1
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Abdeljaleel F, Azar J, Ayasa LA, Rabaia D. Kaposi sarcoma-induced immune reconstitution syndrome: a case report. Ann Med Surg (Lond) 2024; 86:2242-2247. [PMID: 38576974 PMCID: PMC10990315 DOI: 10.1097/ms9.0000000000001842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 02/08/2024] [Indexed: 04/06/2024] Open
Abstract
Introduction and importance Kaposi sarcoma (KS) is an angioproliferative disease, that mostly affects HIV-infected patients with a high viral load and a low CD4 count. In rare cases, the paradoxical worsening of a pre-existing or previously unrecognized opportunistic infection occurs in a phenomenon known as immune reconstitution inflammatory response (IRIS). Case presentation The authors presented a male patient in his 30s with HIV, who developed a series of complications caused by KS following the initiation of antiretroviral therapy. Despite ongoing antiretroviral therapy (ART), chemotherapy, and supportive measures, the patient developed KS-related IRIS, characterized by rapid clinical deterioration, multiorgan failure, and ultimately succumbed to the disease. Clinical discussion To the best of our knowledge, very rare cases have been reported with KS-IRIS after the initiation of ART. Many predictors of KS-IRIS development have been identified. Patients must meet the known diagnostic criteria to be diagnosed with IRIS. The treatment of KS-IRIS depends on the stage of KS. ART alone is usually adequate in mild cutaneous KS. Chemotherapy and ART are recommended for patients with severe cutaneous and visceral KS. Conclusion HIV patients with KS undergoing ART initiation or modification should be closely monitored, particularly during the early stages and in those with extensive disease. Treating opportunistic infections before ART initiation may reduce the risk of KS-IRIS. The increasing prevalence of KS in ART-treated patients with HIV warrants further attention and highlights the need for better management strategies in this population.
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Affiliation(s)
| | - Jehad Azar
- Mayo Clinic Health System, Cleveland, Ohio
| | | | - Dima Rabaia
- Faculty of Medicine and Health Science, An-Najah National University, Nablus, Palestine
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2
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Russo I, Marino D, Cozzolino C, Del Fiore P, Nerjaku F, Finotto S, Cattelan A, Calabrò ML, Belloni Fortina A, Russano F, Mazza M, Galuppo S, Bezzon E, Sbaraglia M, Krengli M, Brunello A, Mocellin S, Piaserico S, Alaibac M. Kaposi's Sarcoma: Evaluation of Clinical Features, Treatment Outcomes, and Prognosis in a Single-Center Retrospective Case Series. Cancers (Basel) 2024; 16:691. [PMID: 38398082 PMCID: PMC10887034 DOI: 10.3390/cancers16040691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 02/01/2024] [Accepted: 02/02/2024] [Indexed: 02/25/2024] Open
Abstract
Kaposi's sarcoma (KS) is a rare angioproliferative tumor classified in four different clinical-epidemiological forms. The diagnosis is based on histopathological and immunohistochemical analyses. The treatment is heterogeneous and includes several local and systemic therapeutic strategies. Methods: This is a retrospective cohort study including 86 KS patients treated between 1993 and 2022 at the University Hospital of Padua (AOPD) and at the Veneto Institute of Oncology (IOV). The data were extracted from an electronic database. Survival curves were generated using the Kaplan-Meier method, and Cox regression models were employed to explore associations with overall and disease-free survival. The male sex (89.53%), classical variant (43.02%), and cutaneous involvement (77.9%) were predominant. More than 61.6% of patients received a single treatment. Surgery, antiretroviral therapy, and chemotherapy were the mostly adopted approaches. A persistent response was observed in approximately 65% of patients, with a 22% relapse rate (at least 2 years). The overall survival ranges from 90 to 70% at 2 to 10 years after the diagnosis. Iatrogenic KS demonstrated a higher mortality (52.9%). This study reflects our experience in the management of KS. Comorbidities are very frequent, and treatments are heterogeneous. A multidisciplinary approach involving multiple referral specialists is essential for the appropriate management of this disease during diagnosis, treatment, and follow-up.
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Affiliation(s)
- Irene Russo
- Soft-Tissue, Peritoneum and Melanoma Surgical Oncology Unit, Veneto Institute of Oncology IOV – IRCCS, 35128 Padova, Italy; (I.R.); (C.C.); (F.R.); (M.M.); (S.M.)
| | - Dario Marino
- Oncology 1 Unit, Department of Oncology, Veneto Institute of Oncology IOV – IRCCS, 35128 Padova, Italy (S.F.)
| | - Claudia Cozzolino
- Soft-Tissue, Peritoneum and Melanoma Surgical Oncology Unit, Veneto Institute of Oncology IOV – IRCCS, 35128 Padova, Italy; (I.R.); (C.C.); (F.R.); (M.M.); (S.M.)
- Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padova, 35128 Padova, Italy
| | - Paolo Del Fiore
- Soft-Tissue, Peritoneum and Melanoma Surgical Oncology Unit, Veneto Institute of Oncology IOV – IRCCS, 35128 Padova, Italy; (I.R.); (C.C.); (F.R.); (M.M.); (S.M.)
| | - Fitnete Nerjaku
- Department of Medicine (DIMED), School of Medicine, University of Padova, 35128 Padova, Italy; (F.N.); (M.S.)
| | - Silvia Finotto
- Oncology 1 Unit, Department of Oncology, Veneto Institute of Oncology IOV – IRCCS, 35128 Padova, Italy (S.F.)
| | - Annamaria Cattelan
- Infectious and Tropical Diseases Unit, Padova University Hospital, 35128 Padova, Italy;
| | - Maria Luisa Calabrò
- Immunology and Molecular Oncology, Veneto Institute of Oncology IOV – IRCCS, 35128 Padova, Italy;
| | - Anna Belloni Fortina
- Dermatology Unit, Department of Medicine, University of Padova, 35128 Padova, Italy; (A.B.F.); (S.P.); (M.A.)
- Pediatric Dermatology Regional Center, Department of Women’s and Children’s Health, University of Padova, 35128 Padova, Italy
| | - Francesco Russano
- Soft-Tissue, Peritoneum and Melanoma Surgical Oncology Unit, Veneto Institute of Oncology IOV – IRCCS, 35128 Padova, Italy; (I.R.); (C.C.); (F.R.); (M.M.); (S.M.)
| | - Marcodomenico Mazza
- Soft-Tissue, Peritoneum and Melanoma Surgical Oncology Unit, Veneto Institute of Oncology IOV – IRCCS, 35128 Padova, Italy; (I.R.); (C.C.); (F.R.); (M.M.); (S.M.)
| | - Sara Galuppo
- Radiotherapy Unit, Veneto Institute of Oncology IOV – IRCCS, 35128 Padova, Italy; (S.G.); (M.K.)
| | - Elisabetta Bezzon
- Radiology Unit, Veneto Institute of Oncology, IOV – IRCCS, 35128 Padova, Italy
| | - Marta Sbaraglia
- Department of Medicine (DIMED), School of Medicine, University of Padova, 35128 Padova, Italy; (F.N.); (M.S.)
- Department of Pathology, Azienda Ospedale—University of Padova, 35128 Padova, Italy
| | - Marco Krengli
- Radiotherapy Unit, Veneto Institute of Oncology IOV – IRCCS, 35128 Padova, Italy; (S.G.); (M.K.)
- Department of Surgery, Oncology and Gastroenterology (DISCOG), University of Padova, 35128 Padova, Italy
| | - Antonella Brunello
- Oncology 1 Unit, Department of Oncology, Veneto Institute of Oncology IOV – IRCCS, 35128 Padova, Italy (S.F.)
| | - Simone Mocellin
- Soft-Tissue, Peritoneum and Melanoma Surgical Oncology Unit, Veneto Institute of Oncology IOV – IRCCS, 35128 Padova, Italy; (I.R.); (C.C.); (F.R.); (M.M.); (S.M.)
- Department of Surgery, Oncology and Gastroenterology (DISCOG), University of Padova, 35128 Padova, Italy
| | - Stefano Piaserico
- Dermatology Unit, Department of Medicine, University of Padova, 35128 Padova, Italy; (A.B.F.); (S.P.); (M.A.)
| | - Mauro Alaibac
- Dermatology Unit, Department of Medicine, University of Padova, 35128 Padova, Italy; (A.B.F.); (S.P.); (M.A.)
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3
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Poizot-Martin I, Brégigeon S, Palich R, Marcelin AG, Valantin MA, Solas C, Veyri M, Spano JP, Makinson A. Immune Reconstitution Inflammatory Syndrome Associated Kaposi Sarcoma. Cancers (Basel) 2022; 14:cancers14040986. [PMID: 35205734 PMCID: PMC8869819 DOI: 10.3390/cancers14040986] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/28/2022] [Accepted: 02/09/2022] [Indexed: 02/01/2023] Open
Abstract
People living with HIV (PLWH) with advanced immunosuppression who initiate antiretroviral therapy (ART) are susceptible to the occurrence of an immune reconstitution inflammatory syndrome (IRIS). Although ART is responsible for AIDS- associated Kaposi sarcoma (KS) improvement and resolution, new onset (unmasking KS-IRIS) or sudden progression of preexisting KS (paradoxical KS-IRIS) can occur after a time delay of between a few days and 6 months after the initiation or resumption of ART, even in patients with a low degree of immunocompromise. KS-IRIS incidence varies from 2.4% to 39%, depending on study design, populations, and geographic regions. Risk factors for developing KS-IRIS include advanced KS tumor stage (T1), pre-treatment HIV viral load >5 log10 copies/mL, detectable pre-treatment plasma-KSHV, and initiation of ART alone without concurrent chemotherapy. Both paradoxical and unmasking KS-IRIS have been associated with significant morbidity and mortality, and thrombocytopenia (<100,000 platelets/mm3 at 12 weeks) has been associated with death. KS-IRIS is not to be considered as ART failure, and an ART regimen must be pursued. Systemic chemotherapy for KS in conjunction with ART is recommended and, in contrast with management of IRIS for other opportunistic infections, glucocorticoids are contra-indicated. Despite our preliminary results, the place of targeted therapies in the prevention or treatment of KS-IRIS needs further assessment.
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Affiliation(s)
- Isabelle Poizot-Martin
- Assistance Publique-Hôpitaux de Marseille (APHM), Inserm, Institut de Recherche pour le Développement (IRD), SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l’Information Médicale, ISSPAM, APHM Sainte-Marguerite, Service D’immuno-Hématologie Clinique, Aix-Marseille Université, 13009 Marseille, France
- Correspondence: ; Tel.: +33-4-9174-4966 or +33-4-9174-6163; Fax: +33-4-9174-4962
| | - Sylvie Brégigeon
- Assistance Publique-Hôpitaux de Marseille (APHM) Sainte-Marguerite, Service D’immuno-Hématologie Clinique, Aix-Marseille Université, 13009 Marseille, France;
| | - Romain Palich
- Department of Infectious Diseases, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (APHP), Pierre Louis Epidemiology and Public Health Institute (iPLESP), INSERM U1136, Sorbonne University, 75013 Paris, France; (R.P.); (M.-A.V.)
| | - Anne-Geneviève Marcelin
- INSERM, Institut Pierre Louis d’Epidémiologie et de Santé Publique (iPLESP), AP-HP, Hôpital Pitié Salpêtrière, Service de Virologie, Sorbonne Université, 75013 Paris, France;
| | - Marc-Antoine Valantin
- Department of Infectious Diseases, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (APHP), Pierre Louis Epidemiology and Public Health Institute (iPLESP), INSERM U1136, Sorbonne University, 75013 Paris, France; (R.P.); (M.-A.V.)
| | - Caroline Solas
- Assistance Publique-Hôpitaux de Marseille (APHM), Hôpital La Timone, Laboratoire de Pharmacocinétique et Toxicologie, INSERM 1207, IRD 190, Unité des Virus Emergents, Aix-Marseille Université, 13005 Marseille, France;
| | - Marianne Veyri
- Department of Medical Oncology, Pitié Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (APHP), Institut Universitaire de Cancérologie (IUC), CLIP2 Galilée, Pierre Louis Epidemiology and Public Health Institute (iPLESP), INSERM U1136, Sorbonne Université, 75013 Paris, France; (M.V.); (J.-P.S.)
| | - Jean-Philippe Spano
- Department of Medical Oncology, Pitié Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (APHP), Institut Universitaire de Cancérologie (IUC), CLIP2 Galilée, Pierre Louis Epidemiology and Public Health Institute (iPLESP), INSERM U1136, Sorbonne Université, 75013 Paris, France; (M.V.); (J.-P.S.)
| | - Alain Makinson
- Centre Hospitalier Universitaire de Montpellier, Département des Maladies Infectieuses et Tropicales, INSERM U1175/IRD UMI 233, 34000 Montpellier, France;
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4
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Dumic I, Radovanovic M, Igandan O, Savic I, Nordstrom CW, Jevtic D, Subramanian A, Ramanan P. A Fatal Case of Kaposi Sarcoma Immune Reconstitution Syndrome (KS-IRIS) Complicated by Kaposi Sarcoma Inflammatory Cytokine Syndrome (KICS) or Multicentric Castleman Disease (MCD): A Case Report and Review. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e926433. [PMID: 33268763 PMCID: PMC7722771 DOI: 10.12659/ajcr.926433] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Patient: Male, 28-year-old Final Diagnosis: Kaposi sarcoma inflammatory cytokine syndrome (KICS) Symptoms: Abdominal pain • anemia • dyspnea • fever • shock • thrombocytopenia Medication: — Clinical Procedure: Skin biopsy Specialty: Infectious Diseases
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Affiliation(s)
- Igor Dumic
- Mayo Clinic Alix School of Medicine, Rochester, MN, USA.,Division of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI, USA
| | - Milan Radovanovic
- Mayo Clinic Alix School of Medicine, Rochester, MN, USA.,Division of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI, USA
| | - Oladapo Igandan
- Mayo Clinic Alix School of Medicine, Rochester, MN, USA.,Division of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI, USA
| | - Ivana Savic
- Institute of Pathology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Charles W Nordstrom
- Mayo Clinic Alix School of Medicine, Rochester, MN, USA.,Division of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI, USA
| | - Djordje Jevtic
- University of Belgrade, School of Medicine, Belgrade, Serbia
| | - Anand Subramanian
- Mayo Clinic Alix School of Medicine, Rochester, MN, USA.,Division of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI, USA
| | - Poornima Ramanan
- Division of Infectious Disease, University of Colorado, Denver, CO, USA
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5
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Gruffaz M, Zhang T, Marshall V, Gonçalves P, Ramaswami R, Labo N, Whitby D, Uldrick TS, Yarchoan R, Huang Y, Gao SJ. Signatures of oral microbiome in HIV-infected individuals with oral Kaposi's sarcoma and cell-associated KSHV DNA. PLoS Pathog 2020; 16:e1008114. [PMID: 31951641 PMCID: PMC6992226 DOI: 10.1371/journal.ppat.1008114] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 01/30/2020] [Accepted: 09/27/2019] [Indexed: 01/01/2023] Open
Abstract
Infection by Kaposi's sarcoma-associated herpesvirus (KSHV) is necessary for the development of Kaposi's sarcoma (KS), which most often develops in HIV-infected individuals. KS frequently has oral manifestations and KSHV DNA can be detected in oral cells. Numerous types of cancer are associated with the alteration of microbiome including bacteria and virus. We hypothesize that oral bacterial microbiota affects or is affected by oral KS and the presence of oral cell-associated KSHV DNA. In this study, oral and blood specimens were collected from a cohort of HIV/KSHV-coinfected individuals all previously diagnosed with KS, and were classified as having oral KS with any oral cell-associated KSHV DNA status (O-KS, n = 9), no oral KS but with oral cell-associated KSHV DNA (O-KSHV, n = 10), or with neither oral KS nor oral cell-associated KSHV DNA (No KSHV, n = 10). We sequenced the hypervariable V1-V2 region of the 16S rRNA gene present in oral cell-associated DNA by next generation sequencing. The diversity, richness, relative abundance of operational taxonomic units (OTUs) and taxonomic composition of oral microbiota were analyzed and compared across the 3 studied groups. We found impoverishment of oral microbial diversity and enrichment of specific microbiota in O-KS individuals compared to O-KSHV or No KSHV individuals. These results suggest that HIV/KSHV coinfection and oral microbiota might impact one another and influence the development of oral KS.
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Affiliation(s)
- Marion Gruffaz
- Department of Molecular Microbiology and Immunology, Keck School of Medicine, University of Southern California, Los Angeles, United States of America
| | - Tinghe Zhang
- Department of Electrical and Computer Engineering, University of Texas at San Antonio, San Antonio, Texas, United States of America
| | - Vickie Marshall
- Viral Oncology Section, AIDS and Cancer Virus Program, Leidos Biomedical Research Inc., Frederick National Laboratory for Cancer Research, Frederick, Maryland, United States of America
| | - Priscila Gonçalves
- HIV and AIDS Malignancy Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, United States of America
| | - Ramya Ramaswami
- HIV and AIDS Malignancy Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, United States of America
| | - Nazzarena Labo
- Viral Oncology Section, AIDS and Cancer Virus Program, Leidos Biomedical Research Inc., Frederick National Laboratory for Cancer Research, Frederick, Maryland, United States of America
| | - Denise Whitby
- Viral Oncology Section, AIDS and Cancer Virus Program, Leidos Biomedical Research Inc., Frederick National Laboratory for Cancer Research, Frederick, Maryland, United States of America
| | - Thomas S. Uldrick
- HIV and AIDS Malignancy Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, United States of America
- Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - Robert Yarchoan
- HIV and AIDS Malignancy Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, United States of America
| | - Yufei Huang
- Department of Electrical and Computer Engineering, University of Texas at San Antonio, San Antonio, Texas, United States of America
- Department of Epidemiology and Biostatistics, The University of Texas Health San Antonio, San Antonio, Texas, United States of America
| | - Shou-Jiang Gao
- Department of Molecular Microbiology and Immunology, Keck School of Medicine, University of Southern California, Los Angeles, United States of America
- UPMC Hillman Cancer Center, Department of Microbiology and Molecular Genetics, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
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6
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Abstract
Kaposi sarcoma (KS) is a mesenchymal tumour caused by KS-associated herpesvirus and is an AIDS-defining illness. Despite a decline in incidence since the introduction of combination anti-retroviral therapy, KS remains the most common cancer in people living with HIV in sub-Saharan Africa, where it causes significant morbidity and mortality. This review reflects on recent epidemiological data as well as current management, unmet needs and future perspectives in the treatment of HIV-associated KS with particular emphasis on the potential role of immune checkpoint inhibitors.
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Affiliation(s)
- Alessia Dalla Pria
- Imperial College London, London, UK
- Chelsea and Westminster Hospital, London, UK
| | - David J. Pinato
- Imperial College London, London, UK
- Chelsea and Westminster Hospital, London, UK
| | | | - Mark Bower
- Imperial College London, London, UK
- Chelsea and Westminster Hospital, London, UK
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7
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Demba RN, Shaviya N, Aradi SM, Mwanda W. Selected genes of Human herpesvirus-8 associated Kaposi's sarcoma among patients with Human Immunodeficiency Virus-1 and Acquired Immunodeficiency Disease Syndrome. Pan Afr Med J 2019; 32:215. [PMID: 31404285 PMCID: PMC6675582 DOI: 10.11604/pamj.2019.32.215.17322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 04/14/2019] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Rodgers Norman Demba
- School of Health Sciences, Kisii University, Kisii, Kenya
- Institute of Tropical and Infectious Diseases, University of Nairobi, Nairobi, Kenya
| | - Nathan Shaviya
- Masinde Muliro University of Science and Technology, Kakamega, Kenya
| | | | - Walter Mwanda
- Institute of Tropical and Infectious Diseases, University of Nairobi, Nairobi, Kenya
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8
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Cipriano P, Nabais I, Melo N, Alves AR. Chylous ascites in disseminated Kaposi sarcoma: an unusual manifestation as immune reconstitution inflammatory syndrome. BMJ Case Rep 2019; 12:e228406. [PMID: 30904896 PMCID: PMC6510130 DOI: 10.1136/bcr-2018-228406] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2019] [Indexed: 01/04/2023] Open
Abstract
A 29-year-old man with diarrhoea, fever, abdominal pain and multiple purple papular lesions, neither pruriginous nor painful, was diagnosed with HIV-1 infection and disseminated Kaposi sarcoma (KS) with gastrointestinal involvement. He was started on highly active antiretroviral therapy immediately, as well as doxorubicin. Three weeks later, the patient developed bilateral moderate pleural effusion and large-volume ascites compatible with chylothorax and chylous ascites. An immune reconstitution inflammatory syndrome (IRIS) reaction was assumed. KS flare was associated with lymphatic obstruction and infiltration of thoracic duct by the tumour itself with leakage of chylous into pleural and peritoneal cavities. KS is the most common tumour in HIV patients and the existence of related effusions is not uncommon. KS-related chylothorax is an unusual manifestation of KS; there are only four cases described in the literature of chylous ascites related to KS-HIV. Overall survival is improving in KS but explosive and debilitating IRIS reactions can explain cases with poor prognosis.
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Affiliation(s)
- Patrícia Cipriano
- Department of Internal Medicine, Hospital de Cascais, Cascais, Portugal
| | - Inês Nabais
- Department of Internal Medicine, Hospital de Cascais, Cascais, Portugal
| | - Nuno Melo
- Department of Internal Medicine, Hospital de Cascais, Cascais, Portugal
| | - Ana Rafaela Alves
- Department of Internal Medicine, Hospital de Cascais, Cascais, Portugal
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9
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Mariggiò G, Koch S, Schulz TF. Kaposi sarcoma herpesvirus pathogenesis. Philos Trans R Soc Lond B Biol Sci 2018; 372:rstb.2016.0275. [PMID: 28893942 PMCID: PMC5597742 DOI: 10.1098/rstb.2016.0275] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2017] [Indexed: 12/15/2022] Open
Abstract
Kaposi sarcoma herpesvirus (KSHV), taxonomical name human gammaherpesvirus 8, is a phylogenetically old human virus that co-evolved with human populations, but is now only common (seroprevalence greater than 10%) in sub-Saharan Africa, around the Mediterranean Sea, parts of South America and in a few ethnic communities. KSHV causes three human malignancies, Kaposi sarcoma, primary effusion lymphoma, and many cases of the plasmablastic form of multicentric Castleman's disease (MCD) as well as occasional cases of plasmablastic lymphoma arising from MCD; it has also been linked to rare cases of bone marrow failure and hepatitis. As it has colonized humans physiologically for many thousand years, cofactors are needed to allow it to unfold its pathogenic potential. In most cases, these include immune defects of genetic, iatrogenic or infectious origin, and inflammation appears to play an important role in disease development. Our much improved understanding of its life cycle and its role in pathogenesis should now allow us to develop new therapeutic strategies directed against key viral proteins or intracellular pathways that are crucial for virus replication or persistence. Likewise, its limited (for a herpesvirus) distribution and transmission should offer an opportunity for the development and use of a vaccine to prevent transmission. This article is part of the themed issue ‘Human oncogenic viruses’.
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Affiliation(s)
- Giuseppe Mariggiò
- Institute of Virology, Hannover Medical School, Carl Neuberg Strasse 1, 30625 Hannover, Germany.,German Centre for Infection Research, Hannover-Braunschweig site, Hannover, Germany
| | - Sandra Koch
- Institute of Virology, Hannover Medical School, Carl Neuberg Strasse 1, 30625 Hannover, Germany.,German Centre for Infection Research, Hannover-Braunschweig site, Hannover, Germany
| | - Thomas F Schulz
- Institute of Virology, Hannover Medical School, Carl Neuberg Strasse 1, 30625 Hannover, Germany .,German Centre for Infection Research, Hannover-Braunschweig site, Hannover, Germany
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10
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Chiarella P, Vermeulen M, Montagna DR, Vallecorsa P, Strazza AR, Meiss RP, Bustuoabad OD, Ruggiero RA, Prehn RT. Improvement of Antitumor Therapies Based on Vaccines and Immune-Checkpoint Inhibitors by Counteracting Tumor-Immunostimulation. Front Oncol 2018; 8:6. [PMID: 29435437 PMCID: PMC5790794 DOI: 10.3389/fonc.2018.00006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 01/09/2018] [Indexed: 12/19/2022] Open
Abstract
Immune-checkpoint inhibitors and antitumor vaccines may produce both tumor-inhibitory and tumor-stimulatory effects on growing tumors depending on the stage of tumor growth at which treatment is initiated. These paradoxical results are not necessarily incompatible with current tumor immunology but they might better be explained assuming the involvement of the phenomenon of tumor immunostimulation. This phenomenon was originally postulated on the basis that the immune response (IR) evoked in Winn tests by strong chemical murine tumors was not linear but biphasic, with strong IR producing inhibition and weak IR inducing stimulation of tumor growth. Herein, we extended those former observations to weak spontaneous murine tumors growing in pre-immunized, immune-competent and immune-depressed mice. Furthermore, we demonstrated that the interaction of specifical T cells and target tumor cells at low stimulatory ratios enhanced the production of chemokines aimed to recruit macrophages at the tumor site, which, upon activation of toll-like receptor 4 and p38 signaling pathways, would recruit and activate more macrophages and other inflammatory cells which would produce growth-stimulating signals leading to an accelerated tumor growth. On this basis, the paradoxical effects achieved by immunological therapies on growing tumors could be explained depending upon where the therapy-induced IR stands on the biphasic IR curve at each stage of tumor growth. At stages where tumor growth was enhanced (medium and large-sized tumors), counteraction of the tumor-immunostimulatory effect with anti-inflammatory strategies or, more efficiently, with selective inhibitors of p38 signaling pathways enabled the otherwise tumor-promoting immunological strategies to produce significant inhibition of tumor growth.
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Affiliation(s)
- Paula Chiarella
- Department of Experimental Oncology, Instituto de Medicina Experimental, Academia Nacional de Medicina (CONICET), Academia Nacional de Medicina de Buenos Aires, Ciudad autónoma de Buenos Aires, Argentina
| | - Mónica Vermeulen
- Department of Immunology, Instituto de Medicina Experimental, Academia Nacional de Medicina (CONICET), Academia Nacional de Medicina de Buenos Aires, Ciudad autónoma de Buenos Aires, Argentina
| | - Daniela R. Montagna
- Department of Experimental Oncology, Instituto de Medicina Experimental, Academia Nacional de Medicina (CONICET), Academia Nacional de Medicina de Buenos Aires, Ciudad autónoma de Buenos Aires, Argentina
| | - Pablo Vallecorsa
- Department of Pathology, Instituto de Estudios Oncológicos, Academia Nacional de Medicina de Buenos Aires, Ciudad autónoma de Buenos Aires, Argentina
| | - Ariel Ramiro Strazza
- Department of Experimental Oncology, Instituto de Medicina Experimental, Academia Nacional de Medicina (CONICET), Academia Nacional de Medicina de Buenos Aires, Ciudad autónoma de Buenos Aires, Argentina
| | - Roberto P. Meiss
- Department of Pathology, Instituto de Estudios Oncológicos, Academia Nacional de Medicina de Buenos Aires, Ciudad autónoma de Buenos Aires, Argentina
| | | | - Raúl A. Ruggiero
- Department of Experimental Oncology, Instituto de Medicina Experimental, Academia Nacional de Medicina (CONICET), Academia Nacional de Medicina de Buenos Aires, Ciudad autónoma de Buenos Aires, Argentina
| | - Richmond T. Prehn
- Department of Pathology, University of Washington, Seattle, WA, United States
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11
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Khan JA, Maki RG, Ravi V. Pathologic Angiogenesis of Malignant Vascular Sarcomas: Implications for Treatment. J Clin Oncol 2018; 36:194-201. [DOI: 10.1200/jco.2017.74.9812] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Angiosarcoma, epithelioid hemangioendothelioma, and Kaposi sarcoma are classified according to the line of differentiation that these neoplastic cells most closely resemble: the endothelial cell. Although these malignant vascular sarcomas demonstrate immunohistochemical and ultrastructural features typical of this lineage, they vary dramatically in presentation and behavior, reflecting oncologic mechanisms unique to each. Antineoplastic therapies offer significant benefit, but because of the rarity of these cancers, novel therapies are slow to develop, and treatment options for these cancers remain limited. Antiangiogenic approaches that have shown benefit in other malignancies have not fully realized their promise in vascular tumors, suggesting that these tumors do not depend entirely on either angiogenic growth factors or on neighboring endothelia that are affected by these agents. Nonetheless, translational studies have begun to unravel these distinct pathologies, identifying novel translocation products, targets of oncogenic virulence factors, and genomic mutations that hijack angiogenic signaling and drive malignant growth. Concurrently, an elaborate and highly regulated model of angiogenesis and lymphangiogenesis involving vascular endothelial growth factor–receptor tyrosine kinase and TGF-β and Notch pathways has emerged that informs treatment of these tumors as well as cancer in general. This review summarizes the literature on malignant vascular sarcomas in the context of current models of angiogenesis and, in light of recent clinical trial data, could help clinician-scientists generate novel therapeutic approaches.
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Affiliation(s)
- Jalal A. Khan
- Jalal A. Khan, Mount Sinai Hospital, New York City; Robert G. Maki, Monter Cancer Center, Northwell Health, and Cold Spring Harbor Laboratory, Lake Success, NY; and Vinod Ravi, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Robert G. Maki
- Jalal A. Khan, Mount Sinai Hospital, New York City; Robert G. Maki, Monter Cancer Center, Northwell Health, and Cold Spring Harbor Laboratory, Lake Success, NY; and Vinod Ravi, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Vinod Ravi
- Jalal A. Khan, Mount Sinai Hospital, New York City; Robert G. Maki, Monter Cancer Center, Northwell Health, and Cold Spring Harbor Laboratory, Lake Success, NY; and Vinod Ravi, University of Texas MD Anderson Cancer Center, Houston, TX
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12
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Volkow P, Cesarman-Maus G, Garciadiego-Fossas P, Rojas-Marin E, Cornejo-Juárez P. Clinical characteristics, predictors of immune reconstitution inflammatory syndrome and long-term prognosis in patients with Kaposi sarcoma. AIDS Res Ther 2017; 14:30. [PMID: 28558783 PMCID: PMC5450046 DOI: 10.1186/s12981-017-0156-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Accepted: 05/24/2017] [Indexed: 12/18/2022] Open
Abstract
Objective To investigate the predictive factors for the development of Kaposi sarcoma-related immune reconstitution inflammatory syndrome (KS-IRIS) and long-term prognosis in patients starting combined antiretroviral therapy (cART). Methods We studied a retrospective-cohort of consecutive antiretroviral-naïve patients with KS initiating cART from January 2005 to December 2011 and followed through June 2013. KS-IRIS was defined as ≥2 of the following: abrupt increase in number of KS lesions, appearance or exacerbation of lung-opacities or lymphedema, concomitantly with an increase in CD4+ cell-count ≥50 cells/mm3 and a decrease of >1 log in viral-load once started cART. We compared individuals who met KS-IRIS criteria with those that did not and described the long-term follow-up. Results We included 89 patients, 88 males; 35 (39%) developed KS-IRIS at a median of 10 weeks (IQR 4–16). KS-IRIS patients had more pulmonary-involvement (60% vs. 16.6% of patients; p < 0.0001), eight died attributed to pulmonary-KS. Thrombocytopenia <100,000/mm3 at follow-up occurred in 36% of KS-IRIS vs. 4% in non-KS-IRIS patients (p = 0.0002), 45% KS-IRIS patients with thrombocytopenia died, non without KS-IRIS. Chemotherapy (bleomicyn–vincristine) was more frequently prescribed in KS-IRIS patients (88.6% vs. 29.6%) with no differences in outcome; 80% of all patients achieve KS complete remission, 52% of them never received chemotherapy. No difference between groups in the long-term follow-up (mean 52.4 ± 27.4 months) was found, only one patient developed a secondary malignancy (1.12%). Conclusions Lung-involvement was predictive of IRIS development. Thrombocytopenia in KS-IRIS patients at week 12 follow-up after cART initiation was associated with high mortality. Over a third of patients with KS achieve remission without chemotherapy. Individuals that survive the initial period of KS-IRIS adhere to cART had a good long-term prognosis. Electronic supplementary material The online version of this article (doi:10.1186/s12981-017-0156-9) contains supplementary material, which is available to authorized users.
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13
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Gopal R, Rapaka RR, Kolls JK. Immune reconstitution inflammatory syndrome associated with pulmonary pathogens. Eur Respir Rev 2017; 26:26/143/160042. [PMID: 28049128 PMCID: PMC5642276 DOI: 10.1183/16000617.0042-2016] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 06/09/2016] [Indexed: 12/21/2022] Open
Abstract
Immune reconstitution inflammatory syndrome (IRIS) is an exaggerated immune response to a variety of pathogens in response to antiretroviral therapy-mediated recovery of the immune system in HIV-infected patients. Although IRIS can occur in many organs, pulmonary IRIS, associated with opportunistic infections such as Mycobacterium tuberculosis and Pneumocystis jirovecii, is particularly associated with high morbidity and mortality. The pathology of IRIS is associated with a variety of innate and adaptive immune factors, including CD4+ T-cells, CD8+ T-cells, γδ T-cells, natural killer cells, macrophages, the complement system and surfactant proteins, Toll-like receptors and pro-inflammatory cytokines and chemokines. Although there are numerous reports about the immune factors involved in IRIS, the mechanisms involved in the development of pulmonary IRIS are poorly understood. Here, we propose that studies using gene-deficient murine and nonhuman primate models will help to identify the specific molecular targets associated with the development of IRIS. An improved understanding of the mechanisms involved in the pathology of pulmonary IRIS will help to identify potential biomarkers and therapeutic targets in this syndrome. Mechanisms of pulmonary IRIS in HIV-infected individuals recently initiated on ART are poorly definedhttp://ow.ly/AAOR301Bh36
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Affiliation(s)
- Radha Gopal
- Richard King Mellon Foundation Institute for Pediatric Research, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Rekha R Rapaka
- Division of Infectious Diseases and Center for Vaccine Development, University of Maryland Medical Center, Baltimore, MD, USA
| | - Jay K Kolls
- Richard King Mellon Foundation Institute for Pediatric Research, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
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14
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Pulmonary Kaposi Sarcoma: An Uncommon Cause of Respiratory Failure in the Era of Highly Active Antiretroviral Therapy-Case Report and Review of the Literature. Case Rep Infect Dis 2016; 2016:9354136. [PMID: 27872774 PMCID: PMC5107221 DOI: 10.1155/2016/9354136] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 08/28/2016] [Indexed: 11/17/2022] Open
Abstract
Kaposi Sarcoma (KS) is the most common malignancy associated with Acquired Immune Deficiency Syndrome (AIDS) and is caused by Human Herpesvirus 8 (HHV 8) or Kaposi Sarcoma Herpesvirus (KSHV). In about 90% of cases Kaposi Sarcoma is associated with cutaneous lesions; however visceral disease can occur in the absence of cutaneous involvement. In the era of Highly Active Antiretroviral Therapy (HAART), the incidence of KS has declined. Clinical features of pulmonary KS might be difficult to distinguish from pneumonia in the immunocompromised patients and could lead to diagnostic challenges. First-line treatment of KS is with HAART and the incidence has declined with its use. Systemic chemotherapy may play a role depending on the extent of the disease. We report the case of a young man who presented with pulmonary symptoms and was later found to have pulmonary KS. Interestingly this diagnosis was made in the absence of the classic skin lesions. His disease was complicated by progressive respiratory failure and he eventually died.
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15
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HIV-1 Evolutionary Patterns Associated with Metastatic Kaposi's Sarcoma during AIDS. Sarcoma 2016; 2016:4510483. [PMID: 27651732 PMCID: PMC5019946 DOI: 10.1155/2016/4510483] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 08/07/2016] [Indexed: 12/19/2022] Open
Abstract
Kaposi's sarcoma (KS) in HIV-infected individuals can have a wide range of clinical outcomes, from indolent skin tumors to a life-threatening visceral cancer. KS tumors contain endothelial-related cells and inflammatory cells that may be HIV-infected. In this study we tested if HIV evolutionary patterns distinguish KS tumor relatedness and progression. Multisite autopsies from participants who died from HIV-AIDS with KS prior to the availability of antiretroviral therapy were identified at the AIDS and Cancer Specimen Resource (ACSR). Two patients (KS1 and KS2) died predominantly from non-KS-associated disease and KS3 died due to aggressive and metastatic KS within one month of diagnosis. Skin and visceral tumor and nontumor autopsy tissues were obtained (n = 12). Single genome sequencing was used to amplify HIV RNA and DNA, which was present in all tumors. Independent HIV tumor clades in phylogenies differentiated KS1 and KS2 from KS3, whose sequences were interrelated by both phylogeny and selection. HIV compartmentalization was confirmed in KS1 and KS2 tumors; however, in KS3, no compartmentalization was observed among sampled tissues. While the sample size is small, the HIV evolutionary patterns observed in all patients suggest an interplay between tumor cells and HIV-infected cells which provides a selective advantage and could promote KS progression.
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16
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Suresh K, Semaan R, Arias S, Karakousis P, Lee H. Pleuropulmonary Kaposi Sarcoma in the Setting of Immune Reactivation. ACTA ACUST UNITED AC 2016; 6. [PMID: 27429861 PMCID: PMC4943458 DOI: 10.4172/2161-105x.1000352] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
We present a case of a 26 year with history of HIV/AIDS who presented with a pleural effusion. Serial radiography, pleural fluid analysis as well as clinical symptoms revealed development of Kaposi Sarcoma related immune reconstitution inflammatory syndrome (KS-IRIS) in the setting of initiation of effective anti- retroviral therapy.
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Affiliation(s)
- Karthik Suresh
- Department of Medicine, Division of Pulmonary and Critical Care medicine, Johns Hopkins School of Medicine, Baltimore, USA
| | - Roy Semaan
- Department of Medicine, Division of Pulmonary and Critical Care medicine, Johns Hopkins School of Medicine, Baltimore, USA
| | - Sixto Arias
- Department of Medicine, Division of Pulmonary and Critical Care medicine, Johns Hopkins School of Medicine, Baltimore, USA
| | - Petros Karakousis
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, USA
| | - Hans Lee
- Department of Medicine, Division of Pulmonary and Critical Care medicine, Johns Hopkins School of Medicine, Baltimore, USA
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17
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Abstract
Pulmonary malignancies are a major source of morbidity and mortality in HIV-infected persons. Non-AIDS-defining lung cancers (mostly non-small cell lung cancers) are now a leading cause of cancer death among HIV-infected persons. HIV-associated factors appear to affect the risk of lung cancer and may adversely impact cancer treatment and outcomes. HIV infection also may modify the potential harms and benefits of lung cancer screening with computed tomography. AIDS-defining lung malignancies include pulmonary Kaposi sarcoma and pulmonary lymphoma, both of which are less prevalent with widespread adoption of antiretroviral therapy.
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Affiliation(s)
- Keith Sigel
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Robert Pitts
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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18
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Chabria S, Barakat L, Ogbuagu O. Steroid-exacerbated HIV-associated cutaneous Kaposi's sarcoma immune reconstitution inflammatory syndrome: 'Where a good intention turns bad'. Int J STD AIDS 2016; 27:1026-9. [PMID: 26769754 DOI: 10.1177/0956462415627735] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Accepted: 12/22/2015] [Indexed: 01/17/2023]
Abstract
A 51-year-old man with head and neck skin lesions was diagnosed with Kaposi's sarcoma (KS) as his initial presentation of acquired immunodeficiency syndrome. Following initiation of antiretroviral therapy and subsequent full virologic suppression, his facial lesions worsened, consistent with immune reconstitution inflammatory syndrome (IRIS). He was started on glucocorticoids in an attempt to ameliorate the KS-IRIS but experienced paradoxical worsening of the KS lesions. Steroids were subsequently discontinued and he required chemotherapy for severe and cosmetically disfiguring skin lesions. This article describes the potential for worsening of KS lesions in individuals started on glucocorticoids for KS-IRIS as this has been reported rarely in published literature. The mechanisms underlying this phenomenon remain poorly understood but potential explanations are offered in the case discussion. This article aims to raise clinician awareness on the harms of steroid use in patients with KS-IRIS.
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Affiliation(s)
- Shiven Chabria
- Department of Medicine, Waterbury Hospital, Waterbury, CT, USA
| | - Lydia Barakat
- Yale AIDS Program, Section of Infectious Diseases, Yale University School of Medicine, New Haven, CT, USA
| | - Onyema Ogbuagu
- Yale AIDS Program, Section of Infectious Diseases, Yale University School of Medicine, New Haven, CT, USA
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19
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Kato H, Yanagisawa N, Morioka H, Sasaki S, Sekiya N, Suganuma A, Imamura A, Ajisawa A. Laryngeal Kaposi's Sarcoma Complicated by the Immune Reconstitution Inflammatory Syndrome in an HIV-infected Patient. Intern Med 2016; 55:1001-5. [PMID: 27086821 DOI: 10.2169/internalmedicine.55.5813] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We herein report a case of laryngeal Kaposi's sarcoma (KS) complicated by immune reconstitution inflammatory syndrome in a human immunodeficiency virus (HIV)-infected patient. The patient initially presented with KS involving the larynx, which was successfully treated with pegylated liposomal doxorubicin (PLD) and antiretroviral therapy (ART). PLD was discontinued after 2 courses because of a marked clinical improvement; however, the patient experienced progressive odynophagia and dyspnea 2 months after the initiation of ART. Laryngoscopy revealed a severely swollen, inflamed epiglottis. The readministration of PLD was successful, and the patient was thereafter discharged without any subsequent complications.
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Affiliation(s)
- Hirofumi Kato
- Department of Infectious Diseases, Tokyo Metropolitan Komagome Hospital, Japan
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20
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Shahani L, Hamill RJ. Therapeutics targeting inflammation in the immune reconstitution inflammatory syndrome. Transl Res 2016; 167:88-103. [PMID: 26303886 DOI: 10.1016/j.trsl.2015.07.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 07/14/2015] [Accepted: 07/31/2015] [Indexed: 02/04/2023]
Abstract
Immune reconstitution inflammatory syndrome (IRIS) is characterized by improvement in a previously incompetent human immune system manifesting as worsening of clinical symptoms secondary to the ability of the immune system to now mount a vigorous inflammatory response. IRIS was first recognized in the setting of human immunodeficiency virus, and this clinical setting continues to be where it is most frequently encountered. Hallmarks of the pathogenesis of IRIS, independent of the clinical presentation and the underlying pathogen, include excessive activation of the immune system, with increased circulating effector memory T cells, and elevated levels of serum cytokines and inflammatory markers. Patients with undiagnosed opportunistic infections remain at risk for unmasking IRIS at the time of active antiretroviral therapy (ART) initiation. Systematic screening for opportunistic infections before starting ART is a key element to prevent this phenomenon. Appropriate management of IRIS requires prompt recognition of the syndrome and exclusion of alternative diagnoses, particularly underlying infections and drug resistance. Controlled studies supporting the use of pharmacologic interventions in IRIS are scare, and recommendations are based on case series and expert opinions. The only controlled trial published to date, showed reduction in morbidity in patients with paradoxical tuberculosis-related IRIS with the use of oral corticosteroids. There are currently limited data to recommend other anti-inflammatory or immunomodulatory therapies that are discussed in this review, and further research is needed. Ongoing research regarding the immune pathogenesis of IRIS will likely direct future rational therapeutic approaches and clinical trials.
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Affiliation(s)
- Lokesh Shahani
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, Tex
| | - Richard J Hamill
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, Tex; Medical Care Line, Section of Infectious Diseases, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex.
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21
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Walker NF, Scriven J, Meintjes G, Wilkinson RJ. Immune reconstitution inflammatory syndrome in HIV-infected patients. HIV AIDS (Auckl) 2015; 7:49-64. [PMID: 25709503 PMCID: PMC4334287 DOI: 10.2147/hiv.s42328] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Access to antiretroviral therapy (ART) is improving worldwide. Immune reconstitution inflammatory syndrome (IRIS) is a common complication of ART initiation. In this review, we provide an overview of clinical and epidemiological features of HIV-associated IRIS, current understanding of pathophysiological mechanisms, available therapy, and preventive strategies. The spectrum of HIV-associated IRIS is described, with a particular focus on three important pathogen-associated forms: tuberculosis-associated IRIS, cryptococcal IRIS, and Kaposi's sarcoma IRIS. While the clinical features and epidemiology are well described, there are major gaps in our understanding of pathophysiology and as a result therapeutic and preventative strategies are suboptimal. Timing of ART initiation is critical to reduce IRIS-associated morbidity. Improved understanding of the pathophysiology of IRIS will hopefully enable improved diagnostic modalities and better targeted treatments to be developed.
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Affiliation(s)
- Naomi F Walker
- Department of Medicine, Imperial College London, London, UK
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - James Scriven
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Graeme Meintjes
- Department of Medicine, Imperial College London, London, UK
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Robert J Wilkinson
- Department of Medicine, Imperial College London, London, UK
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- MRC National Institute of Medical Research, London, UK
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22
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Abstract
Human immunodeficiency virus type 1 (HIV-1) is the retrovirus responsible for the development of AIDS. Its profound impact on the immune system leaves the host vulnerable to a wide range of opportunistic infections not seen in individuals with a competent immune system. Pulmonary infections dominated the presentations in the early years of the epidemic, and infectious and noninfectious lung diseases remain the leading causes of morbidity and mortality in persons living with HIV despite the development of effective antiretroviral therapy. In addition to the long known immunosuppression and infection risks, it is becoming increasingly recognized that HIV promotes the risk of noninfectious pulmonary diseases through a number of different mechanisms, including direct tissue toxicity by HIV-related viral proteins and the secondary effects of coinfections. Diseases of the airways, lung parenchyma and the pulmonary vasculature, as well as pulmonary malignancies, are either more frequent in persons living with HIV or have atypical presentations. As the pulmonary infectious complications of HIV are generally well known and have been reviewed extensively, this review will focus on the breadth of noninfectious pulmonary diseases that occur in HIV-infected individuals as these may be more difficult to recognize by general medical physicians and subspecialists caring for this large and uniquely vulnerable population.
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23
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Vishnu P, Dorer RP, Aboulafia DM. Immune reconstitution inflammatory syndrome-associated Burkitt lymphoma after combination antiretroviral therapy in HIV-infected patients. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2014; 15:e23-9. [PMID: 25458079 DOI: 10.1016/j.clml.2014.09.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 09/25/2014] [Indexed: 12/19/2022]
Affiliation(s)
- Prakash Vishnu
- Floyd and Delores Jones Cancer Institute at Virginia Mason Medical Center, Seattle, WA.
| | - Russell P Dorer
- Department of Pathology, Virginia Mason Medical Center, Seattle, WA
| | - David M Aboulafia
- Floyd and Delores Jones Cancer Institute at Virginia Mason Medical Center, Seattle, WA; Division of Hematology, University of Washington, Seattle, WA
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24
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Triple secondary neoplasms: penis, lip and oral cavity in an AIDS patient treated with pegylated liposomal doxorubicin for cutaneous Kaposi's sarcoma. AIDS 2014; 28:2327-9. [PMID: 25313589 DOI: 10.1097/qad.0000000000000420] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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25
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Abstract
Thyroid abnormalities and nonthyroidal illness complicate human immunodeficiency virus (HIV) infection. Among the effects that result from HIV and other opportunistic infections, distinctive features of HIV infection include early lowering of reverse tri-iodothyromine (T3) levels, with normal free T3 levels. Later, some patients develop an isolated low free thyroxine level. After highly active antiretroviral therapy, the immune system reconstitutes in a way that leads to dysregulation of the autoimmune response and the appearance of Graves disease in 1% to 2% of patients. Opportunistic thyroid infections with unusual organisms are most commonly asymptomatic, but can lead to acute or subacute thyroiditis.
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Affiliation(s)
- Anthony P Weetman
- Department of Human Metabolism, University of Sheffield, Beech Hill Road, Sheffield S10 2RX, UK.
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26
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Abstract
Kaposi's sarcoma-associated herpesvirus (KSHV; also known as human herpesvirus 8) is the etiologic agent of Kaposi's sarcoma, primary effusion lymphoma, and multicentric Castleman's disease. These cancers often occur in the context of immunosuppression, which has made KSHV-associated malignancies an increasing global health concern with the persistence of the AIDS epidemic. KSHV has also been linked to several acute inflammatory diseases. KSHV exists between a lytic and latent lifecycle, which allows the virus to transition between active replication and quiescent infection. KSHV encodes a number of proteins and small RNAs that are thought to inadvertently transform host cells while performing their functions of helping the virus persist in the infected host. KSHV also has an arsenal of components that aid the virus in evading the host immune response, which help the virus establish a successful lifelong infection. In this comprehensive chapter, we will discuss the diseases associated with KSHV infection, the biology of latent and lytic infection, and individual proteins and microRNAs that are known to contribute to host cell transformation and immune evasion.
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Affiliation(s)
- Louise Giffin
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Blossom Damania
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
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27
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Read PJ, Lucas S, Morris S, Kulasegaram R. Immune reconstitution inflammatory syndrome Kaposi sarcoma in the liver manifesting as acute obstructive hepatitis: another potential role for montelukast? Int J STD AIDS 2014; 24:156-8. [PMID: 24400347 DOI: 10.1177/0956462412472819] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Immune reconstitution inflammatory syndrome has been described in Kaposi sarcoma, but does not usually manifest as acute hepatitis. We describe a case of rapid obstructive jaundice after initiation of antiretroviral therapy, in which the liver biopsy confirmed hepatic Kaposi sarcoma, and the clinical course was altered by the addition of montelukast.
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28
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Arruda É, Jacome AADA, Toscano ALDCC, Silvestrini AA, Rêgo ASB, Wiermann EG, Cunha GFD, Melo HRLD, Morejón KML, Goldani LZ, Pereira LC, Silva MH, Treistman MS, Pereira MCT, Romero PMBX, Schmerling RA, Guedes RAV, Camargo VPD. Consensus of the Brazilian Society of Infectious Diseases and Brazilian Society of Clinical Oncology on the management and treatment of Kaposi's sarcoma. Braz J Infect Dis 2014; 18:315-26. [PMID: 24525061 PMCID: PMC9427498 DOI: 10.1016/j.bjid.2014.01.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Accepted: 01/23/2014] [Indexed: 12/26/2022] Open
Abstract
Kaposi's sarcoma is a multifocal vascular lesion of low-grade potential that is most often present in mucocutaneous sites and usually also affects lymph nodes and visceral organs. The condition may manifest through purplish lesions, flat or raised with an irregular shape, gastrointestinal bleeding due to lesions located in the digestive system, and dyspnea and hemoptysis associated with pulmonary lesions. In the early 1980s, the appearance of several cases of Kaposi's sarcoma in homosexual men was the first alarm about a newly identified epidemic, acquired immunodeficiency syndrome. In 1994, it was finally demonstrated that the presence of a herpes virus associated with Kaposi's sarcoma called HHV-8 or Kaposi's sarcoma herpes virus and its genetic sequence was rapidly deciphered. The prevalence of this virus is very high (about 50%) in some African populations, but stands between 2% and 8% for the entire world population. Kaposi's sarcoma only develops when the immune system is depressed, as in acquired immunodeficiency syndrome, which appears to be associated with a specific variant of the Kaposi's sarcoma herpes virus. There are no treatment guidelines for Kaposi's sarcoma established in Brazil, and thus the Brazilian Society of Clinical Oncology and the Brazilian Society of Infectious Diseases developed the treatment consensus presented here.
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Affiliation(s)
- Érico Arruda
- Sociedade Brasileira de Infectologia Infectologia, Vila Mariana, SP, Brazil
| | | | | | | | | | | | | | | | | | | | | | | | - Mauro Sergio Treistman
- Serviço de Infectologia de Rede Hospitalar Privada e Câmara Técnica de Doenças Infecciosas do CREMERJ
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29
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Pria AD, Hayward K, Bower M. Do we still need chemotherapy for AIDS-associated Kaposi’s sarcoma? Expert Rev Anticancer Ther 2014; 13:203-9. [DOI: 10.1586/era.12.179] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Radons J. The role of inflammation in sarcoma. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2014; 816:259-313. [PMID: 24818727 DOI: 10.1007/978-3-0348-0837-8_11] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Sarcomas encompass a heterogenous group of tumors with diverse pathologically and clinically overlapping features. It is a rarely curable disease, and their management requires a multidisciplinary team approach. Chronic inflammation has emerged as one of the hallmarks of tumors including sarcomas. Classical inflammation-associated sarcomas comprise the inflammatory malignant fibrous histiocytoma and Kaposi sarcoma. The identification of specific chromosomal translocations and important intracellular signaling pathways such as Ras/Raf/MAPK, insulin-like growth factor, PI3K/AKT/mTOR, sonic hedgehog and Notch together with the increasing knowledge of angiogenesis has led to development of targeted therapies that aim to interrupt these pathways. Innovative agents like oncolytic viruses opened the way to design new therapeutic options with encouraging findings. Preclinical evidence also highlights the therapeutic potential of anti-inflammatory nutraceuticals as they can inhibit multiple pathways while being less toxic. This chapter gives an overview of actual therapeutic standards, newest evidence-based studies and exciting options for targeted therapies in sarcomas.
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Affiliation(s)
- Jürgen Radons
- Department of Radiotherapy and Radiation Oncology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81675, Munich, Germany,
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Younai FS. Thirty years of the human immunodeficiency virus epidemic and beyond. Int J Oral Sci 2013; 5:191-9. [PMID: 24136672 PMCID: PMC3967318 DOI: 10.1038/ijos.2013.76] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Accepted: 07/16/2013] [Indexed: 11/30/2022] Open
Abstract
After more than 30 years of battling a global epidemic, the prospect of eliminating human immunodeficiency virus (HIV) as the most challenging infectious disease of the modern era is within our reach. Major scientific discoveries about the virus responsible for this immunodeficiency disease state, including its pathogenesis, transmission patterns and clinical course, have led to the development of potent antiretroviral drugs that offer great hopes in HIV treatment and prevention. Although these agents and many others still in development and testing are capable of effectively suppressing viral replication and survival, the medical management of HIV infection at the individual and the population levels remains challenging. Timely initiation of antiretroviral drugs, adherence to the appropriate therapeutic regimens, effective use of these agents in the pre and post-exposure prophylaxis contexts, treatment of comorbid conditions and addressing social and psychological factors involved in the care of individuals continue to be important considerations.
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Ruocco E, Ruocco V, Tornesello ML, Gambardella A, Wolf R, Buonaguro FM. Kaposi's sarcoma: etiology and pathogenesis, inducing factors, causal associations, and treatments: facts and controversies. Clin Dermatol 2013; 31:413-422. [PMID: 23806158 PMCID: PMC7173141 DOI: 10.1016/j.clindermatol.2013.01.008] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Kaposi's sarcoma (KS), an angioproliferative disorder, has a viral etiology and a multifactorial pathogenesis hinged on an immune dysfunction. The disease is multifocal, with a course ranging from indolent, with only skin manifestations to fulminant, with extensive visceral involvement. In the current view, all forms of KS have a common etiology in human herpesvirus (HHV)-8 infection, and the differences among them are due to the involvement of various cofactors. In fact, HHV-8 infection can be considered a necessary but not sufficient condition for the development of KS, because further factors (genetic, immunologic, and environmental) are required. The role of cofactors can be attributed to their ability to interact with HHV-8, to affect the immune system, or to act as vasoactive agents. In this contribution, a survey of the current state of knowledge on many and various factors involved in KS pathogenesis is carried out, in particular by highlighting the facts and controversies about the role of some drugs (quinine analogues and angiotensin-converting enzyme inhibitors) in the onset of the disease. Based on these assessments, it is possible to hypothesize that the role of cofactors in KS pathogenesis can move toward an effect either favoring or inhibiting the onset of the disease, depending on the presence of other agents modulating the pathogenesis itself, such as genetic predisposition, environmental factors, drug intake, or lymph flow disorders. It is possible that the same agents may act as either stimulating or inhibiting cofactors according to the patient’s genetic background and variable interactions. Treatment guidelines for each form of KS are outlined, because a unique standard therapy for all of them cannot be considered due to KS heterogeneity. In most cases, therapeutic options, both local and systemic, should be tailored to the patient’s peculiar clinical conditions.
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Affiliation(s)
- Eleonora Ruocco
- Department of Dermatology, Second University of Naples, via S. Pansini, 5 - 80131 Naples, Italy
| | - Vincenzo Ruocco
- Department of Dermatology, Second University of Naples, via S. Pansini, 5 - 80131 Naples, Italy.
| | - Maria Lina Tornesello
- Molecular Biology and Viral Oncology and AIDS Reference Centre, National Cancer Institute, "Fondazione Pascale," via M. Semmola - 80131 Naples, Italy
| | - Alessio Gambardella
- Department of Dermatology, Second University of Naples, via S. Pansini, 5 - 80131 Naples, Italy
| | - Ronni Wolf
- Dermatology Unit, Kaplan Medical Center, Rehovot 76100 Israel; The School of Medicine, Hebrew University and Hadassah Medical Center, Jerusalem, Israel
| | - Franco M Buonaguro
- Molecular Biology and Viral Oncology and AIDS Reference Centre, National Cancer Institute, "Fondazione Pascale," via M. Semmola - 80131 Naples, Italy
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Prehn RT, Prehn LM. Tumor inhibitory T cell immunity may be largely a transplantation artifact not necessarily dependent upon a lack of Tregs. Theor Biol Med Model 2013; 10:42. [PMID: 23800315 PMCID: PMC3750814 DOI: 10.1186/1742-4682-10-42] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Accepted: 06/06/2013] [Indexed: 11/10/2022] Open
Abstract
There exists a very large literature suggesting that T cells come in a variety of species and that without the action of Tregs tumors would seldom survive inhibition by T cell effectors. We believe that much of the evidence supporting the role of Tregs in cancer is compatible with a perhaps simpler hypothesis based upon the demonstration that that small quantities of effector T cells tend to stimulate tumors while larger quantities of seemingly the same cells are inhibitory (an hormesis-like effect). This possibility seems to destroy much of the need to postulate a role for T cell suppressors (Tregs) in cancer, but the exposure of effector T cells to antigen may convert them into Tregs (Tregs do exist). Furthermore, many other data suggest the possibility that immune inhibition of cancer could be a laboratory artifact seldom if ever seen in unmodified nature.
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Affiliation(s)
- Richmond T Prehn
- Department of Pathology, University of Washington School of Medicine, Seattle 98118, USA.
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Govender I, Motswaledi MH, Mabuza LH. A case report of the rapid dissemination of Kaposi’s sarcoma in a patient with HIV. Afr J Prim Health Care Fam Med 2013. [DOI: 10.4102/phcfm.v5i1.526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Introduction: Kaposi’s sarcoma is the most common HIV-associated neoplastic disease. In most cases it starts on the skin and later spreads to other visceral organs. We reported a case of HIV-associated cutaneous Kaposi’s sarcoma which rapidly progressed to involve the visceral organs within a few weeks and resulted in fatality. Case presentation: A 21-year old man who recently started antiretroviral therapy developed disseminated Kaposi’s sarcoma with a right-sided pleural effusion. Chest x-ray confirmed the effusion which was tapped for diagnostic purposes. Biopsy confirmed Kaposi’s sarcoma. He insisted on being discharged so that he could visit a traditional healer. Management and outcome: Despite antiretroviral therapy and supportive management his condition deteriorated rapidly and he died within a month of the diagnosis of disseminated Kaposi’s sarcoma. He died before chemotherapy could be commenced. Discussion: The lessons that could be learned from this case include the following: Kaposi’s sarcoma is asymptomatic and, since one out of three are HHV-8 positive, patients should have a thorough examination before starting on highly-active antiretroviral therapy. Patients with Kaposi’s sarcoma or even those on treatment should be warned of deterioration in the first 12 weeks of treatment. Pulmonary Kaposi’s sarcoma is fatal and requires timeous management and chemotherapy. Patients with HIV-related Kaposi’s sarcoma and chest signs require sputa to exclude pulmonary tuberculosis. Finally, traditional healers may be used to assist, especially if they are taught to identify HIV-related skin conditions and can refer patients appropriately.
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Towards a better understanding of Kaposi sarcoma-associated immune reconstitution inflammatory syndrome. AIDS 2013; 27:1667-9. [PMID: 24047765 DOI: 10.1097/qad.0b013e328360106b] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Immune reconstitution inflammatory syndrome associated with Kaposi sarcoma: higher incidence and mortality in Africa than in the UK. AIDS 2013; 27:1603-13. [PMID: 23462220 DOI: 10.1097/qad.0b013e328360a5a1] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES To assess the incidence, predictors, and outcomes of Kaposi sarcoma-associated paradoxical immune reconstitution inflammatory syndrome (KS-IRIS) in antiretroviral therapy (ART)-naive HIV-infected patients with Kaposi sarcoma initiating ART in both well resourced and limited-resourced settings. DESIGN Pooled analysis of three prospective cohorts of ART-naive HIV-infected patients with Kaposi sarcoma from sub-Saharan Africa (SSA) and one from the UK. METHODS KS-IRIS case definition was standardized across sites. Cox regression and Kaplan-Meier survival analysis were used to identify the incidence and predictors of KS-IRIS and Kaposi sarcoma-associated mortality. RESULTS Fifty-eight of 417 (13.9%) eligible individuals experienced KS-IRIS with an incidence 2.5 times higher in the African vs. European cohorts (P=0.001). ART alone as initial Kaposi sarcoma treatment (hazard ratio 2.97, 95% confidence interval (CI) 1.02-8.69); T1 Kaposi sarcoma stage (hazard ratio 2.96, 95% CI 1.26-6.94); and plasma HIV-1 RNA more than 5 log₁₀ copies/ml (hazard ratio 2.14, 95% CI 1.25-3.67) independently predicted KS-IRIS at baseline. Detectable plasma Kaposi sarcoma-associated herpes virus (KSHV) DNA additionally predicted KS-IRIS among the 259 patients with KSHV DNA assessed (hazard ratio 2.98, 95% CI 1.23-7.19). Nineteen KS-IRIS patients died, all in SSA. Kaposi sarcoma mortality was 3.3-fold higher in Africa, and was predicted by KS-IRIS (hazard ratio 19.24, CI 7.62-48.58), lack of chemotherapy (hazard ratio 2.35, 95% CI 1.09-5.05), pre-ART CD4 cell count less than 200 cells/μl (hazard ratio 2.04, 95% CI 0.99-4.2), and detectable baseline KSHV DNA (hazard ratio 2.12, 95% CI 0.94-4.77). CONCLUSION KS-IRIS incidence and mortality are higher in SSA than in the UK. This is largely explained by the more advanced Kaposi sarcoma disease and lower chemotherapy availability. KS-IRIS is a major contributor to Kaposi sarcoma-associated mortality in Africa. Our results support the need to increase awareness on KS-IRIS, encourage earlier presentation, referral and diagnosis of Kaposi sarcoma, and advocate on access to systemic chemotherapy in Africa.
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Abstract
This review of lung malignancies in human immunodeficiency virus (HIV) briefly highlights key epidemiologic and clinical features in the pulmonary involvement of AIDS-defining malignancies of Kaposi sarcoma and non-Hodgkin lymphoma. Then, focusing on non-AIDS defining lung cancer, the epidemiology and mechanisms, clinical presentation, pathology, treatment and outcomes, and prevention of HIV-associated lung cancer are discussed. Finally, the important knowledge gaps and future directions for research related to HIV-associated lung malignancies are highlighted.
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Affiliation(s)
- Allison A Lambert
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
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Abstract
The spectrum of HIV-associated pulmonary diseases is broad. Opportunistic infections, neoplasms, and noninfectious complications are all major considerations. Clinicians caring for persons infected with HIV must have a systematic approach. The approach begins with a thorough history and physical examination and often involves selected laboratory tests and a chest radiograph. Frequently, the clinical, laboratory, and chest radiographic presentation suggests a specific diagnosis or a few diagnoses, which then prompts specific diagnostic testing and treatment. This article presents an overview of the evaluation of respiratory disease in persons with HIV/AIDS.
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Patton LL, Ramirez-Amador V, Anaya-Saavedra G, Nittayananta W, Carrozzo M, Ranganathan K. Urban legends series: oral manifestations of HIV infection. Oral Dis 2013; 19:533-50. [PMID: 23517181 DOI: 10.1111/odi.12103] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Revised: 02/27/2013] [Accepted: 03/01/2013] [Indexed: 12/13/2022]
Abstract
Human immunodeficiency virus-related oral lesions (HIV-OLs), such as oral candidiasis (OC) and oral hairy leukoplakia (OHL), have been recognized as indicators of immune suppression since the beginning of the global HIV epidemic. The diagnosis and management of HIV disease and spectrum of opportunistic infection has changed over the past 30 years as our understanding of the infection has evolved. We investigated the following controversial topics: (i) Are oral manifestations of HIV still relevant after the introduction of highly active antiretroviral therapy (HAART)? (ii) Can we nowadays still diagnose HIV infection through oral lesions? (iii) Is the actual classification of oral manifestations of HIV adequate or does it need to be reviewed and updated? (iv) Is there any novelty in the treatment of oral manifestations of HIV infection? Results from extensive literature review suggested the following: (i) While HAART has resulted in significant reductions in HIV-OLs, many are still seen in patients with HIV infection, with OC remaining the most common lesion. While the relationship between oral warts and the immune reconstitution inflammatory syndrome is less clear, the malignant potential of oral human papillomavirus infection is gaining increasing attention. (ii) Effective antiretroviral therapy has transformed HIV from a fatal illness to a chronic manageable condition and as a result expanded screening policies for HIV are being advocated both in developed and in developing countries. Affordable, reliable, and easy-to-use diagnostic techniques have been recently introduced likely restricting the importance of HIV-OLs in diagnosis. (iii) The 1993 EC-Clearinghouse classification of HIV-OLs is still globally used despite controversy on the relevance of periodontal diseases today. HIV-OL case definitions were updated in 2009 to facilitate the accuracy of HIV-OL diagnoses by non-dental healthcare workers in large-scale epidemiologic studies and clinical trials. (iv) Research over the last 6 years on novel modalities for the treatment of HIV-OLs has been reported for OC and OHL.
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Affiliation(s)
- L L Patton
- Department of Dental Ecology, School of Dentistry, University of North Carolina, Chapel Hill, NC 27599-7450, USA.
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Lacombe JM, Boue F, Grabar S, Viget N, Gazaignes S, Lascaux-Cametz AS, Pacanowski J, Partisani M, Launay O, Matheron S, Rosenthal E, Rouveix E, Tattevin P, de Truchis P, Costagliola D, Goedert JJ. Risk of Kaposi sarcoma during the first months on combination antiretroviral therapy. AIDS 2013; 27:635-43. [PMID: 23196937 PMCID: PMC3623279 DOI: 10.1097/qad.0b013e32835cba6c] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine whether incident AIDS-defining Kaposi sarcoma or Pneumocystis jiroveci pneumonia (PJP) is associated with combination antiretroviral therapy (cART) initiation. DESIGN Compare risk for Kaposi sarcoma and PJP by time on cART and CD4 reconstitution. METHODS : In the FHDH-ANRS CO4 cohort (N = 66 369), Kaposi sarcoma (N = 1811) and PJP (N = 1718) incidence rates were computed by demographic and HIV strata. Crude and adjusted relative risk (RR) with 95% confidence intervals (CIs) following cART initiation were calculated by Poisson regression with untreated patients during 1996-2009 as reference. CD4 cell counts were compared by Wilcoxon rank sum tests. RESULTS The risk of Kaposi sarcoma was very high during months 1-3 on cART (N = 160, RRCrude 3.94, 95% CI 3.26-4.76), which was incompletely attenuated by adjustment for demographics and contemporaneous CD4 cell count (RRAdj 1.25, 95% CI 1.02-1.53). Corresponding PJP risk was minimally elevated (N = 84, RRCrude 1.80, 95% CI 1.42-2.30) and markedly reduced with adjustment on the same variables and PJP prophylaxis (RRAdj 0.52, CI 0.41-0.67). HIV load had no added effect. Median CD4 cell count at cART initiation was much lower in patients with incident Kaposi sarcoma (82 cells/μl) or PJP (61 cells/μl) within 3 months than in those who did not develop these conditions (>250 cells/μl). Notably, median CD4 cell count change was +44 cells/μl per month with incident Kaposi sarcoma within 3 months of cART initiation versus 0 cells/μl per month with incident PJP (P = 0.0003). CONCLUSION Failure of CD4 cell count reconstitution during months 1-3 on cART fully accounted for incident PJP. In contrast, there were 1.6 additional Kaposi sarcoma cases per 1000 person-years during months 1-3 on cART, suggesting that immune reconstitution may contribute to the risk for AIDS-defining Kaposi sarcoma.
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Baxi S, Platts-Mills J, Dhruva S, Huang L, Hanks D, Dhaliwal G. A double-edged sword. J Hosp Med 2013; 8:47-51. [PMID: 23293015 DOI: 10.1002/jhm.1999] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Revised: 11/01/2012] [Accepted: 11/07/2012] [Indexed: 11/11/2022]
Affiliation(s)
- Sanjiv Baxi
- Department of Medicine, Division of Infectious Diseases, University of California San Francisco, San Francisco, California 94110, USA.
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Zeichner SB, Ruiz AL, Suciu GP, Zeichner RL, Rodriguez E. Trends in Kaposi's Sarcoma in Miami Beach from 1987 to 2007. ISRN ONCOLOGY 2012; 2012:642106. [PMID: 23320191 PMCID: PMC3540766 DOI: 10.5402/2012/642106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Accepted: 12/09/2012] [Indexed: 12/28/2022]
Abstract
Purpose. Kaposi's sarcoma (KS) is a rare low-grade vascular tumor associated with the human herpes virus 8. By analyzing the epidemiology, staging, and treatment of KS, we hoped to improve the quality of care at our institution. Methods. Review of the Mount Sinai Medical Center tumor registry database in Miami Beach, FL, USA, identified 143 cases of KS between January 1, 1987 and December 31, 2007. Results. The majority of patients were non-Hispanic whites, non smoking males diagnosed between 1987 and 1996. Most of the patients were HIV positive, with an equal percentage diagnosed with local or distant disease. Most patients received no chemotherapy or radiation. There were no significant differences in patient survival based on sex, HIV status, or radiation received. There was a trend toward improved survival among older patients who smoked, received no chemotherapy, and had localized stage at diagnosis. Multivariate analysis revealed that non-Hispanic whites had a significant worse survival than Hispanic whites (HR = 0.55, 95% CI (0.33, 0.90), P = 0.02). Patients diagnosed between 1987 and 1996 had a worse survival than those between 1997 and 2007 (HR = 0.33 (95% CI 0.19, 0.55), P < 0.0001). Conclusion. This large retrospective study provides further insight into KS. Ethnicity and date of diagnosis are important predictors of long-term survival.
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Affiliation(s)
- Simon B. Zeichner
- Department of Internal Medicine, Mount Sinai Medical Center, 4300 Alton Road, Miami Beach, FL 33140, USA
| | - Ana L. Ruiz
- Department of Hematology and Oncology, Mount Sinai Medical Center, Miami Beach, FL 33140, USA
| | - Gabriel P. Suciu
- Department of Public Health and Biostatistics, College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale-Davie, FL 33314, USA
| | - Rachel Lerner Zeichner
- Department of Clinical Psychology, Nova Southeastern University, Fort Lauderdale-Davie, FL 33314, USA
| | - Estelamari Rodriguez
- Department of Hematology and Oncology, Mount Sinai Medical Center, Miami Beach, FL 33140, USA
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Adeyemo A, Wood C, Govind A. Kaposi's sarcoma in pregnancy after initiation of highly active antiretroviral therapy: a manifestation of immune reconstitution syndrome. Int J STD AIDS 2012; 23:905-6. [DOI: 10.1258/ijsa.2012.012141] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
A case of Kaposi's sarcoma (KS) presenting as an immune reconstitution inflammatory syndrome in pregnancy with conservative management is reported. Successful outcomes for mother and baby were achieved. HIV was diagnosed at antenatal booking and highly active antiretroviral therapy commenced at 20 weeks. Multiple lymphadenopathies developed two months later. Excision biopsy of a node confirmed KS. In the absence of advanced disease, she was managed conservatively until delivery. The placenta showed no evidence of KS or human herpes virus 8 (HHV-8). The baby had negative HIV and HHV-8 polymerase chain reaction tests at zero, six and 12 weeks of life. Six months postpartum, the KS had regressed and HHV-8 viral load was undetectable.
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Affiliation(s)
- A Adeyemo
- Department of Obstetrics and Gynaecology
| | - C Wood
- Department of HIV Medicine, North Middlesex University Hospital NHS Trust, Edmonton, London N18 1QX, UK
| | - A Govind
- Department of Obstetrics and Gynaecology
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Meintjes G, Scriven J, Marais S. Management of the immune reconstitution inflammatory syndrome. Curr HIV/AIDS Rep 2012; 9:238-50. [PMID: 22752438 DOI: 10.1007/s11904-012-0129-5] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The immune reconstitution inflammatory syndrome (IRIS) is a frequent early complication of antiretroviral therapy (ART) in patients with advanced HIV. Because there is no confirmatory diagnostic test, the diagnosis is based on clinical presentation and exclusion of alternative causes for deterioration, such as antimicrobial drug resistance. Opportunistic infection treatment should be optimized. Mild cases may require symptomatic therapy alone or nonsteroidal anti-inflammatory drugs. Corticosteroids have been used to treat more severe cases of IRIS associated with mycobacterial and fungal infections. There is evidence from a randomized controlled trial that prednisone reduces morbidity and improves symptoms in paradoxical tuberculosis (TB)-IRIS. Neurological TB-IRIS is potentially life-threatening; high-dose corticosteroids are indicated and ART interruption should be considered if level of consciousness is depressed. When considering corticosteroid treatment clinicians should be aware of their side effects and only use them when the diagnosis of IRIS is certain. In viral forms of IRIS corticosteroids are generally avoided.
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Affiliation(s)
- Graeme Meintjes
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
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Perfetti V, Ricotti M, Buonaguro F, Tirelli U, Pedrazzoli P. An overview of viral oncology in Italy - report from the Pavia meeting on solid tumors. Infect Agent Cancer 2012; 7:23. [PMID: 22950644 PMCID: PMC3523043 DOI: 10.1186/1750-9378-7-23] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Accepted: 08/30/2012] [Indexed: 02/06/2023] Open
Abstract
This is a report on some of the research activities currently ongoing in Italy as outlined at the “Viruses and solid tumors” meeting jointly organized by the Oncology Sections of IRCCS Policlinico “San Matteo” (Pavia) and IRCCS National Cancer Institute (Aviano), held in Pavia, Italy, on October 2011. Experts from the various disciplines involved in the study of the complex relationships between solid tumors and viruses met to discuss recent developments in the field and to report their personal contributions to the specified topics. Secondary end point was to establish a multidisciplinary work group specifically devoted to solid tumors and infectious agents, aimed to identify areas of common interest, promoting and establishing collaborative projects and programs, and to coordinate clinical and research activities. The group, which will be named IVOG (Italian Viral Oncology Group), will operate under the patronage of the various scientific societies of interest.
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Pathogenesis of the immune reconstitution inflammatory syndrome in HIV-infected patients. Curr Opin Infect Dis 2012; 25:312-20. [PMID: 22562000 DOI: 10.1097/qco.0b013e328352b664] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW The immune reconstitution inflammatory syndrome (IRIS) is an important clinical complication in HIV-infected patients initiating antiretroviral therapy. This review focuses on the latest literature pertaining to the pathogenesis of IRIS. RECENT FINDINGS The clinical manifestations of IRIS are heterogeneous due to the variety of opportunistic infections that are associated with this inflammatory syndrome. However, the disproportionate inflammation is a defining hallmark for which common mechanisms are suspected. Lymphopenia-induced proliferation in the context of systemic immune activation, presence of high antigenic exposure and a wider availability of interleukin-7 contribute to the exacerbated immune response underlying IRIS. Defect in pathogen clearance by phagocytes might favor high pathogen burden, which in turn is thought to activate both innate immune cells and pathogen-specific T cells upon correction of the CD4 T-cell lymphopenia, predisposing to IRIS. This common scenario might be further invigorated by functional impairments among regulatory T cells. SUMMARY Further insight into the cellular mechanisms driving IRIS is urgently needed. Understanding the relative contribution of distinct effector and regulatory T-cell subsets, and innate immune components to IRIS is required to inspire future therapeutic approaches.
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Abstract
The prevalence of AIDS-related Kaposi sarcoma (KS) has markedly declined in the era of highly active antiretroviral therapy (HAART) although it remains one of the most common AIDS-defining malignancies. Although immune reconstitution inflammatory syndrome (IRIS)-related KS (IRIS-KS) represents only a fraction of the IRIS cases, it can be a life-threatening situation. This report describes a fatal case of IRIS-KS. A 32-year-old man with HIV/AIDS was initiated on HAART and experienced rapid immunological and virological response to therapy. He subsequently experienced progressively severe dyspnea and papulonodular skin lesions and was admitted to the hospital with hypoxic respiratory failure. Bronchoscopy revealed numerous friable endobronchial lesions. Histopathology of a skin lesion was consistent with KS. The relatively rapid progression of disease in the setting of improvement in immune function after initiating HAART suggested IRIS-KS. This report reviews previously published cases of IRIS-KS and describes risk factors, immunopathogenesis and treatment options.
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Abstract
Antiretroviral therapy (ART) initiation in HIV-infected patients leads to recovery of CD4+T cell numbers and restoration of protective immune responses against a wide variety of pathogens, resulting in reduction in the frequency of opportunistic infections and prolonged survival. However, in a subset of patients, dysregulated immune response after initiation of ART leads to the phenomenon of immune reconstitution inflammatory syndrome (IRIS). The hallmark of the syndrome is paradoxical worsening of an existing infection or disease process or appearance of a new infection/disease process soon after initiation of therapy. The overall incidence of IRIS is unknown, but is dependent on the population studied and the burden of underlying opportunistic infections. The immunopathogenesis of the syndrome is unclear and appears to be result of unbalanced reconstitution of effector and regulatory T-cells, leading to exuberant inflammatory response in patients receiving ART. Biomarkers, including interferon-γ (INF-γ), tumour necrosis factor-α (TNF-α), C-reactive protein (CRP) and inter leukin (IL)-2, 6 and 7, are subject of intense investigation at present. The commonest forms of IRIS are associated with mycobacterial infections, fungi and herpes viruses. Majority of patients with IRIS have a self-limiting disease course. ART is usually continued and treatment for the associated condition optimized. The overall mortality associated with IRIS is low; however, patients with central nervous system involvement with raised intracranial pressures in cryptococcal and tubercular meningitis, and respiratory failure due to acute respiratory distress syndrome (ARDS) have poor prognosis and require aggressive management including corticosteroids. Paradigm shifts in management of HIV with earlier initiation of ART is expected to decrease the burden of IRIS in developed countries; however, with enhanced rollout of ART in recent years and the enormous burden of opportunistic infections in developing countries like India, IRIS is likely to remain an area of major concern.
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Affiliation(s)
- Surendra K Sharma
- Department of Internal Medicine, All India Institute of Medical Sciences, New Delhi, India.
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Prehn RT, Prehn LM. Is an immune reaction required for malignant transformation and cancer growth? Cancer Immunol Immunother 2012; 61:963-6. [PMID: 22618883 PMCID: PMC3378832 DOI: 10.1007/s00262-012-1233-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Accepted: 02/21/2012] [Indexed: 10/28/2022]
Abstract
Increasing evidence has shown that probably all malignant mouse cells, even those of spontaneous sporadic cancers, are endowed with tumor-specific antigens. Stimulation of cancer growth, rather than inhibition by the immune reaction, is seemingly the prevalent effect in the animal of origin (the autochthonous animal). Small initial dosages of even strong tumor antigens tend to produce stimulatory immune reactions rather than tumor inhibition in any animal. Thus, an immune response at a low level may be an essential growth-driving feature of nascent cancers, and this may be why all cancers apparently have tumor-specific antigens. Inasmuch as a low level of immunity is stimulatory to tumor growth while larger dosages are inhibitory, immuno-selection via this low response may tend to keep the antitumor immune reaction weak and at a nearly maximal stimulatory level throughout most of a tumor's existence. These facts suggest that both suppression of tumor immunity and a heightened immune reaction might each be therapeutic although very contrasting modalities.
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Uldrick TS, Wyvill KM, Kumar P, O'Mahony D, Bernstein W, Aleman K, Polizzotto MN, Steinberg SM, Pittaluga S, Marshall V, Whitby D, Little RF, Yarchoan R. Phase II study of bevacizumab in patients with HIV-associated Kaposi's sarcoma receiving antiretroviral therapy. J Clin Oncol 2012; 30:1476-83. [PMID: 22430271 PMCID: PMC3383119 DOI: 10.1200/jco.2011.39.6853] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2011] [Accepted: 01/06/2012] [Indexed: 12/19/2022] Open
Abstract
PURPOSE Alternatives to cytotoxic agents are desirable for patients with HIV-associated Kaposi's sarcoma (KS). Vascular endothelial growth factor-A (VEGF-A) contributes to KS pathogenesis. We evaluated the humanized anti-VEGF-A monoclonal antibody, bevacizumab, in patients with HIV-KS. PATIENTS AND METHODS Patients with HIV-KS who either experienced progression while receiving highly active antiretroviral therapy (HAART) for at least 1 month or did not regress despite HAART for at least 4 months were administered bevacizumab 15 mg/kg intravenously on days 1 and 8 and then every 3 weeks. The primary objective was assessment of antitumor activity using modified AIDS Clinical Trial Group (ACTG) criteria for HIV-KS. HIV-uninfected patients were also eligible and observed separately. RESULTS Seventeen HIV-infected patients were enrolled. Fourteen patients had been receiving effective HAART for at least 6 months (median, 1 year). Thirteen patients had advanced disease (ACTG T(1)), 13 patients had received prior chemotherapy for KS, and seven patients had CD4 count less than 200 cells/μL. Median number of cycles was 10 (range, 1 to 37 cycles); median follow-up was 8.3 months (range, 3 to 36 months). Of 16 assessable patients, best tumor responses observed were complete response (CR) in three patients (19%), partial response (PR) in two patients (12%), stable disease in nine patients (56%), and progressive disease in two patients (12%). Overall response rate (CR + PR) was 31% (95% CI, 11% to 58.7%). Four of five responders had received prior chemotherapy for KS. Over 202 cycles, grade 3 to 4 adverse events at least possibly attributed to therapy included hypertension (n = 7), neutropenia (n = 5), cellulitis (n = 3), and headache (n = 2). CONCLUSION Bevacizumab is tolerated in patients with HIV-KS and has activity in a subset of patients.
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MESH Headings
- Adult
- Aged
- Angiogenesis Inhibitors/administration & dosage
- Angiogenesis Inhibitors/adverse effects
- Angiogenesis Inhibitors/therapeutic use
- Anti-Retroviral Agents/therapeutic use
- Antibodies, Monoclonal, Humanized/administration & dosage
- Antibodies, Monoclonal, Humanized/adverse effects
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antiretroviral Therapy, Highly Active
- Bevacizumab
- Cytokines/blood
- Disease-Free Survival
- Drug Administration Schedule
- Female
- HIV Infections/complications
- HIV Infections/diagnosis
- HIV Infections/drug therapy
- Humans
- Kaplan-Meier Estimate
- Male
- Maryland
- Middle Aged
- Sarcoma, Kaposi/blood
- Sarcoma, Kaposi/blood supply
- Sarcoma, Kaposi/drug therapy
- Sarcoma, Kaposi/virology
- Time Factors
- Treatment Outcome
- Vascular Endothelial Growth Factor A/antagonists & inhibitors
- Vascular Endothelial Growth Factor A/blood
- Young Adult
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Affiliation(s)
- Thomas S. Uldrick
- Thomas S. Uldrick, Kathleen M. Wyvill, Pallavi Kumar, Deirdre O'Mahony, Wendy Bernstein, Karen Aleman, Mark N. Polizzotto, Seth M. Steinberg, Stefania Pittaluga, Richard F. Little, and Robert Yarchoan, Center for Cancer Research, National Cancer Institute (NCI), Bethesda; Vickie Marshall and Denise Whitby, SAIC-Frederick, NCI, Frederick, MD
| | - Kathleen M. Wyvill
- Thomas S. Uldrick, Kathleen M. Wyvill, Pallavi Kumar, Deirdre O'Mahony, Wendy Bernstein, Karen Aleman, Mark N. Polizzotto, Seth M. Steinberg, Stefania Pittaluga, Richard F. Little, and Robert Yarchoan, Center for Cancer Research, National Cancer Institute (NCI), Bethesda; Vickie Marshall and Denise Whitby, SAIC-Frederick, NCI, Frederick, MD
| | - Pallavi Kumar
- Thomas S. Uldrick, Kathleen M. Wyvill, Pallavi Kumar, Deirdre O'Mahony, Wendy Bernstein, Karen Aleman, Mark N. Polizzotto, Seth M. Steinberg, Stefania Pittaluga, Richard F. Little, and Robert Yarchoan, Center for Cancer Research, National Cancer Institute (NCI), Bethesda; Vickie Marshall and Denise Whitby, SAIC-Frederick, NCI, Frederick, MD
| | - Deirdre O'Mahony
- Thomas S. Uldrick, Kathleen M. Wyvill, Pallavi Kumar, Deirdre O'Mahony, Wendy Bernstein, Karen Aleman, Mark N. Polizzotto, Seth M. Steinberg, Stefania Pittaluga, Richard F. Little, and Robert Yarchoan, Center for Cancer Research, National Cancer Institute (NCI), Bethesda; Vickie Marshall and Denise Whitby, SAIC-Frederick, NCI, Frederick, MD
| | - Wendy Bernstein
- Thomas S. Uldrick, Kathleen M. Wyvill, Pallavi Kumar, Deirdre O'Mahony, Wendy Bernstein, Karen Aleman, Mark N. Polizzotto, Seth M. Steinberg, Stefania Pittaluga, Richard F. Little, and Robert Yarchoan, Center for Cancer Research, National Cancer Institute (NCI), Bethesda; Vickie Marshall and Denise Whitby, SAIC-Frederick, NCI, Frederick, MD
| | - Karen Aleman
- Thomas S. Uldrick, Kathleen M. Wyvill, Pallavi Kumar, Deirdre O'Mahony, Wendy Bernstein, Karen Aleman, Mark N. Polizzotto, Seth M. Steinberg, Stefania Pittaluga, Richard F. Little, and Robert Yarchoan, Center for Cancer Research, National Cancer Institute (NCI), Bethesda; Vickie Marshall and Denise Whitby, SAIC-Frederick, NCI, Frederick, MD
| | - Mark N. Polizzotto
- Thomas S. Uldrick, Kathleen M. Wyvill, Pallavi Kumar, Deirdre O'Mahony, Wendy Bernstein, Karen Aleman, Mark N. Polizzotto, Seth M. Steinberg, Stefania Pittaluga, Richard F. Little, and Robert Yarchoan, Center for Cancer Research, National Cancer Institute (NCI), Bethesda; Vickie Marshall and Denise Whitby, SAIC-Frederick, NCI, Frederick, MD
| | - Seth M. Steinberg
- Thomas S. Uldrick, Kathleen M. Wyvill, Pallavi Kumar, Deirdre O'Mahony, Wendy Bernstein, Karen Aleman, Mark N. Polizzotto, Seth M. Steinberg, Stefania Pittaluga, Richard F. Little, and Robert Yarchoan, Center for Cancer Research, National Cancer Institute (NCI), Bethesda; Vickie Marshall and Denise Whitby, SAIC-Frederick, NCI, Frederick, MD
| | - Stefania Pittaluga
- Thomas S. Uldrick, Kathleen M. Wyvill, Pallavi Kumar, Deirdre O'Mahony, Wendy Bernstein, Karen Aleman, Mark N. Polizzotto, Seth M. Steinberg, Stefania Pittaluga, Richard F. Little, and Robert Yarchoan, Center for Cancer Research, National Cancer Institute (NCI), Bethesda; Vickie Marshall and Denise Whitby, SAIC-Frederick, NCI, Frederick, MD
| | - Vickie Marshall
- Thomas S. Uldrick, Kathleen M. Wyvill, Pallavi Kumar, Deirdre O'Mahony, Wendy Bernstein, Karen Aleman, Mark N. Polizzotto, Seth M. Steinberg, Stefania Pittaluga, Richard F. Little, and Robert Yarchoan, Center for Cancer Research, National Cancer Institute (NCI), Bethesda; Vickie Marshall and Denise Whitby, SAIC-Frederick, NCI, Frederick, MD
| | - Denise Whitby
- Thomas S. Uldrick, Kathleen M. Wyvill, Pallavi Kumar, Deirdre O'Mahony, Wendy Bernstein, Karen Aleman, Mark N. Polizzotto, Seth M. Steinberg, Stefania Pittaluga, Richard F. Little, and Robert Yarchoan, Center for Cancer Research, National Cancer Institute (NCI), Bethesda; Vickie Marshall and Denise Whitby, SAIC-Frederick, NCI, Frederick, MD
| | - Richard F. Little
- Thomas S. Uldrick, Kathleen M. Wyvill, Pallavi Kumar, Deirdre O'Mahony, Wendy Bernstein, Karen Aleman, Mark N. Polizzotto, Seth M. Steinberg, Stefania Pittaluga, Richard F. Little, and Robert Yarchoan, Center for Cancer Research, National Cancer Institute (NCI), Bethesda; Vickie Marshall and Denise Whitby, SAIC-Frederick, NCI, Frederick, MD
| | - Robert Yarchoan
- Thomas S. Uldrick, Kathleen M. Wyvill, Pallavi Kumar, Deirdre O'Mahony, Wendy Bernstein, Karen Aleman, Mark N. Polizzotto, Seth M. Steinberg, Stefania Pittaluga, Richard F. Little, and Robert Yarchoan, Center for Cancer Research, National Cancer Institute (NCI), Bethesda; Vickie Marshall and Denise Whitby, SAIC-Frederick, NCI, Frederick, MD
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