Simona Badiu, Florina Vasilescu, Gabriel Becheanu, Cristian Țieranu, Adrian Săftoiu
Gastroenterology, Hepatology and Digestive Endoscopy Clinic of the ELIAS University Emergency Hospital, Carol Davila University of Medicine and Pharmacy Bucharest
A 44-year-old patient with known HIV infection and cutaneous Kaposi’s sarcoma, diagnosed exclusively on clinical grounds without biopsy of skin lesions, currently on antiretroviral therapy with Delstrigo (doravirine / lamivudine / tenofovir) at the hospital accusing melenic stools, started about 7 days before the presentation, accompanied by nausea and fatigue. On objective examination, the patient is adynamic, asthenic with pale skin and mucous membranes, with multiple purplish nodular lesions in the anterior thorax, normotensive (Tamedie = 95 mmHg) but tachycardic (AV = 118 bpm), intestinal transit present, with affirmative melenic stool, but with an empty rectal ampoule at the rectal touch. Biologically, the presence of a severe anemic syndrome, normochrome, normocyte (Hb = 6.2 g / dL), mild leukopenia (leukocytes 3.65 / * 10 ^ 3 / microL) and inflammatory syndrome (C-reactive protein = 40mg / dl) were identified. , ferritin = 1008 ng / mL). Risk scores calculated at the guard room: Rockend preendoscopic 3 points, Glasgow-Blatchford 8 points, AIMS65 1 point. The patient was urgently investigated endoscopically in order to establish the etiology of digestive hemorrhage, possibly tempting an endoscopic hemostasis. Multiple erythematous protrusive lesions of varying size, disseminated to the entire upper digestive tract, from the pharyngeal to the duodenal level, suggestive of Kaposi’s gastrointestinal sarcoma, are highlighted in the upper digestive endoscopy. Particularly, at the gastric level, there is a heterogeneity of the dimensions of the observed lesions, some being large, confluent, with bleeding in the abdomen, others, at the antral level, being small (Fig 1.A-D).
Bleeding was stopped spontaneously due to heavy washing and aspiration of fresh intragastric blood, and no endoscopic hemostatic maneuver was required. Duodenal biopsies were taken. The evolution was favorable, without further bleeding, with the clinical-biological improvement of the patient, under treatment with proton pump inhibitor and transfusion hematological rebalancing.
The diagnosis of Kaposi’s sarcoma was later confirmed histopathologically, with the presence of characteristic elements such as mesenchymal proliferation, with the presence of spindle cells, immunohistochemical tests for endothelial markers (CD 31), and for the detection of HHV8 (human herpes virus 8), being of also positive. (Fig. 2.A-D).
Given the extent of Kaposi’s sarcoma lesions, with interest in the upper digestive tract, the patient is referred to oncology, in order to initiate treatment with pegylated liposomal doxorubicin.
FIG. 1.A Esophageal – protruding lesions, erythematous-purplish, without bleeding, suggestive of Kaposi’s sarcoma
FIG. 1.B Stomach – (gastric fornix – retroversion) – multiple erythematous protruding lesions, confluent, with bleeding in the cloth.
FIG. 1.C Prepyloric antrum – protruding, erythematous lesions, small in size, suggestive of Kaposi’s sarcoma.
FIG. 1.D D2 – protruding lesions, erythematous, with umbilical center, without stigmas of recent bleeding.
Fig 2.A HEx50: Duodenal mucosa with preserved villous architecture, with a zone of mesenchymal proliferation with spindle cells -splindle cells- in the basal part of the lamina propria (arrow).
Fig. 2.B. HEx200: Detail of the area marked with an arrow in Fig. 2.A: fascicular proliferation of spindle-shaped cells, with discrete polymorphism and cellular atypia, plasma cell infiltrate, interstitial hemosiderin and siderophages.
Fig 2.C: Positive IHC reaction for CD 31 in spindle cells, highlighting the fascicular arrangement of spindle cells and frequent endothelial structures.
FIG. 2.D. Positive IHC reaction for HHV8 in spindle and endothelial cells.