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(B) Positive immunoreaction to CD34, making more evident the presence of vascular spaces, some shaped as a cleft and others as capillaries with thin walls.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case Report</span><p id="par0005" class="elsevierStylePara elsevierViewall">Kaposi's sarcoma (KS) is one of the most common neoplasms in patients suffering HIV/AIDS, especially in patients with CD4+ counts below 200<span class="elsevierStyleHsp" style=""></span>cells/μl.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> There is a strong association between infection by human herpes virus 8 (HVH8) and the appearance of this neoplasm.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Under the optic microscope, KS is a multicentric, angioproliferative disorder characterised by the proliferation of spindle cells, neoangiogenesis, inflammation and oedema.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a 30-year-old male, diagnosed with infection by HIV 1 year and 4 months earlier. The CD4+ count was of 24<span class="elsevierStyleHsp" style=""></span>cells/μl and the HIV viral load (HIV-VL) of 15.331<span class="elsevierStyleHsp" style=""></span>copies/ml. The following diagnoses were established during admission: <span class="elsevierStyleItalic">Molluscum contagiosum</span> in upper and lower limbs and genitalia, <span class="elsevierStyleItalic">Condyloma acuminatum</span> in the genital area, oral candidiasis, pulmonary tuberculosis, disseminated infection by cytomegalovirus (CMV) and disseminated disease by <span class="elsevierStyleItalic">Micobacterium avium complex</span> (MAC).</p><p id="par0015" class="elsevierStylePara elsevierViewall">One month after the start of treatment of the opportunistic infections, we began highly active antiretroviral therapy (HAART) with emtricitabine/tenofovir and efavirenz. No KS lesions had been documented at that point.</p><p id="par0020" class="elsevierStylePara elsevierViewall">One year after the start of HAART, the CD4+ count had reached 105<span class="elsevierStyleHsp" style=""></span>cells/μl and HIV-VL was undetectable. The treatment for tuberculosis, MAC and CMV infections had concluded and no activity of these diseases was recorded.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The patient was referred to the otolaryngology service after a nodular lesion was detected in the dorsum of the tongue 1 month earlier. Upon questioning, the patient reported mild odynophagia and intermittent dysphagia for solids. We conducted an indirect laryngoscopy (IL) which revealed a rounded tumour with an ulcerous-necrotic surface in the right half of the tongue base, with a diameter of approximately 2<span class="elsevierStyleHsp" style=""></span>cm (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). Incisional biopsies of the tumour, which was soft and friable, were taken by indirect laryngoscopy. A microscopic study revealed spindle cells with an elongated nucleus and vascular clefts (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A). Immunohistochemical analysis was positive for antigen CD34 (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B). The histopathological diagnosis was of KS.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">We actively sought other KS lesions at a cutaneous level and reviewed imaging studies from 1 week earlier, including thoracic and abdominal scans. KS was only confirmed in the dorsum of the tongue.</p><p id="par0035" class="elsevierStylePara elsevierViewall">We opted for maintaining the patient under surveillance and continuing HAART, awaiting an involution of the tumour. In the follow-up period of 1 month we observed a 60% decrease in the size of the tumour (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B).</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">The increase of the use of HAART among the population of patients infected by HIV has caused a significant reduction of the prevalence of KS. Exceptionally, KS manifests paradoxically, that is, it appears or worsens after HAART. In these paradoxical cases, as the immune system recovers there can even be a worsening or appearance of KS lesions as a manifestation of immune reconstitution inflammatory syndrome (IRIS).<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The rate of prevalence of IRIS is between 8% and 30%, and it is generally associated to tuberculosis, MAC, retinitis by CMV and disseminated <span class="elsevierStyleItalic">Cryptococcus</span>.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> There are several works on KS related to IRIS, with prevalence around 6.4% of total cases of IRIS.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Nevertheless, there are very few cases of isolated, oral KS.</p><p id="par0050" class="elsevierStylePara elsevierViewall">This case report fulfils the criteria for belated IRIS<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>), as it appeared in a patient suffering HIV infection who, after more than 1 year of HAART, presented an increase in CD4+ T-cell count (a minor criterion) and a persistently undetectable HIV viral load, followed by formation of a neoplasm, in this case KS (2 major criteria). One month after the appearance of KS, after adopting an expecting attitude and continuing with HAART, the lesion began its involution (a major criterion).<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">In cases presenting KS lesions which do not represent a significant clinical symptom for patients and do not affect the airway, despite being a case of KS secondary to IRIS, according to the clinical experience in these cases, continuing with HAART is expected to lead to a full remission of the lesion.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,10</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of Interests</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case Report" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflict of Interests" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-06-08" "fechaAceptado" => "2012-07-10" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as: Valdés-Pineda S, Lara-Sánchez H, Torruco-García U, Dorantes-Heredia R. Síndrome inflamatorio de reconstitución inmune manifiesto como sarcoma de Kaposi en lengua. 2014;65:123–125.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 629 "Ancho" => 1550 "Tamanyo" => 155506 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Lesion in the right half of the tongue base formed by a round tumour with an ulcerous-necrotic surface, measuring 2<span class="elsevierStyleHsp" style=""></span>cm in diameter. (B) The same lesion, now with a pink hue and measuring 0.8<span class="elsevierStyleHsp" style=""></span>cm in diameter, showing an involution of oral KS.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1297 "Ancho" => 975 "Tamanyo" => 296719 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(A) A malignant mesenchymatous neoplasm with a solid and nodular growth pattern alternating with elongated vascular spaces can be seen under the stratified flat epithelium of the tongue. (B) Positive immunoreaction to CD34, making more evident the presence of vascular spaces, some shaped as a cleft and others as capillaries with thin walls.</p>" ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Source: based on French et al.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Major criteria \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Minor criteria \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">A. Atypical presentation of opportunistic infections or tumours in patients responding to HAART</span><span class="elsevierStyleHsp" style=""></span>• <span class="elsevierStyleItalic">Localised disease (lymph nodes, liver and spleen)</span><span class="elsevierStyleHsp" style=""></span>• <span class="elsevierStyleItalic">Exaggerated inflammatory reaction</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>∘ Severe fever, without an established cause<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>∘ Painful lesions<span class="elsevierStyleHsp" style=""></span>• <span class="elsevierStyleItalic">Atypical inflammatory response in affected tissue</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>∘ Granulomas, suppuration, necrosis<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>∘ Perivascular lymphocytic inflammatory cellular infiltrate<span class="elsevierStyleHsp" style=""></span>• <span class="elsevierStyleItalic">Progression of organic dysfunction or extension of preexisting lesions, after definition of clinical improvement following germ-specific treatment before starting HAART and exclusion of toxicity of treatment and new diagnoses</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>∘ Development or extension of lesions occupying space in the brain following treatment for cerebral cryptococcosis or toxoplasmosis<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>∘ Progressive pneumonitis or development of organised pneumonia following treatment for pulmonary TB or pneumonia by <span class="elsevierStyleItalic">Pneumocystis</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>∘ New instalment or worsening of uveitis/vitreitis following resolution of retinitis by CMV<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>∘ Fever and cytopenia following treatment for disseminated MAC<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>∘ Extension of KS lesions and subsequent resolution or partial remission without start of radiotherapy, systemic chemotherapy or intralesional therapy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Increase of cellular CD4 count following HAART• Increase of specific immune response for a relevant pathogen (for example: response like delayed hypersensitivity for mycobacterial antigens)• Spontaneous resolution of disease without specific antimicrobial therapy or tumoural chemotherapy without continuing HAART \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">B. Decrease in plasma levels of HIV-RNA >1</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">log</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">10</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">copies/ml</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab487948.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "*" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">The diagnosis of IRIS requires at least 2 major criteria or 2 minor criteria and 1 major criterion.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Criteria Proposed for the Diagnosis of IRIS in Patients With HIV Following HAART.<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a></p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Kaposi's sarcoma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "K. 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Journal Information
Vol. 65. Issue 2.
Pages 123-125 (March - April 2014)
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Vol. 65. Issue 2.
Pages 123-125 (March - April 2014)
Case Study
Immune Reconstitution Inflammatory Syndrome Manifested as a Kaposi's Sarcoma in the Tongue
Síndrome inflamatorio de reconstitución inmune manifiesto como sarcoma de Kaposi en lengua
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Samantha Valdés-Pinedaa,
, Hugo Lara-Sáncheza,b, Uri Torruco-Garcíab, Rita Dorantes-Herediac
Corresponding author
a Servicio de Otorrinolaringología y Cirugía de Cabeza y Cuello, Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”, Mexico City, Mexico
b Unidad de Epidemiología Clínica, Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”, Mexico City, Mexico
c Departamento de Patología Clínica, Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”, Mexico City, Mexico
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