SAEM Clinical Image Series: Bumps and Balls

A 31 year old African-American male, with a history of HIV, non-compliant with medications, presents with 3 months of painful “balls and bumps” on his left thigh. He was evaluated at another hospital prior to this visit and was discharged with 7 days of TMP-SMX. He denies any fever, chills, weight loss, night sweats, or anorexia.

kaposi sarcoma xray leg

kaposi sarcoma CT leg

Physical Exam

Vitals: Temp: 36.6C, HR 79, BP 123/75, RR 18, SpO2: 99%

General: Well appearing

Skin: Left medial thigh has multiple red and violaceous nodules with additional plaques coalescing into larger tumors; pitting edema from groin to calf.

Laboratory Data/Imaging Reads

WBC: 2.4 K/mcL

Imaging X-ray: Several well circumscribed soft tissue lesions

CT Left Lower Extremity: Enhancing, high attenuating, polypoid lesions

Case Question: What are your top three differential diagnoses? How to diagnose?

Bacillary angiomatosis
Kaposi sarcoma
Angiosarcoma

Diagnosis can be determined via biopsy of the lesion.

Case Question: What was the confirmed diagnosis?

Kaposi Sarcoma

Case Discussion

Kaposi Sarcoma (KS) is a malignancy of vascular endothelial cells first described by Moritz Kaposi in 1872. More recently, it is the most common tumor associated with HIV/AIDS. The widespread use of antiretroviral therapy has decreased the incidence of KS in the United States significantly; however, emergency physicians still need to recognize and manage KS.

Clinically, cutaneous KS most often appears on the lower extremities, face, oral mucosa, and genitalia in an assortment of shapes, sizes, and colors.

Bacillary angiomatosis (caused by Bartonella henselae/quintana) may be clinically indistinguishable from KS in immunocompromised patients as it presents similarly with a variety of cutaneous lesions. Biopsy is needed to differentiate.

Take Home Points

Have a high suspicion for KS in immunocompromised individuals.
Diagnose KS with a biopsy.
The primary treatment of KS is strengthening the immune system with highly active antiretroviral therapy (HAART).

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2019 SAEM Annual Meeting | Copyrighted by SAEM 2019 – all rights reserved. View other other cases from this series on ALiEM.