Fatal Immune Reconstitution due to Kaposi’s Sarcoma Following HAART Initiation: Case Report and Literature Review

HEIDI M. CRANE, MD, MPH and ROBERT D. HARRINGTON,

Author address: 

Univ. of Washington, Seattle, WA

Abstract: 

Introduction: Immune reconstitution syndrome (IRS) associated with Kaposi’s sarcoma (KS) following initiation of HAART has been rarely reported. In most cases clinical improvement of KS due to HAART is the rule. We describe a patient with an intense and ultimately fatal inflammatory response to KS after starting HAART. Case: A 47-year-old man with HIV and a recent CD4 count of 150 cells/mm3 presented with fever, fatigue, and a dry cough 6 weeks after initiating HAART. Exam was notable for a fever (39.3° C), hypoxia (SpO2 88%), lower extremity edema, and partial resolution of a small (0.8cm) lesion on his thigh suggestive of KS. A CXR revealed a prominent interstitium and pleural effusions. A CT showed splenomegaly and diffuse lymphadenopathy. The patient was treated for presumed PCP and communityacquired pneumonia. Bronchoscopy with biopsy, bone marrow aspiration, and an inguinal lymph node biopsy were negative. The patient was later treated with ethambutol, clarithromycin, and prednisone for possible IRS related to occult MAC infection. He responded dramatically to this treatment and was Health System & Univ. of North Dakota Sch. of Medicine & Health Science, Fargo, ND and RAYMOND A. SMEGO, Jr., MD, MPH, Univ. of North Dakota Sch. of Medicine & Health Science, Fargo, ND We reviewed 43 cases (42 literature cases and one seen at our institution) of Histoplasma capsulatum endocarditis to determine the salient clinical and microbiologic features for this life-threatening blood culture-negative infection. The male:female ratio of the study cohort was 35:8, and mean patient age 45.4 years (range, 17-64 years). Diagnosis of Histoplasma endocarditis was generally delayed a mean of 9 months from onset of symptoms, and was made by serology (19 cases), culture (12; only 3 (6.9%) patients had positive blood cultures), autopsy (10), histopathology (6), UK (5), NS (3), nucleic acid amplification and immunofluorescent staining (1 each). Cardiac involvement included aortic (17 patients), mitral (9), aortic & mitral (3), and tricuspid (4) valves, NS (4), UK (4), and atrial myxoma and aortofemoral graft (1 each). Six (17%) infections occurred on prosthetic valves or endovascular grafts. Where stated, 28 patients had disseminated histoplasmosis (21) or other extracardiac sites of infection (7); only 4 patients had isolated endocarditis. Management for 39 pts involved: antifungal therapy alone (13 pts)[amphotericin B (AMB) alone 10 patients; AMB followed by ketoconazole - 1), antifungal( s) surgery (7), and no Rx (21 patients). All untreated patients died; 7/11 (64%) patients receiving antifungal treatment alone recovered vs. 6/7 (86%) undergoing valve replacement (p 0.05). Although systemic embolization complicated almost 40% of cases of Histoplasma infection, for these patients the response to antifungal therapy in AMB-treated subjects was 67% (6/9 patients) vs. 50% (2/4 patients managed with AMB surgery). Indications for surgical intervention appear to be the same as for bacterial endocarditis, e.g., refractory heart failure, uncontrolled infection, and recurrent systemic emboli. In summary, H. capsulatum is an infrequent but important cause of culturenegative endocarditis. A combined medical-surgical approach may optimize cure.
2003

abstract No: 

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Full conference title: 

41st Annual Meeting Infectious Diseases Society of America
    • Infectious Diseases Society of America 41st