Oral HIV-associated Kaposi sarcoma: A clinical study from theGa-Rankuwa area, South Africa

Abstract

Background: Kaposi sarcoma (KS) is the most common neoplasm diagnosed in HIV-seropositive subjects. HIV-associated KS (HIV-KS) may affect any body system and the disease may be slowly progressing or fulminant. Oral involvement is frequent and extensive oral HIV-KS is associated with poor prognosis. Methods: All cases of oral HIV-KS treated in the Department of Periodontology and Oral Medicine over a period of seven years were included in this retrospective study. A record was made regarding the clinical and laboratory features, and differences in these features between males and females were statistically tested. The differences between the percentages of the different clinical appearances of oral HIV-KS lesions; and between the features of oral HIV-KS in patients who contracted HIV infection before the diagnosis of oral KS and those who were diagnosed with HIV infection at the time of oral KS presentation were also tested. Results: Of the 37 patients included in the study, 54% were females and 46% were males and two patients (5%) were children. In 21 patients (57%) the initial presentation of HIV-KS was in the mouth. Seventeen patients (46%) were diagnosed with HIV infection and oral KS at the same time. At the time of oral HIV-KS diagnosis, 29 patients (78%) had multiple lesions affecting one or several sites. There were no statistically significant differences between males and females regarding the clinical and laboratory features of oral HIV-KS except for the size of the lesions. The percentage of lesions <10mm was significantly lower in females than males (chi-squared test: p=0.007), whereas the percentage of lesions ≥10mm≤50mm was significantly higher in females than in males (chi-squared test: p=0.0004). There were significantly more patients with multiple oral HIV-KS lesions than patients with single oral HIV-KS lesions (binomial distribution test: p=0.0003). At the time of oral HIV-KS diagnosis, the difference between ix the average CD4+ T cell counts of the patients who were concurrently diagnosed with HIV infection and oral KS (130cells/mm3), and those who contracted HIV infection before developing oral HIV-KS (90 cells/mm3) was not statistically different. Nine patients (24%) developed facial lymphoedema in association with multifocal exophytic oral HIV-KS lesions. The average CD4+ T cell counts of these patients at the time of oral HIV-KS diagnosis was 28 cells/mm3, and was statistically significantly lower (t-test: p= 0.01) than the average CD4+ T cell count (133 cells/mm3) of those who did not develop facial lymphoedema. All the patients with facial lymphoedema died, on average within two weeks from the occurrence of facial lymphoedema. One patient (2.7%) developed immune reconstitution inflammatory syndrome (IRIS) – associated oral HIV-KS, and his oral HIV-KS resolved following administration of highly active antiretroviral therapy (HAART) and systemic cytotoxic chemotherapy, and surgical excision. Out of the 28 patients who were not lost to follow-up, 21 (75%) died, on average within 13.6 weeks from the time of oral HIV-KS diagnosis and seven (25%) survived. At the time of oral HIV-KS diagnosis the difference in the average CD4+ T cell count of the patients who died (64 cells/mm3) and those who survived (166 cells cells/mm3) was statistically significant (t-test: p=0.016). The prognosis of the patients who received cytotoxic chemotherapy was better than the prognosis of those who received only HAART, or those who were HAART-naïve. Conclusions: Oral HIV-KS affects females more frequently than males (M:F = 1:1.2), and it is not uncommon in children. A lower CD4+ T cell count at the time of oral HIV-KS diagnosis is associated with a poor prognosis. Patients who develop facial lymphoedema during the course of HIV-KS disease, die soon thereafter. Oral HIV-KS can be successfully treated with systemic cytotoxic chemotherapy.