Main complaint and medical history:
A 33 year-old male presented to the oral medicine clinic at Groote Schuur Hospital (GSH). He was referred for the evaluation of painless growths affecting his maxillary gingival tissues since it was noticed three months ago.
The patient was diagnosed with HIV and tuberculosis (TB), and was placed on anti-retroviral therapy (ARV) as well as a multi drug TB regimen since February 2016. He was a smoker until he was diagnosed and has since quit smoking. The last available absolute CD4 count measured 45 cells/uL .
Extraoral examination revealed mild submental lymphadenopathy, oedema at the lower legs and feet, and callouses on skin of lower jaw with mild folliculitis on the skin of the cheek. Multiple purple vascular appearing nodules were present bilaterally upon the skin of both temples
Intraoral examination revealed multiple red/purple spongy macules along the buccal gingiva extending from the 17 up to the 11 (Figure1). A more exophytic spongy, deep purple/red mass was present at the 15 with evidence of surface trauma and hyperkeratosis. From distal to the 18, a similar macular lesion extended across the right hard palate and became increasingly exophytic from 15 and mesially. The palate contained multiple coalescing masses with localized surface keratosis and necrotic ulceration. Lesions overlapped the palatal midline (Figure2). Tooth 15 measured Class II mobility but otherwise asymptomatic.
Similar lesions of les severity were found in the second quadrant from the 23 up to 28, (Figure3,4). Maxillary vestibules were also involved. In the third quadrant, the lesion involved the retromolar and buccal mucosa up to 36, area of the 36 appeared exophytic and spongy in consistency. In the 4th quadrant, the macular lesions extended to the retromolar area around the 48 with lingual involvement.
Figure 1: First quadrant buccal
Figure 2: Red nodular exophytic mass involving the first quadrant palate
Figure 3: Second quadrant
Figure 4: Frontal view in occlusion
Diagnosis:
Due to the distinct clinical appearance, a differential diagnosis of Kaposi Sarcoma was made. Alternate less likely entities included:
- Bacilliary angiomatosis
- Hematologic malignancy ( leukemia/lymphoma)
- Melanoma
Management:
The patient was referred for additional hematologic tests and referred to the infectious disease clinic at GSH for further medical management. Final biopsy was taken from the skin lesions found bilaterally on the temples and a definitive diagnosis of Kaposi Sarcoma was achieved prior to his return for oral biopsy. Absolute CD4 in July 2017 measured 90 cell/uL.
Case 2:
Main complaint and medical history:
A 28 year old female was referred from Karl Bremmer hospital to evaluate a lesion on the hard palate. She is HIV positive and hepatitis A positive (12/06/2016). The last available CD4 count measured 14 cell/uL
The lesion is asymptomatic with irregular zone of erythema and telangiectasia affecting the left palatal mucosa apical to 27 and 28 and approaching the palatal raphe. The greatest zone of erythema lies at the midpoint between the raphe and the marginal palatal gingiva. The patient had never noticed the lesion and assumed it had always been present. The lesion is flat, smooth non-blanching and blends into the surrounding tissue.
Figure 5: erythematous lesion of the palate
Diagnosis and management:
Incisional biopsy confirmed the diagnosis of Kaposi Sarcoma and one again the case was referred to infectious diseases for further management
