Clinical Manual for Management of the HIV-Infected ... - myCME.com

6–56 | Clinical Manual for Management of the HIV-Infected Adult/2006
Common Manifestations
Skin lesions
Skin lesions may occur anywhere on the skin. Common
sites include the face (under the eyes and on the tip
of the nose), behind the ears, and on the extremities
and torso. Lesions may be macules, papules, plaques,
or nodules. At first, the lesions are small and may be
flat. Their color may vary from pink or red to purple
or brown-black (the latter particularly in dark-skinned
individuals), and they are nonblanching, nonpruritic,
and painless. Over time, the lesions often increase in
size and number, darken, and rise from the surface; they
may progress to tumor plaques (eg, on the thighs or
soles of the feet), or to exophytic tumor masses, which
can cause bleeding, necrosis, or extreme pain.
Oral lesions
Oral lesions may be flat or nodular and are red or
purplish. They usually appear on the hard palate,
but may develop on the soft palate, gums, tongue, or
elsewhere.
Lymphedema
Lymphedema associated with KS usually appears in
patients with visible cutaneous lesions, and edema may
be out of proportion to the extent of visible lesions.
Lymphedema may also occur in patients with no
visible skin lesions. Common sites include the face,
neck, external genitals, and lower extremities. Usually, a
contiguous area of skin is also involved. Lymph nodes
may be enlarged.
Pulmonary KS
Pulmonary KS usually causes severe, pneumonia-like
symptoms and is rapidly progressive. The patient may
exhibit difficulty breathing, bronchospasm, cough
(sometimes with hemoptysis), and hypoxemia. The chest
x-ray typically shows diffuse interstitial infiltrates, often
accompanied by nodules or pleural effusion.
Gastrointestinal KS
Gastrointestinal KS may arise anywhere in the
gastrointestinal tract. Patients are usually asymptomatic
except in cases of intestinal obstruction or bleeding.
KS may also cause protein-losing enteropathy. Visceral
disease is uncommon in the absence of extensive
cutaneous disease.
A: Assessment
The partial differential diagnosis depends on the type of
symptoms present.
For cutaneous, oral, and lymph node presentations,
consider the following:
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Bacillary angiomatosis
Lymphoma
Dermatofibromas
Bacterial or fungal skin infections
Stasis
For pulmonary symptoms, consider:
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Pneumocystis jiroveci pneumonia (PCP)
Cytomegalovirus (CMV) pneumonia
Pulmonary lymphoma (rare)
P: Plan
Diagnostic Evaluation
For cutaneous or oral KS, a presumptive diagnosis can
often be made by the appearance of skin or mucous
membrane lesions. Biopsy of a lesion (or a suspect
lymph node) is recommended to verify the diagnosis
and rule out infectious or other neoplastic causes.
Biopsy is particularly important if the lesions are
unusual in appearance or if the patient has systemic or
atypical symptoms.
If respiratory symptoms are present, obtain chest x-rays
or computed tomography (CT) studies. Radiographic
findings may be suggestive of KS, but cannot provide a
definitive diagnosis. Bronchoscopy with visualization of
characteristic endobronchial lesions is usually adequate
for diagnosis.
For patients with gastrointestinal symptoms and
suspected KS, perform endoscopy.
Review recent CD4 cell counts. The CD4 count is
typically low (