Rapidly progressive penile ulcer: an unusual manifestation of Kaposi's sarcoma

Isolated penile Kaposi's sarcoma in a HIV-positive patient stable on treatment for three years

Kaposi's sarcoma (KS) is an AIDS-defining condition. Typically, KS affects the skin with or without visceral involvement. The extensive use of antiretroviral therapy (ART) has decreased the incidence of KS amongst the HIV-positive population. We report a case of a 40-year-old man with HIV-1 infection with CD4 count of 551 cells/mm(3)and an undetectable viral load who presented with two skin-coloured KS lesions on the prepuce of the penis. Diagnosis was confirmed by histopathology. He had been commenced on ART three years earlier with a nadir CD4 count of 255 cells/mm(3) He had achieved and maintained viral suppression since commencing ART. The patient was initially treated with cryotherapy and 5% imiquimod as the lesions were presumed to be warts. The lack of response to treatment prompted further investigation. We carried out a literature search of published cases of penile KS over the past 10 years. The majority of articles regarding penile KS were published in the pre-ART era and involved patients with AIDS. Over the past 10 years, published cases of penile KS have almost exclusively been in HIV-negative men. We found 10 published cases of penile KS in HIV-negative men and only one other published case of penile KS in a HIV-positive man, who had severe immune suppression with CD4 count below 200 cells/mm(3) This is the first case report to describe a HIV-positive patient stable on ART with a CD4 count above 200 cells/mm(3)and suppressed HIV-1 viral load, to develop two KS lesions on the penis. Clinicians have to remain suspicious of penile lesions and appreciate the crucial role a biopsy with histopathological analysis plays in confirming a diagnosis. In addition, this case illustrates that unusual presentations of KS can still occur in treated HIV-positive patients with sustained immune recovery.

Exclusive penile Kaposi's sarcoma: report of an HIV-negative man successfully treated with radiotherapy

Kaposi's sarcoma (KS) is a rare neoplasm of endovascular cells with multifocal origin. The exact nature of the disease is not clear, but current data support the notion that KS is a vascular hyperplasia with a tight link to human herpesvirus 8 (HHV-8) infection. Classic KS occurs primarily on the lower extremities in elderly men living in the Mediterranean region. Penile involvement has rarely been reported in non-human immune deficiency virus (HIV) patients. Herein we present a 71-year-old HIV-negative man with isolated KS on the penis who was treated successfully with radiotherapy. A review of the literature is also presented.

Wounds and malignancy

Due to the prevalence of skin cancers, health care practitioners involved with wound management are likely to encounter cutaneous malignancies as part of their practice. This article focuses on 2 ways in which malignancies and wounds are related: the malignant degeneration of chronic wounds into cancer and malignancies that present as chronic wounds. The most common scenario in which chronic wounds have been associated with the development of squamous cell carcinoma is in the presence of chronic osteomyelitis. However, wounds secondary to burns, trauma, radiotherapy, and diabetes are also at risk for malignant degeneration. It is often difficult to distinguish malignant transformations from primary malignant ulcers. Given the uncommon nature of degeneration of a chronic wound or a malignancy presenting as a chronic wound, some suggest that only suspicious wounds undergo biopsy. Primary malignancy should be considered if the ulcer has a relatively short duration and the patient does not have a history of prior radiotherapy. Until recently, amputation has been the treatment of choice for squamous cell carcinomas that arose within chronic wounds associated with chronic osteomyelitis; however, other reports have shown that other methods of ensuring complete local excision are also useful.

Genitourinary manifestations of the acquired immunodeficiency syndrome

As the number of HIV-1 infected individuals and AIDS patients continues to increase, more cases involving the genitourinary tract will be encountered. Often, genitourinary manifestations will be the initial presentation of AIDS. Proper diagnosis will require awareness and a high index of suspicion. In addition to routine cultures, opportunistic infections with unusual organisms will require staining for fungi and acid-fast bacilli. Repeat cultures of blood, urine, seminal fluid, and abscess cavities may be required to establish a diagnosis. Prolonged courses of antibiotic treatment for prophylaxis and for relapses are usually required. Clinical understaging and rapid progression of tumors distinguish HIV-1-associated malignancies involving the genitourinary tract. Treatment for these malignancies will depend on the stage of HIV-1 infection. Any concomitant drug therapy and evidence of malnutrition will be important factors in selecting the proper timing and mode of therapeutic intervention. Although AIDS predominantly affects individuals between 30 and 50 years of age, an increasing percentage of patients over 50 years of age are being diagnosed. Common risk factors for acquisition of HIV include homosexuality or bisexuality and transfusion of blood or blood products. For the urologist, it is important to recognize that older patients more frequently present with AIDS at the time of diagnosis of HIV infection. A more rapid course of deterioration and high mortality is noted in this population. Clearly, protocols including surveillance, dosing regimens, and surgical intervention will need to be established and clarified to treat an anticipated increasing number of affected patients. In addition, it appears that adequate adherence to universal precautions is far from being achieved. Close monitoring and active surveillance of infection control may be needed to improve compliance.