The patient was a 77 year-old Hispanic male who initially presented to the emergency room with a 6-week history of progressive dyspnea on exertion, cough productive of yellow sputum, intermittent hemoptysis, worsening fatigue and weight loss of 10 lbs. On admission, he denied fever, chills, chest pain, sick contacts, recent travel, or tuberculosis exposure and history. His past medical history was significant for Non-Hodgkin follicular B cell lymphoma (NHL) diagnosed in 1997, treated with Rituximab, Cyclophosphamide, Hydroxydaunorubicin, Oncovin and Prednisone (RCHOP) three times. Last treatment was completed 1 year prior to presentation. He also had biopsy-confirmed cutaneous Kaposi's Sarcoma (KS), identified within the same year of presentation, treated with pegylated liposomal doxorubicin 20 mg/m 2 once every 21 days for two cycles.
On admission, he had a low grade fever and was tachycardic. His physical exam was remarkable for a 2 cm firm, non-tender, mobile right submandibular lymph node. Lungs were clear to auscultation bilaterally. He was grossly anasarcic with 4 (+) pitting edema of the lower extremities. He also had multiple violet, non-tender skin lesions localized to the lower extremities, mainly around the medial aspect of his ankles and anterior thighs bilaterally.
His labs revealed a normal cardiac panel, a white blood cell (WBC) count of 8,100/mm 3 with no leukocytosis. Manual differentiation of the white blood cells showed 28% neutrophils, 48% lymphocytes, 17% monocytes and 5% eosinophils. Urinalysis and urine culture were negative for infections. Blood cultures were positive for Streptococcus pneumoniae. 
A chest X-ray done on admission showed a right lung consolidation consistent with pneumonia thus the patient was started on empiric vancomycin 1gm every 12 hours and piperacillin-tazobactam 4.5gm every 8 hours for a duration of 8 days. A computerized axial tomographic (CT) scan of the chest, abdomen and pelvis, showed numerous nodular opacities throughout each lung which were suspected to be consistent with KS as well as small pleural effusions in both lungs ( Figure 1).
Despite completing a course of antibiotics for pneumonia, his symptoms did not improve. A follow-up CT scan of the chest demonstrated that the bilateral pleural effusions had worsened ( Figure 2). Patient underwent a thoracentesis of the larger effusion in the right lung which showed a sero-sanguineous and exudative fluid based on chemistry analysis. Histopathology failed to demonstrate malignant cells.
A bronchoscopy was also performed, revealing diffusely hyperemic and edematous mucosa of the lower airways with mucopurulent secretions ( Figure 3). Biopsy was not performed at this time given concern for endobronchial bleeding. Bronchoalveolar lavage (BAL) stains and cultures were negative for bacteria, fungi or acid fast bacilli. Pneumocystis jiroveci PCR and fluid cytology were also negative but PCR for HHV-8 showed 5800 DNA copies/mL. The patient had a HIV p24 rapid antigen test done which was negative.
After two weeks of supportive treatment, the patient's symptoms began to improve. He continued to have numerous indurated confluent lesions on his body and face consistent with KS. His pulmonary symptoms were thought to be due to disseminated KS. Following significant discussions with the patient and his family regarding the poor prognosis of his disease, he decided not to undergo any further antineoplastic treatments and eventually was discharged home with hospice.
CT of the chest on admission to hospital. . CT of the chest demonstrating several nodular opacities throughout both lungs. Two nodules are measured to show size. Arrows point to pleural effusions on both lungs.