Photo Rounds

Lesions on elbow

A 35-year-old gay man sought care for papular lesions that had developed on his elbow 3 months earlier. He had no associated symptoms. The patient was not on any medications and the remainder of his exam was normal.

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The family physician (FP) performed a shave biopsy, which revealed Kaposi’s sarcoma (KS). The patient subsequently tested positive for human immunodeficiency virus (HIV) and began treatment with antiretroviral combination therapy.

KS is the most common malignancy seen in acquired immune deficiency syndrome (AIDS) patients. KS is an angioproliferative disease, with abnormal proliferation of endothelial cells, myofibroblasts, and monocyte cells. Human herpes virus 8 produces a receptor that promotes endothelial cell proliferation. Lesions often begin as papules or patches and progress to plaques as proliferation continues.

Cutaneous lesions are usually multifocal, papular, and reddish-purple in color. Plaques or fungating lesions can be seen on the lower extremities, including the soles of the feet. Oral cavity lesions can be flat or nodular and are red to purple in color. Gastrointestinal lesions can be asymptomatic or cause abdominal pain, nausea, vomiting, bleeding, or weight loss. Pulmonary lesions can cause shortness of breath or may appear as infiltrates, nodules, or pleural effusions on chest radiographs.

KS is not curable; treatments include antiretrovirals and chemotherapeutic agents to reduce disease burden and slow progression. Alitretinoin gel 0.1% can be applied to lesions 2 times a day, increasing to 3 to 4 times a day if tolerated, for 4 to 8 weeks. The response rate is 66%. Liposomal doxorubicin 20 mg/m2 every 3 weeks or liposomal daunorubicin 40 mg/m2 every 2 weeks has produced a 50% response rate. Intralesional vinblastine (70% response rate) or radiation therapy (80% response rate) are also effective for skin lesions.

The FP referred the patient to an oncologist who suggested the topical alitretinoin gel treatment, as described above. The KS lesions resolved within 6 weeks. Fortunately, the patient had no gastrointestinal or pulmonary involvement. Also, his HIV viral load dropped to undetectable levels with antiretroviral therapy.

Photo courtesy of Heather Goff, MD, and McGraw-Hill. Text for Photo Rounds Friday is courtesy of Richard P. Usatine, MD. This case was adapted from: Chumley H. Kaposi’s sarcoma. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. The Color Atlas of Family Medicine. New York, NY: McGraw-Hill; 2009:929-932.

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