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Osseous Kaposi Sarcoma
To the Editor: Kaposi sarcoma (KS) was originally described in 1872 and was first noted as an acquired immunodeficiency syndrome (AIDS)–associated neoplasm in 1981.1 The common radiological modalities used in the diagnosis of extracutaneous KS have been sequential gallium and thallium scintigraphy. We describe a case of disseminated osseous KS of noncontiguous spread that was not detected by the conventional nuclear scans and was confirmed only by bone biopsy guided by computed tomography (CT).
Report of a Case
A homosexual man of Mediterranean origin presented with progressive dyspnea developing over a 1-month period and back pain. He had had AIDS and cutaneous KS for 1 year, and had a CD4 cell count of 51/µL at the time of presentation. He was found to have bilateral pleural effusions. He had multiple mucocutaneous lesions that were identified as KS by punch biopsy. Bronchoscopy revealed endobronchial lesions consistent with KS. A CT scan revealed multiple lytic lesions in the thoracolumbar vertebrae, ribs, and iliac bones (Figure 1). A CT-guided biopsy of the L1 vertebra revealed the lytic lesions to be KS. None of the lesions were revealed by plain radiographs, skeletal survey, or thallium and gallium scans. Despite 3 cycles of chemotherapy with adriamycin, bleomycin, and vincristine he developed progressive dysphagia, constipation, and anasarca and died 3 months after hospitalization. An autopsy was not performed.
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Figure. Lytic Lesion of L1 Vertebra, Representing Kaposi Sarcoma
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Comment
There have been only a very few reports of osseous KS.2 While it is generally recognized that osseous KS is usually the result of contiguous invasion from an adjacent nonosseous lesion,2 the possibility that osseous involvement could occur as a result of noncontiguous spread has not been ruled out. To our knowledge, however, the latter form of involvement has not been reported in the literature. We describe a case of AIDS-associated KS with osseous involvement without any evidence of adjacent nonosseous lesions, suggesting dissemination. While the possibility of multifocal primary KS cannot be excluded, the clinical course suggests metastatic dissemination.3
Despite their osteolytic character, KS lesions do not seem to present well on plain radiographs. The use of sequential thallium and gallium scintigraphs in the diagnosis of extracutaneous KS has been reported; a positive thallium scan result and a negative gallium scan result suggests the diagnosis.4 In our patient both thallium and gallium scintigraphy results were negative, thus raising questions about the applicability of thallium scans in osseous KS. The osseous lesions in our case were readily identifiable on CT and confirmed by CT-guided biopsy, thus making this the most reliable diagnostic modality. The possibility of osseous KS should be evaluated in patients with known KS presenting with bone pain.
Ganesh Krishna, MD;
Rajinder K. Chitkara, MD
Division of Pulmonary and Critical Care Medicine
Stanford University School of Medicine
Palo Alto, Calif
1. Centers for Disease Control. Kaposi's sarcoma and Pneumocystis carinii pneumonia among homosexual men—New York City and California. MMWR Morb Mortal Wkly Rep. 1981;30:305-308.
PUBMED
2. Isenberger DW, Aronson NE. Lytic vertebral lesions: an unusual manifestation of AIDS-related Kaposi's sarcoma. Clin Infect Dis. 1994;19:751-755.
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3. Safai B, Johnson KG, Myskowski PL, et al. The natural history of Kaposi's sarcoma in the acquired immunodeficiency syndrome. Ann Intern Med. 1985;103:744-750.
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4. Vanarthos WJ, Ganz WI, Vanarthos JC, Serafini AN, Tehranzadeh J. Diagnostic uses of nuclear medicine in AIDS. Radiographics. 1992;12:731-749.
ABSTRACT
Letters Section Editor: Stephen J. Lurie, MD, PhD, Senior Editor.
JAMA. 2003;289:1106.
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