S4722 HIV-Associated Kaposi Sarcoma Without Cutaneous Lesions Presenting With Gastrointestinal Bleeding: A Case Report

Introduction: Kaposi sarcoma is an AIDS-defining illness which usually presents with cutaneous lesions. It then progresses to visceral lesions involving gastrointestinal tract and lungs. Our case is amongst the very few cases reported of gastrointestinal Kaposi sarcoma without skin lesions and presenting with gastrointestinal bleeding in an AIDS/HIV patient. Case Description/Methods: A 24-year-old man with a history of syphilis presented with a 3 week history of severe, persistent, diffuse abdominal pain associated with vomiting, unexplained weight loss, odynophagia and bright red blood per rectum. He was cachectic, with oral thrush over tongue and buccal mucosa and bilateral inguinal lymphadenopathy on palpation. Labs reported anemia (7.8 g/dl), leukopenia (3.1 K/μL), thrombocytopenia (97 K/μL) and elevated CRP and ESR. He tested positive for HIV-1 antibodies (with viral load of 1,040,000 copies per milliliter and CD4 count of 199 cells/μL) and for syphilis re-exposure. Imaging studies revealed irregular anorectal enhancement raising suspicion for malignancy. Evaluation with colonoscopy showed diffuse colitis with ulcerations and proctitis extending from hepatic flexure to rectum. Rectal examination revealed a large necrotic ulcer, with several polypoid folds. Upper endoscopy noted multiple raised gastric ulcers and a large polypoid lesion measuring 2 × 4 cm at the gastroesophageal junction with surrounding fungating areas; along with markedly friable, erythematous esophageal mucosa with several centrally ulcerated 1 cm patches. Multiple biopsies taken from stomach, esophagus and gastroesophageal junction revealed proliferation of atypical spindle cells and slit-like vascular channels positive for CD 31 and CD 117. Immunostaining for human herpesvirus-8 confirmed diagnosis for Kaposi sarcoma. Patient was started on Bikhtarvy for HIV management, penicillin G for syphilis and was scheduled to begin chemotherapy for visceral Kaposi sarcoma with appropriate follow up plans. Discussion: Kaposi sarcoma (KS) has 4 subtypes (classic, African, AIDS associated and iatrogenic KS) and majority (90%) of them present with cutaneous lesions. More than 25% of patients with AIDS related KS have visceral lesions but majority (81.5%) of them are asymptomatic unless complications develop. Only a few cases have been reported for gastrointestinal (GI) manifestations without concurrent skin lesions, which questions the need for routine endoscopic investigation of the GI tract in HIV-infected patients for prompt treatment.