J Formos Med Assoc 2002 • Vol 101 • No 8 585

Intussusception in AIDS-Associated Kaposi’s Sarcoma

(J Formos Med Assoc2002;101:585–7)

Key words:intussusceptionKaposi’s sarcomaAIDS

Division of Infectious Diseases and Tropical Medicine, and Departments of 1Internal Medicine, 2Pathology and 3Surgery,Tri-Service General Hospital, National Defense Medical Center, Taipei.Received: 15 March 2002. Revised: 15 April 2002. Accepted: 7 May 2002.Reprint requests and correspondence to: Dr. Yao-Chi Liu, Division of General Surgery, Department of Surgery, Tri-ServiceGeneral Hospital, National Defense Medical Center, 325, Section 2, Cheng-Kung Road, Nei-Hu, Taipei, Taiwan.

INTUSSUSCEPTION AS THE INITIAL MANIFESTATIONOF AIDS ASSOCIATED WITH PRIMARYKAPOSI’S SARCOMA: A CASE REPORT

Ning-Chi Wang, Feng-Yee Chang, Yen-Yi Chou,1 Chih-Lung Chiu,1 Chih-Kung Lin,2

Yuen-Hua Ni, and Yao-Chi Liu3

Gastrointestinal symptoms usually develop in AIDSpatients at some time during the course of illness.Kaposi’s sarcoma (KS) is the most frequent neoplasticdisease and is a common cause of gastrointestinal tractinvolvement in AIDS patients [1]. KS occurs predomi-nantly in homosexual men with AIDS [1]. Patients whosuffer from gastrointestinal KS usually have skin orlymph node involvement [2]. However, Friedman foundthat 40% of AIDS patients with an initial diagnosis ofcutaneous or lymph node KS also had gastrointestinaltract involvement [3]. Most cases of enteric KS areclinically silent and found incidentally by endoscopy orradiologic examination [4]. We report the case of a 31-year-old AIDS patient with homosexual behavior whodeveloped intestinal obstruction due to intussuscep-tion of the ileum in association with KS. Primary gas-trointestinal KS was the initial AIDS-defining illness inthis patient.

Abstract: Kaposi’s sarcoma (KS) is the most common AIDS-associated neoplasm. Itinvolves the gastrointestinal tract, skin and lymph nodes with about equal frequency.However, most cases of gastrointestinal KS are clinically silent and found incidentally.We report the case of a 31-year-old homosexual man who developed intussusceptionin association with a primary ileal KS. He was admitted due to abdominal pain lasting2 hours. Flat abdominal roentgenogram revealed small bowel ileus in the centralabdomen. Abdominal sonography and computerized tomography revealed an intra-luminal soft tissue mass in the small intestine with an intussusception. Exploratorylaparotomy found an ileal tumor mass 90 cm proximal to the ileocecal valve.Pathologic examination of the resected intestine showed KS. HIV-1 infection wasconfirmed by Western blot. The CD4 T-cell count was 59/mm3. In conclusion,intussusception by enteric KS may present as the initial AIDS-associated neoplasmin patients with HIV infection.

Case ReportA 31-year-old homosexual man was admitted to our hospitaldue to abdominal pain lasting 2 hours. There was no historyof fever, jaundice, melena or hematochezia. There wasneither prior history of abdominal surgery nor other systemicdisease including HIV infection. Physical examination re-vealed an acutely ill, febrile male with a body temperature of38.5°C. The skin and oral cavity were normal. The abdomenwas flat and bowel sounds increased on auscultation. Therewas diffuse tenderness and rebound pain over the wholeabdomen. Rectal examination revealed no mass orhemorrhoid. There was no external hernia.

Laboratory investigations disclosed a white blood cellcount of 5,000/mm3, with 56% neutrophils, 30% lympho-cytes and hematocrit 31%. Flat abdominal roentgenogramrevealed small bowel ileus in the central abdomen. There was

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Fig. 3. Histopathologic examination of the resected ileal tumor. Lightmicroscopy shows many spindle cells, small anastomotic vascularchannels, and extravasation of red blood cells. (Hematoxylin andeosin, X 400).

no pneumoperitoneum. Abdominal sonography revealed a2.5-cm intraluminal soft tissue mass in the small intestine overthe right lower quadrant of the abdomen (Fig. 1). Computer-ized tomography revealed a 2-cm soft tissue mass in the smallintestine with an intussusception over the same site (Fig. 2).No abnormalities were seen in the liver, spleen or pancreas.There was no retroperitoneal or pelvic lymphadenopathy.

After supportive treatment with intravenous fluid andnasogastric tube decompression with low-pressure suction,exploratory laparotomy was performed, revealing a 4 x 3 x3-cm tumor mass over the ileum 90 cm proximal to theileocecal valve. There were no other abnormal findings in thevisceral organs, nor any visceral or retroperitoneallymphadenopathy. The intussuscepted intestinal segmentwas resected. Pathologic examination of the resected intes-tine showed a KS lesion 3.5 x 2.5 x 0.8 cm in size that waslocated 6.5 cm from one cut end (Fig. 3). Anti-HIV antibodytests using enzyme immunoassay and Western blot were bothpositive. The CD4 T-cell count was 59/mm3. The patientrecovered well and postoperative panendoscopy was normal.

Fig. 1. Abdominal sonogram shows an intraluminal soft tissue mass,2.5 cm in diameter, in the small intestine over the right lowerquadrant.

Fig. 2. Axial computerized tomogram shows an intraluminal softtissue mass, 2 cm in diameter, involving the small intestine and adilated portion of the proximal bowel loop.

The patient refused highly active antiretroviral therapy(HAART) and was discharged on the 13th hospital day.

DiscussionKS is a multisystem neoplastic disease. Skin manifesta-tions are usually seen first. Visceral involvement isfrequently seen, especially in the gastrointestinal tract(38–50%) and lung (34%) [2, 5, 6]. The incidence ofKS with gastrointestinal involvement has been reportedto be as high as 40 to 70% in the presence of cutaneouslesions [2, 7]. Localization of KS is more common inthe upper than in the lower gastrointestinal tract [2, 4].The oropharynx is the most common site of involve-ment [1]. The frequency of lower-gastrointestinal tractKS with cutaneous or lymph node disease is 12% [4].KS involving the gastrointestinal tract without cutane-ous lesions is rare [8, 9]. Zoller et al found that less than5% of AIDS patients with gastrointestinal KS had nocutaneous lesions [7]. Lemlich et al found that the rateof gastrointestinal involvement in AIDS patients with-out KS skin lesions was 8% [10]. Primary gastrointesti-nal KS without cutaneous lesion was the initial and onlyAIDS-defining illness in our patient. Studies have re-ported no difference in CD4 cell count between diffuseKS and KS confined only to the gastrointestinal tract [4,11].

In the early 1980s, KS was the first AIDS-definingillness (primary KS) in approximately 30% of AIDScases [12, 13]. The incidence of KS as the AIDS-defining illness has decreased in the USA [14, 15],Europe [16] and Australia [11, 17], and this decreaseis associated with HAART [18, 19].

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Intestinal intussusception in adults is uncommonand represents less than 15% of reported cases ofintussusception [20]. Only one case of intussusception,occurring in the jejunum, has been previously re-ported in a patient with KS [21]. Most patients withgastrointestinal KS are asymptomatic. Bleeding [22],obstruction [23], appendicitis [24], perforation withperitonitis [25], and persistent gastrointestinal symp-toms [26] have all been reported in gastrointestinal KS,with bleeding being the most common complication[10, 27].

Patients with AIDS are surviving longer with HAARTand are overcoming opportunistic infections morefrequently with antibiotic prophylaxis. Gastrointesti-nal KS should be considered in the differential diagno-sis of acute abdomen in AIDS patients.

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