and the histological examination of the surgical specimen showed the typical findings of KS together with the HHV-8 positivity. The patient achieved a good health status, without any sign of disease recurrence.

Conclusions

In the present case, we can assume that VDZ may have promoted the reactivation of a latent HHV-8 infection endowed with oncogenic potentialities and, in turn, the onset of KS. We also briefly reviewed all the cases of KS in HIV-negative patients with inflammatory bowel disease.

Association of IL-6, IL-10 and CXCL10 serum concentrations with visceral Kaposi's sarcoma in people living with HIV/AIDS

Human gammaherpesvirus 8 (HHV-8) is the etiologic agent of Kaposi's sarcoma (KS), one of the most common cancers in people living with HIV/AIDS. It is believe that the course of both HIV and HHV-8 infection is associated with the imbalance of anti- and/or pro-inflammatory cytokines. Here, we evaluated the IL-6, TNF-α, IL-10, CCL2 and CXCL10 serum concentrations in HIV- and HIV/HHV-8 (without KS) individuals, and in patients with cutaneous or visceral AIDS-KS. Serum concentrations of IL-6, IL-10 and CXCL10 were significantly higher in the AIDS-KS group compared to HIV and HIV/HHV-8 individuals. Similarly, the concentrations of theses cytokines were higher in patients with visceral than in those with cutaneous AIDS-KS. The TNF-α concentration was significantly higher in the HIV group compared to HIV/HHV-8 (with and without KS) individuals, and CCL2 levels did not present significant difference among the groups. The HIV viral load was undetectable in all patients from the HIV and HIV/HHV-8 groups. On the other hand, in the AIDS-KS group, most patients had detectable HIV viral load. In this context, we believe that the cytokine levels in AIDS-KS may be result of a complex interaction between HIV, HHV-8 and immunity.

Dermatologic Vasculature Diseases as a Risk Factor of Subconjunctival Hemorrhage

To evaluate the relationship between subconjunctival hemorrhage (SCH) and dermatologic vasculature diseases (DVDs) via the national health insurance research database (NHIRD) of Taiwan. This retrospective cohort study used data from the NHIRD for the 2009 to 2013 period. Patients diagnosed with DVDs were enrolled in the study group, and a propensity score-matching population was selected as the control group after exclusion. The main outcome was set as the development of SCH in both groups. Multivariable Cox regression analysis and survival analysis were performed to estimate the adjusted hazard ratio (aHR) and cumulative probability of SCH. A total number of 3426 patients were enrolled and split equally into the study and the control groups. There was no prominent difference between the age, gender, urbanization, income level, systemic co-morbidities, and ocular diseases between the two groups after matching. During the whole study period, 131 patients in the study group and 98 patients in the control group developed SCH with a significant higher aHR of 2.69 in the study group (p < 0.05). In the survival analysis, the study group also demonstrated a higher cumulative probability of developing SCH than the control group throughout the study period (p = 0.02). In conclusion, the presence of DVDs may be a risk factor for the development of SCH.

A case of mistaken identity: classic Kaposi sarcoma misdiagnosed as a diabetic foot ulcer in an atypical patient

Background

The presentation of Kaposi sarcoma is divided into four known clinical subtypes. In this case report we describe classic Kaposi sarcoma in an African-American heterosexual, diabetic, seronegative human immunodeficiency virus male. Classic Kaposi sarcoma is rare in this patient demographic and can be easily misdiagnosed.

Case presentation

The patient presented with a lesion between the fourth and fifth digits of his right foot which was initially diagnosed as a diabetic foot ulcer. Despite local wound care, the lesion did not resolve. A shave biopsy was performed and histopathology findings were consistent with classic Kaposi sarcoma.

Conclusions

The patient tolerated local radiotherapy well and had complete resolution of his pedal lesion. There have been emerging associations between diabetes and Kaposi sarcoma. As such, clinicians should have a low threshold when considering the biopsy of suspicious pedal lesions in patients with diabetes. The utilization of appropriate biopsy technique may lead to the diagnosis of classic KS tumors in populations outside of the current four widely accepted clinical subtypes.

Biomedical and genetic characteristics of the Ryukyuans: demographic history, diseases and physical and physiological traits

Context: The Ryukyu Islands stretch across a southwestern area of the Japanese Archipelago. Because of their unique geographical and historical backgrounds, Ryukyuans have their own genetic and phenotypic characteristics, which have been disclosed in previous anthropological and biomedical studies. Objective: The history, peopling and biomedical and genetic characteristics of Ryukyuans are reviewed and future research directions are discussed. Conclusion: Morphological and genetic studies have suggested the complex demographic history of Ryukyuans and their relationships with other Asian populations. Knowledge of population formation processes is important to understand the distribution of pathogens. In viral infectious diseases, some strains that may be associated with disease symptoms are specific to Ryukyuans. Dramatic changes in diet have played an important role among Ryukyuans in terms of increases in lifestyle-related diseases and mortality risks. To achieve a better understanding of pathogenic disease factors, further integration of findings regarding the genetic and biomedical characteristics of the Ryukyuans is needed.

Clinical features of Kaposi's sarcoma: experience from a Taiwanese medical center

BACKGROUND

Most of the previous reports regarding the clinical features of Kaposi's sarcoma (KS) have been performed in Western and African countries. The clinical characteristics of KS have not been well defined in Han Chinese or Taiwanese patients. In this study, we analyzed the clinical features of KS patients in a Taiwanese medical center.

METHODS

Medical records from Kaohsiung Medical University Hospital over the past 20 years (1996-2016) were comprehensively reviewed.

RESULTS

There were 55 patients with KS (50 males and 5 females), including 37 patients (67%) with classic disease, 17 patients (31%) with AIDS-associated disease, and one patient (2%) with immunosuppressive medication-related disease. The average age was 58.7 years (range 20-87 years), and the average age was younger for AIDS patients (33.8 years) compared with non-AIDS patients (69.8 years). Among patients with classic KS, lesions were mostly localized to the lower extremities, whereas AIDS-associated KS patients were more likely to develop disseminated skin lesions, skin lesions on atypical sites (head and neck, trunk), and extracutaneous involvement (particularly oral cavity). The most common underlying diseases were diabetes mellitus (20% of patients) and hepatitis B (15% patients), and 38% of KS patients were smokers. Patients with AIDS-associated KS usually responded well to chemotherapy, whereas only 32% of patients with non-AIDS-associated KS showed complete response to radiotherapy.

CONCLUSIONS

The findings of the current study will serve as important references for clinicians in the diagnosis of KS and may form the basis for the implementation of KS clinical practice guidelines in Taiwan.

Protein-Losing Enteropathy as the Initial Presentation of Gastrointestinal Kaposi's Sarcoma in Previously Undiagnosed HIV Disease

Occult Kaposi's sarcoma (KS) presenting as a protein-losing gastroenteropathy is a rare occurrence. We report the case of a 23-year-old male presenting with leg bilateral swelling and epigastric discomfort. A workup revealed human immunodeficiency virus seropositivity, hypoalbuminemia, and small bowel wall thickening on computed tomography scan. Initially there were no mucosal or cutaneous lesions visible. An upper endoscopy demonstrated subepithelial lesions with a reddish appearance involving the palate, cardia, duodenum, and jejunum, consistent with KS. Gastrointestinal involvement is the most common extracutaneous site of KS and is found in about half of the acquired immune deficiency syndrome (AIDS)-related cases. However, only one out of 5 patients are symptomatic in the absence of skin lesions. Antiretroviral therapy along with anthracycline chemotherapy must be promptly initiated to improve chances of survival.

Selected genes of Human herpesvirus-8 associated Kaposi's sarcoma among patients with Human Immunodeficiency Virus-1 and Acquired Immunodeficiency Disease Syndrome

INTRODUCTION

Kaposi's sarcoma (KS) is a kind of cancer that causes flat or raised lesions containing Human herpes virus 8 (HHV8). The KS lesions are common among immunosuppressed HIV patients. Highly Active Antiretroviral (HHART) treats and prevents the development of KS. The objective of this study was to determine the presence of K1 and K15 (predominant alleles) genes in Kaposi's sarcoma-associated herpes virus (KSHV) among immunosuppressed patients due to HIV-1.

METHODS

This was a cross-sectional descriptive study where consecutive sampling technique was adopted to pick archived tissue blocks from the Thematic Unit of Anatomic Pathology, Department of Human Pathology, College of Health Sciences, University of Nairobi and Department of Laboratory Medicine, Histology Section, Kenyatta National Hospital.

RESULTS

Upon staining 81 tissue blocks with H & E, 84% (68/81) were diagnosed as KS and 16% (13/81) as KS-like. The K1 and K15 (P) genes were both detected at 88.9% (72/81) in the tissue blocks, with 95.8% (69/72) detection from KS and 4.2% (3/72) from the KS-like.

CONCLUSION

The K1 and K15 (P) genes of KSHV were present among the immunosuppressed patients with Human Immunodeficiency Virus (HIV)-1. It is important to carry out K1 and K15 (P) genes detection on tissues that are diagnosed as KS or KS-like by histology technique.

Kaposi's sarcoma-associated herpesvirus ORF57 protein protects viral transcripts from specific nuclear RNA decay pathways by preventing hMTR4 recruitment

Nuclear RNAs are subject to a number of RNA decay pathways that serve quality control and regulatory functions. As a result, any virus that expresses its genes in the nucleus must have evolved mechanisms that avoid these pathways, but the how viruses evade nuclear RNA decay remains largely unknown. The multifunctional Kaposi’s sarcoma-associated herpesvirus (KSHV) ORF57 (Mta) protein is required for the nuclear stability of viral transcripts. In the absence of ORF57, we show that viral transcripts are subject to degradation by two specific nuclear RNA decay pathways, PABPN1 and PAPα/γ-mediated RNA decay (PPD) in which decay factors are recruited through poly(A) tails, and an ARS2-mediated RNA decay pathway dependent on the 5ʹ RNA cap. In transcription pulse chase assays, ORF57 appears to act primarily by inhibiting the ARS2-mediated RNA decay pathway. In the context of viral infection in cultured cells, inactivation of both decay pathways by RNAi is necessary for the restoration of ORF57-dependent viral genes produced from an ORF57-null bacmid. Mechanistically, we demonstrate that ORF57 protects viral transcripts by preventing the recruitment of the exosome co-factor hMTR4. In addition, our data suggest that ORF57 recruitment of ALYREF inhibits hMTR4 association with some viral RNAs, whereas other KSHV transcripts are stabilized by ORF57 in an ALYREF-independent fashion. In conclusion, our studies show that KSHV RNAs are subject to nuclear degradation by two specific host pathways, PPD and ARS2-mediated decay, and ORF57 protects viral transcripts from decay by inhibiting hMTR4 recruitment.

Eukaryotic cells contain numerous nuclear RNA quality control (QC) systems that ensure transcriptome fidelity by detecting and degrading aberrant RNAs. Some viral RNAs are also predicted to be degraded by these RNA QC systems, so viruses have evolved mechanisms that counter host RNA QC pathways. Previous studies showed that the Kaposi’s sarcoma-associated herpesvirus (KSHV) expresses the ORF57 protein to protect its RNAs from nuclear decay. However, neither the specific host pathways that degrade KSHV RNAs nor the mechanisms describing ORF57 protection of viral RNAs were known. Our data suggest that ORF57 protects viral RNAs from two different nuclear RNA QC pathways, PABPN1 and PAPα/γ-mediated RNA decay (PPD) and an ARS2-mediated RNA decay pathway. Mechanistically, we show that ORF57 binds directly to viral RNAs and prevents the recruitment of hMTR4, a cellular factor whose function is to recruit the exosome, the complex responsible for RNA decay, to the transcript. We conclude that by preventing hMTR4 recruitment, ORF57 protects viral RNAs from degradation resulting in robust expression of viral genes.

The Spectrum of Underlying Causes of Iatrogenic Kaposi's Sarcoma in a Large Series: A Retrospective Study

Background:

The frequency of clinicoepidemiological variants of Kaposi's sarcoma (KS) differs markedly throughout the world. The iatrogenic variant is mainly associated with the use of immunosuppressive therapy.

Aims:

We aimed to investigate the distribution of KS variants in our practice and elucidate the underlying causes of iatrogenic KS.

Methods:

Consecutive KS patients seen in a single tertiary center were grouped according to the tumor variants and iatrogenic KS patients were evaluated about associated conditions.

Results:

Among 137 patients, classic variant was the most frequent presentation (n = 88), followed by iatrogenic (n = 37) variant. Among the iatrogenic group, ten were transplant recipients. In 16 iatrogenic KS patients, systemic corticosteroid was used, in four for myasthenia gravis (MG) and in three for rheumatoid arthritis. In three patients, KS developed under topical corticosteroid (TC) treatment. Among iatrogenic KS patients, ten of them had a second primary neoplasm and one had congenital immunodeficiency syndrome.

Conclusions:

Our study revealed one of the highest rates for iatrogenic KS (27%) reported in the literature. Besides well-known causes, relatively frequent association with MG was remarkable. Usage of different forms of TCs was the cause of KS in a few cases.

EPHA2 sequence variants are associated with susceptibility to Kaposi's sarcoma-associated herpesvirus infection and Kaposi's sarcoma prevalence in HIV-infected patients

BACKGROUND

To determine if variations exist in the KSHV host receptor EPHA2's coding region that affect KSHV infectivity and/or KS prevalence among South African HIV-infected patients.

METHODS

A retrospective candidate gene association study was performed on 150 patients which were randomly selected from a total of 756 HIV-infected patients and grouped according to their KS status and KSHV serodiagnosis; namely group 1: KS+/KSHV+; group 2: KS-/KSHV+; group 3: KS-/KSHV-. Peripheral blood DNA was used to extract DNA and PCR amplify and sequence the entire EPHA2 coding region, which was compared to the NCBI reference through multiple alignment.

RESULTS

100% (95% CI 92.9-100%) of the KS positive patients, and 31.6% (95% CI 28.3-35.1%) of the KS negative patients were found to be KSHV seropositive. Aggregate variation across the entire EPHA2 coding region identified an association with KS (OR = 6.6 (95% CI 2.8, 15.9), p = 2.2 × 10-5). This was primarily driven by variation in the functionally important protein tyrosine kinase domain (Pkinase-Tyr; OR = 4.9 (95% CI 1.9, 12.4), p = 0.001) and the sterile-α-motif (SAM; OR = 13.8 (95% CI 1.7, 111.6), p = 0.014). Mutation analysis revealed two novel, non-synonymous heterozygous variants (c.2254 T > C: OR undefined, adj. p = 0.02; and c.2990 G > T: OR undefined, adj. p = 0.04) in Pkinase-Tyr and SAM, respectively, to be statistically associated with KS; and a novel heterozygous transition (c.2727C > T: OR = 6.4 (95% CI 1.4, 28.4), adj. p = 0.03) in Pkinase-Tyr to be statistically associated with KSHV.

CONCLUSIONS

Variations in the KSHV entry receptor gene EPHA2 affected susceptibility to KSHV infection and KS development in a South African HIV-infected patient cohort.

Activation and counteraction of antiviral innate immunity by KSHV: an Update

The innate immune responses triggering production of type I interferons and inflammatory cytokines constitute a nonspecific innate resistance that eliminates invading pathogens including viruses. The activation of innate immune signaling through pattern recognition receptors (PRRs) is by sensing pathogen-associated molecular patterns derived from viruses. According to their distribution within cells, PRRs are classified into three types of receptors: membrane, cytoplasmic, and nuclear. Kaposi's sarcoma-associated herpesvirus (KSHV), a large DNA virus, replicates in the nucleus. Its genome is protected by capsid proteins during transport in the cytosol. Multiple PRRs are involved in KSHV recognition. To successfully establish latent infection, KSHV has evolved to manipulate different aspects of the host antiviral innate immune responses. This review presents recent advances in our understanding about the activation of the innate immune signaling in response to infection of KSHV. It also reviews the evasion strategies used by KSHV to subvert host innate immune detection for establishing a persistent infection.

Recommendations for Counseling and Education of Service Members on Endemic African Cutaneous Kaposi Sarcoma: A Case Study

We report a case of Endemic African Cutaneous Kaposi Sarcoma (EACKS) on the lower extremity of an immunocompetent 31-yr-old male service member from Cameroon. Diagnosis was made using clinical and histologic findings. The service member was treated with local radiation therapy with resolution of his tumor.The goal of this article is to educate practitioners to counsel susceptible service members and leadership on the risk of developing EACKS when traveling to Sub-Saharan Africa, monitor for disease development, and guide in the diagnosis and treatment of patients with this rare disease.

Kaposi sarcoma incidence in females is nearly four-fold higher in the Lower Rio Grande Valley compared to the Texas average

The Lower Rio Grande Valley (LRGV) is located on U.S.-Mexican border with a population that is 90% Hispanic [1]. Comprised of Hidalgo, Cameron, Starr and Willacy counties, this region has the highest poverty rate and one of the highest incidences of Type 2 diabetes in the United States [2-4]. Previous studies demonstrated a high prevalence of Human Herpes Virus 8 (HHV8) in the LRGV [5-7]. HHV8 infection has been causally linked to Kaposi Sarcoma (KS) [8]. Here, we retrospectively examine the incidence of KS in the LRGV in a set of HIV-negative Hispanic patients. Strikingly, the incidence of KS was higher in LRGV women compared to the Texas state average (nearly four-fold higher in McAllen-Edinburg-Pharr Metro Statistical Area). This unique profile aligns with the increased HHV8 prevalence in the LRGV, suggesting that HHV8 contributes to a high incidence of HIV-negative KS on the U.S.-Mexican border in Texas.

Kaposi Sarcoma in the Era of Rapamycin Remains a Therapeutic Challenge in Organ Transplant Recipients

Solid-organ transplant recipients are at higher risk of developing Kaposi sarcoma, which is a multicentric vascular neoplasm of lymphatic endothelium-derived cells. Reducing doses of immunosuppressive drugs and switching from calcineurin inhibitors to the mammalian target of rapamycin inhibitor rapamycin have been suggested as an effective first-line treatment modality in most patients. Herein, we report a 64-year-old renal transplant recipient who developed multiple cutaneous and visceral Kaposi sarcoma lesions 2 months after transplant. The patient showed no improvement, with progression of the disease until month 15 of the suggested therapy of rapamycin.

Toe web intertrigo in Kaposi's sarcoma patients: a microbiological study in a large cohort of patients

Kaposi 's sarcoma (KS) is a rare multifocal angioproliferative disease associated with human herpes virus 8 (HHV-8) infection, characterized by cutaneous nodules or plaques especially on the lower limbs. Some skin modifications, such as chronic lymphedema, plantar hyperkeratosis and interdigital desquamation, may be associated with consequent impairment of the local immunosurveillance and increased risk of some bacterial or mycotic infections. With the objective of evaluating if bacterial or mycotic infections in KS patients are supported by different microorganisms compared to control patients, we performed an observational retrospective study, comparing positive cultural swabs of interdigital intertrigo of KS patients with positive cultural swabs of interdigital intertrigo of patients admitted to our dermatologic unit during the last 10 years. One hundred KS patients and 84 control patients were admitted to this study. Some of the skin swabs from interdigital spaces were positive for more than one microorganism, and therefore we found 187 microorganisms among the KS group and 182 microorganisms in the control group. The most common microrganisms among KS patients were T. mentagrophytes (16%), S. aureus (14.9%), P. aeruginosa (13.9%), S. marcescens (5,9%), while among non-KS patients were S. aureus (26,9%), C. albicans (22%), S. agalactiae (7.7%) and E. coli (9.9%). These differences are statistically significant (p < 0.01). KS patients may be more affected by toe web intertrigo due to other bacteria and dermatophytes than the general population. During clinical examination, a careful inspection is necessary for an early diagnosis of toe web intertrigo, in order to prevent serious complications, such as cellulitis and sepsis. Consequently, a cultural examination with antibiogram is required to identify the causative agent of intertrigo and guide antimicrobial therapy.

High Prevalence of Distinct Human Herpesvirus 8 Contributes to the High Incidence of Non-acquired Immune Deficiency Syndrome-Associated Kaposi's Sarcoma in Isolated Japanese Islands

Background

Non-acquired immune deficiency syndrome (AIDS) Kaposi's sarcoma (KS) is extremely rare in Japan but highly endemic in Okinawa, especially in Miyako Islands. We aimed to elucidate the exact incidence and cause of this high prevalence.

Methods

Non-AIDS KS cases in Okinawa Prefecture over the past 31 years were reviewed, and human herpesvirus 8 (HHV8) seroprevalence in Miyako Islands was determined. We examined whole-genome sequences of 3 HHV8 strains and performed whole-exome sequencing of 4 male patients from Miyako Islands.

Results

Approximately half of the non-AIDS KS cases in Okinawa Prefecture were from Miyako Islands. The age-adjusted incidence rate was 0.87/105 per year for Miyako Islands and 0.056/105 per year for the rest of Okinawa. Human herpesvirus 8 seroprevalence was 15.4% in Miyako Islands. The 3 HHV8 genomes isolated from Miyako islanders formed a phylogenetically branch distinct from those of previously sequenced HHV8 strains and shared specific mutations in 9 proteins. These mutations were verified in Okinawan patients other than those from Miyako Islands. Whole-exome sequencing of the 4 male Miyako Islanders did not reveal shared pathogenic mutations.

Conclusions

Miyako Islands are an endemic area of non-AIDS KS. The high rate of a distinct HHV8 may contribute to the high incidence of KS in the region.

Comparison of Kaposi Sarcoma Risk in Human Immunodeficiency Virus-Positive Adults Across 5 Continents: A Multiregional Multicohort Study

BACKGROUND

We compared Kaposi sarcoma (KS) risk in adults who started antiretroviral therapy (ART) across the Asia-Pacific, South Africa, Europe, Latin, and North America.

METHODS

We included cohort data of human immunodeficiency virus (HIV)-positive adults who started ART after 1995 within the framework of 2 large collaborations of observational HIV cohorts. We present incidence rates and adjusted hazard ratios (aHRs).

RESULTS

We included 208140 patients from 57 countries. Over a period of 1066572 person-years, 2046 KS cases were diagnosed. KS incidence rates per 100000 person-years were 52 in the Asia-Pacific and ranged between 180 and 280 in the other regions. KS risk was 5 times higher in South African women (aHR, 4.56; 95% confidence intervals [CI], 2.73-7.62) than in their European counterparts, and 2 times higher in South African men (2.21; 1.34-3.63). In Europe, Latin, and North America KS risk was 6 times higher in men who have sex with men (aHR, 5.95; 95% CI, 5.09-6.96) than in women. Comparing patients with current CD4 cell counts ≥700 cells/µL with those whose counts were <50 cells/µL, the KS risk was halved in South Africa (aHR, 0.53; 95% CI, .17-1.63) but reduced by ≥95% in other regions.

CONCLUSIONS

Despite important ART-related declines in KS incidence, men and women in South Africa and men who have sex with men remain at increased KS risk, likely due to high human herpesvirus 8 coinfection rates. Early ART initiation and maintenance of high CD4 cell counts are essential to further reducing KS incidence worldwide, but additional measures might be needed, especially in Southern Africa.

Imiquimod in dermatology: an overview

Imiquimod is an immune response modifier commercially available as a 3.75 and 5% cream. Topical imiquimod stimulates the innate and adaptive immune responses and induces cytokine production. This allows its use for the treatment of a wide variety of benign and malignant skin conditions due to its potential antiviral, antitumor, and immunoregulatory effects. Currently, topical imiquimod is US Food and Drug Administration (FDA)-approved for the treatment of anogenital warts, actinic keratosis, and superficial basal cell carcinomas. However, it has also shown a beneficial effect in the treatment of many other skin disorders. In this review, we describe existing evidence on the mechanism of action of topical imiquimod, its FDA-approved indications, off-label uses, and side effects.

Effect of electrochemotherapy on human herpesvirus 8 kinetics in classic Kaposi sarcoma

BACKGROUND

Electrochemotherapy (ECT) has shown to be an effective treatment for cutaneous and subcutaneous Kaposi sarcoma (KS) lesions. However, no study has investigated the impact of ECT treatment on the kinetics of human herpesvirus type 8 (HHV8), which is considered the necessary causal agent of KS. We aimed to evaluate HHV8 viral load and expression levels in patients affected by classic KS who received one or more ECT treatments and have been followed semi annually for up to four years.

METHODS

A total of 27 classic KS patients were enrolled in this study. Tumour biopsies and blood samples were obtained before ECT treatment. Additional blood samples were collected at six month intervals for 12-48 months. HHV8 viral load and expression profiles of latent (ORF72 and ORF73) and lytic (K2, K8, K8.1, K10/K10.1, K10.5/K10.6 and ORF16) genes were assessed in all samples by real-time PCR. HHV8 ORF26 and K1 regions were amplified and subjected to direct nucleotide sequencing followed by phylogenetic analysis for variant identification.

RESULTS

All KS biopsies and 46.4% of peripheral blood mononuclear cells (PBMCs) collected before ECT treatment were positive for HHV8 DNA. Viral load ranged from 0.02 to 2.3 copies per cell in KS lesions and 3.0 × 10^-7 to 6.9 × 10^-4 copies per cell in PBMCs. Overall, latent ORF72 and ORF73 as well as lytic K2, K8 and K10/K10.1 were expressed in all KS biopsies. ORF16 mRNA was detected in 71.4% and both K8.1 and K10.5/K10.6 mRNAs in 57.1% of KS samples. The ORF72, ORF73 and K2 transcripts were amplified in 37.5%, 25% and 25% of PBMCs collected before ECT, respectively. After the first ECT session, complete response was achieved in 20 out of 27 (74.1%) patients and HHV8 DNA was detected in four out of 27 (14.8%) PBMC samples at six month follow up. Phylogenetic analysis of ORF26 amplimers showed that most viral variants belonged to A/C (82.3%), and few to C2 (5.9%) or C3 (11.8%) subtype. The K1/VR1 variants fell into A (33.3%) and C (66.7%) HHV8 clade. No correlation was found between HHV8 subtypes and ECT complete response.

CONCLUSIONS

ECT therapy has a significant effect on HHV8 kinetics in patients with classic KS. The complete remission of patients was accompanied by clearance of circulating virus.

Oral Kaposi Sarcoma in HIV-seronegative Saudi patient: Literature review and case report

Kaposi Sarcoma (KS) is an intermediate neoplasm affecting the endothelial cells of mucous membranes and skin. It arises most commonly among HIV-infected individuals. We present an intra-oral KS in an 80-year-old Saudi male patient, who is HIV-seronegative, non-immunosuppressed, and with no history of organ transplantation. The patient was treated with fractionated radiation therapy, and had no recurrence in the 48 months of follow-up. The clinical disease, histologic features, and treatment modality used, as well as the relative literature are presented in this paper.