Fatal outcome of immune reconstitution inflammatory syndrome in a patient with AIDS-associated Kaposi sarcoma

Melé-Ninot, Gemma; Sola-Ortigosa, Joaquim; Iglesias-Sancho, Maribel; Delás-Amat, Jordi

doi:10.1016/j.medcle.2016.04.025

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Imágenes del empeoramiento del sarcoma de Kaposi al mes de iniciar el tratamiento antirretroviral de gran actividad. Aumento del número y tamaño de las lesiones de sarcoma de Kaposi asociado a sida. C. Imágenes durante el ingreso en la Unidad de Cuidados Intensivos del continuo empeoramiento del sarcoma de Kaposi. 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Increasing number and size of injuries of AIDS-associated Kaposi sarcoma. (C) Images, during admission to the Intensive Care Unit, of the continuing Kaposi sarcoma worsening. Increased volume of AIDS-associated Kaposi sarcoma injuries and appearance of purpura due to thrombocytopenia." ] ] ] "textoCompleto" => "The incidence of AIDS-associated Kaposi sarcoma (AIDS-KS) has decreased dramatically in recent years as a result of the widespread use of highly active antiretroviral therapy (HAART). There is a potential worsening or appearance of AIDS-KS with the onset of HAART despite the paradoxical improvement in immune function. This process is called immune reconstitution inflammatory syndrome associated with Kaposi sarcoma (KS-IRIS), of which there are about 50 cases reported in medical literature.<a class="elsevierStyleCrossRef" href="#bib0055">1</a> We report a case of AIDS-KS with torpid evolution due to KS-IRIS.It is a 22-year-old male diagnosed with infection by the human immunodeficiency virus (HIV), classified as a category A3 according to the CDC system and with AIDS-KS lesions. One month after starting HAART with emtricitabine, tenofovir and efavirenz, the patient showed rapid improvement in immune function and a paradoxical worsening of AIDS-KS. Previous injuries increased in size and new skin (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A and B), oropharyngeal and digestive injures appeared. Therefore, he was diagnosed with KS-IRIS. Because of a refractory thrombocytopenia, the patient could not be administered doxorubicin for the treatment of AIDS-KS. The patient showed a nosocomial pneumonia that required admission to ICU. During hospitalization AIDS-KS injuries gradually increased in size, now accompanied by purpura (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C), and facial swelling was becoming more evident. Subsequently, there was a multi-organ failure that caused the patient's death.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>AIDS-KS is distinctive of AIDS and may be the first manifestation in these patients in 15% cases.<a class="elsevierStyleCrossRef" href="#bib0060">2</a> In 1994 Chang et al. identified HHV8 as a causative agent, although recently it has been believed that HIV infection may have a role in the development of KS through the action of the transcription-transactivating protein.<a class="elsevierStyleCrossRef" href="#bib0065">3</a> The AIDS Clinical Trials Group Oncology Committee<a class="elsevierStyleCrossRef" href="#bib0070">4</a> published the criteria for the evaluation of AIDS-KS, considering, as high risk factors, any of the following: tumor-associated edema or ulceration, extensive oral disease, gastrointestinal KS or in other viscera, CD4<150/mm3, history of opportunistic infection, thrush, symptoms B or Karnofsky index <70. The patient reported 4 high risk factors: tumor-associated edema or ulceration, extensive oral disease, visceral involvement and CD4<150/μl. Patients treated with HAART where KS appears have a less aggressive disease compared to those who did not undergo HAART,<a class="elsevierStyleCrossRef" href="#bib0075">5</a> as in this case. The vast majority of patients have skin lesions only, and, if visceral involvement, it is usually gastrointestinal and in lung. The first-line treatment is HAART (a protease inhibitor should be included) and it can be combined with different local therapies.<a class="elsevierStyleCrossRef" href="#bib0075">5</a> The use of chemotherapy has been indicated in diffuse mucocutaneous involvement, visceral involvement, large extension (>25 lesions) or rapid progression.<a class="elsevierStyleCrossRef" href="#bib0075">5</a> First-line chemotherapy is PEGylated liposomal doxorubicin 20mg/m2 intravenously every 2 weeks or daunorubicin citrate liposome 40mg/m2 intravenously every 2 weeks. Paclitaxel has been indicated only for patients with recurrence or refractory to first-line chemotherapy.<a class="elsevierStyleCrossRef" href="#bib0075">5</a> HAART causes partial or complete AIDS-KS injury resolution in 55–60%,<a class="elsevierStyleCrossRef" href="#bib0080">6</a> but there is a risk of KS-IRIS. KS-IRIS is an inflammatory process in which there is paradoxically a temporary relationship between the onset of HAART, the onset or progression of AIDS-KS and improved immune status evidenced by a decreased viral load and increased CD4 count.<a class="elsevierStyleCrossRef" href="#bib0085">7</a> KS patients with low basal CD4 count appear to have increased risk of KS-IRIS,<a class="elsevierStyleCrossRefs" href="#bib0090">8,9</a> rapid increased CD4 count during HAART onset,<a class="elsevierStyleCrossRef" href="#bib0100">10</a> high viral load of HIV,<a class="elsevierStyleCrossRef" href="#bib0095">9</a> edema associated,<a class="elsevierStyleCrossRef" href="#bib0100">10</a> KS present clinically prior to HAART, HHV8 detectable in plasma and hematocrit >30%.<a class="elsevierStyleCrossRef" href="#bib0085">7</a> Corticosteroids are not recommended because they would promote HHV8 and growth factor replication. Thus, KS would be worsened.<a class="elsevierStyleCrossRef" href="#bib0085">7</a> KS early identification and previous or combined use of chemotherapy with HAART appears to be the most effective procedure to prevent the consequences of KS-IRIS<a class="elsevierStyleCrossRef" href="#bib0085">7</a> and reduce mortality.<a class="elsevierStyleCrossRef" href="#bib0055">1</a> In conclusion, it is important to understand this entity, and not to be confused with a failure of HAART, and know it does not imply a change of antiretroviral therapy, except in cases with potential irreversible damage.<a class="elsevierStyleCrossRef" href="#bib0085">7</a>Conflict of interestsThe authors report no conflict of interest in drafting the manuscript." "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interests" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Melé-Ninot G, Sola-Ortigosa J, Iglesias-Sancho M, Delás-Amat J. Síndrome de reconstitución inmunitaria en un caso de sarcoma de Kaposi asociado a sida con desenlace mortal. Med Clin (Barc). 2015;145:551–552." ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 614 "Ancho" => 1899 "Tamanyo" => 249537 ] ] "descripcion" => array:1 [ "en" => "(A and B) Images of worsening of Kaposi sarcoma a month after starting highly active antiretroviral therapy. Increasing number and size of injuries of AIDS-associated Kaposi sarcoma. (C) Images, during admission to the Intensive Care Unit, of the continuing Kaposi sarcoma worsening. Increased volume of AIDS-associated Kaposi sarcoma injuries and appearance of purpura due to thrombocytopenia." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Immune reconstitution inflammatory syndrome associated with Kaposi sarcoma: higher incidence and mortality in Africa than in the UK" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "E. Letang" 1 => "J.J. Lewis" 2 => "M. Bower" 3 => "A. Mosam" 4 => "M. Borok" 5 => "T.B. 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ISSN: 2387-0206

Launched in 1943, Medicina Clínica is a fortnightly journal aimed at the promotion of clinical research and practice among internal medicine and other specialists. The key characteristics of Medicina Clínica are the scientific and methodological rigor of its manuscripts, the topicality of its contents, and, especially, its practical focus with highly useful information for clinical practice. Medicina Clínica is predominantly interested in publishing original research manuscripts, which are rigorously selected according to their quality, originality, and interest, and also in continued medical education-oriented manuscripts, which are commissioned by the journal to relevant authors (Editorials, Reviews, and Diagnosis and Treatment). These manuscripts contain updated topics with a major clinical or conceptual relevance in modern medicine. The journal adheres to the standards of academic research publications in all aspects including peer-review and ethical principles. Medicina Clínica is included in the General and Internal Medicine category of Thomson Reuters.

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Impact factor

The Impact Factor measures the average number of citations received in a particular year by papers published in the journal during the two preceding years.

© Clarivate Analytics, Journal Citation Reports 2022

Impact factor 2023

2.6

Citescore

CiteScore measures average citations received per document published.

Citescore 2023

3.1

SJR

SRJ is a prestige metric based on the idea that not all citations are the same. SJR uses a similar algorithm as the Google page rank; it provides a quantitative and qualitative measure of the journal's impact.

SJR 2023

0.371

SNIP

SNIP measures contextual citation impact by wighting citations based on the total number of citations in a subject field.

SNIP 2023

0.511

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Journal Information

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Vol. 145. Issue 12.

Pages 551-552 (December 2015)

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