A 57-year-old African American male with medical history of AIDS presented with progressively worsening cough, shortness of breath, intermittent fever, and night sweats for about 10 months. He also reported 60-pound weight loss during that time. However, he was on a liquid diet because of difficulty of swallowing due to extensive oral lesions and odynophagia. The patient reported that he was off from HAART therapy for approximately one year but restarted treatment 14 months ago. He was on cobicistat, elvitegravir, emtricitabine, and tenofovir. However, he was noncompliant with his treatment. He had a biopsy of oral lesions done prior to the admission, showing KS.
Physical examination was significant for diffuse dark purple patches and plaques involving the face, back, arms, legs as well as hard palate and gums (Figures 1and 2). On chest examination, he had decreased air entry in the right lower lung fields.
Complete blood count was significant for normocytic anemia and thrombocytopenia. The patient's absolute CD4 count was 27 cells/microliter. Chest x-ray (Figure 3) and subsequent chest computed tomography (Figure 4), showed moderate right lung pleural effusion with scattered bilateral diffuse infiltrates and mild mediastinal and retroperitoneal lymphadenopathy.
Immediately after the admission, the patient continued to deteriorate with worsening hypoxemia, requiring 15-liter oxygen with nonrebreather mask and transferred to the ICU for acute respiratory failure. He underwent thoracentesis which revealed hemorrhagic pleural fluid, negative for infection or malignancy. Infectious etiology has been excluded after blood culture and sputum culture were found to be negative for bacterial, viral, or fungal infections. Pulmonary tuberculosis, Coccidioidomycosis, pneumocystis jiroveci, and syphilis were also ruled out. Other malignancies which can involve lung and pleura in patient with AIDS (such as pulmonary lymphoma and lung cancer) were less likely as CT scan of chest, abdomen, and pelvic did not show any lymphadenopathy and pleural effusion cytology found to be negative for any malignant cells.
After exclusion of Infectious etiologies, and other malignancies, the patient was diagnosed with poor risk and extensive KS (T1I1S1). He was immediately started on chemotherapy with paclitaxel along with HAART. Dexamethasone 10 mg was also added at the time of chemotherapy administration for prevention of hypersensitivity reaction. Since receiving the chemotherapy, his condition has significantly improved with near complete resolution of the pleural effusion, oral and skin lesions. The patient was able to tolerate oral diet and has regained 30-pound weight. He completed total six cycle of chemotherapy with paclitaxel 190 mg with no significant side effects.