Fatal alveolar hemorrhage due to Kaposi sarcoma

摘要

A 43-year-old African-American man with history of diabetes mellitus, chronic systolic heart failure with ejection fraction of 15, atrial fibrillation and stage III kidney disease HIV (Human immunodeficiency virus) diagnosed in 1994 on antiretroviral therapy (ART). Kaposi sarcoma of the skin and lung diagnosed a year ago with lung wedge biopsy and on chemotherapy, presented with 1-week history of progressive worsening shortness of breath with minimal efforts, pleuritic chest pain and productive cough with 'penny-sized blood clots' that were both dark and bright red in color. Furthermore, he reported nocturnal diaphoresis over the same period. Denies any recent exposures or travel outside the USA has been compliant with Trimethoprim/Sulfamethoxazole (TMP/SMX) for Pneumocystis jiroveci Pneumonia (PJP) prophylaxis three times a week for many years. On exam, he was febrile (38.1°C) and hypoxic (SpO2 91 on 4L/min O2 per nasal cannula). He had bilateral coarse crepitations at bases on posterior chest exam. Blood work showed hemoglobin 7.9 g/dl (down from basal of 12.2 g/dl a week prior). Chest roent-genogram (CXR) showed diffuse bilateral mixed interstitial and alveolar infiltrates with bilateral mild pleural effusions. Giving his clinical presentation and history, CT scan of the chest was done and showed diffuse ground-glass opacity admixed with consolidative opacity in the right upper, middle, and lower lobes and the left upper lobes. This was associated with numerous bilateral, mid and lower lung solid pulmonary nodules with soft tissue infiltration along bronchovascular bundles, these findings represent Kaposi's sarcoma (KS) with diffuse alveolar hemorrhage (Figures 1 and 2). Intravenous antibiotics were administered including azithromycin, piperacillin/tazobactam and vancomycin; TMP/ SMX was continued. He had rapidly progressive deterioration of his respiratory status, requiring 100 high-flow oxygen and subsequently airway intubation and mechanical ventilation. Few hours later he had pulseless electrical activity (PEA) cardiac arrest and passed away after 30 min of advanced cardiopulmonary resuscitation efforts.