A Man With Loose Stool and Periumbilical Pain

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• Answer to the Clinical Challenges and Images in GI Question: Image 3 (page 734): Kaposi Sarcoma of the Colon
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Question: A 36-year-old man presented with loose stool passage and periumbilical pain off and on for 3 months. On examination, well-demarcated purpuric papules and plaques were noted on his extremities. Blood tests for cell count and biochemistry were normal. Occult blood without pus cells was noted in stool. Colonoscopy revealed multiple hemorrhagic, raised, plaque-like erythematous lesions diffusely scattered along the entire colon (Figure A). What is the most likely diagnosis?

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Answer to the Clinical Challenges and Images in GI Question: Image 3 (page 734): Kaposi Sarcoma of the Colon 

Microscopic examination of colonic mucosa showed features of Kaposi sarcoma (KS) with whorls of spindle-shaped cells (positive for CD34) and neovascularization with small-vessel proliferation and red cell extravasations (Figures B and C). Polymerase chain reaction of the specimen was positive with single band at 184 base pair, compatible with infection with human herpesvirus-8. Skin biopsy also displayed pictures of KS. The patient was then confirmed to be positive for human immunodeficiency virus (HIV) by Western blot and with a CD4 T-cell count of 458 cells/μL. A diagnosis of HIV-related KS with simultaneous skin and colon involvement was established. The patient was initiated with highly active antiretroviral therapy (HAART) and liposomal doxirubicin, with clinical improvement thereafter.

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KS is divided into 4 subtypes regarding the affected population: Classic among older men of Ashkenazi Jewish and Mediterranean origin; endemic among African infants and young men; iatrogenic among patients under immunosuppressive regimens; and epidemic among men having sex with men affected by HIV infection. Compared with HIV patients without KS, the HIV-related KS is more commonly seen in men (97% vs 77%) and homosexuals (89% vs 42%), but less in intravenous drug abusers (4.3% vs 25.8%).¹ This case presented with neither a history of homosexuality or intravenous drug abuse, but he admitted to having several episodes of unprotected, paid sex. HIV-associated KS has been decreasing in incidence and severity since the introduction of antiretroviral therapy.² KS is typically found on the skin, but may spread elsewhere such as the mouth, gastrointestinal (GI) tract, and respiratory tract. In HIV-positive patients, GI involvement is the second most common site for KS after skin. GI lesions may be silent or may cause weight loss, pain, nausea/vomiting, diarrhea, bleeding, and malabsorption. KS in the GI tract is usually segmental, instead of continuous, as shown in this case. The cellular origin of KS has not yet been fully elucidated, but is assumed to be from lymphatic endothelial cells. The immunohistochemistry of the KS cells shows expression of CD34, CD31, and D2-40. HHV-8 infection is identified as the causative agent of KS.³ Treatment is usually nonoperative, including HAARRT, chemotherapy, radiotherapy, or combination thereof.

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References 

1. Mocroft A, Kirk O, Clumeck N, et al. The changing pattern of Kaposi sarcoma in patients with HIV, 1994-2003: the EuroSIDA Study. Cancer. 2004;100:2644–2654
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2. Gallafent JH, Buskin SE, De Turk PB, et al. Profile of patients with Kaposi's sarcoma in the era of highly active antiretroviral therapy. J Clin Oncol. 2005;23:1253–1260
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   • MEDLINE
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3. Szajerka T, Jablecki J. Kaposi's sarcoma revisited. AIDS Rev. 2007;9:230–236
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