A 44-year-old man comes to the clinic for evaluation of a "mole." He has a slowly enlarging macule that was first noticed by a sexual partner 6 weeks ago. The lesion has no associated pain or itching, but it has changed in color from pink to violet. On review of systems, he denies fever, night sweats, or urinary symptoms. The patient reports an unintentional weight loss of approximately 8 kg (17.5 lb) over the past year. He was treated for syphilis 2 years ago with long-acting penicillin. Otherwise, his medical history is insignificant. He is not currently taking any medications. The patient has had multiple male sexual partners in the last 20 years and works as a freelance website developer. He does not use tobacco or illicit drugs but drinks alcohol heavily on weekends. Temperature is 37.1 C (98.8 F), blood pressure is 115/70 mm Hg, pulse is 80/min, and respirations are 14/min. The skin lesion is shown in the image below. Which of the following is the most likely cause of this patient's skin lesion?

Question

A 44-year-old man comes to the clinic for evaluation of a "mole."  He has a slowly enlarging macule that was first noticed by a sexual partner 6 weeks ago.  The lesion has no associated pain or itching, but it has changed in color from pink to violet.  On review of systems, he denies fever, night sweats, or urinary symptoms.  The patient reports an unintentional weight loss of approximately 8 kg (17.5 lb) over the past year.  He was treated for syphilis 2 years ago with long-acting penicillin.  Otherwise, his medical history is insignificant.  He is not currently taking any medications.  The patient has had multiple male sexual partners in the last 20 years and works as a freelance website developer.  He does not use tobacco or illicit drugs but drinks alcohol heavily on weekends.  Temperature is 37.1 C (98.8 F), blood pressure is 115/70 mm Hg, pulse is 80/min, and respirations are 14/min.  The skin lesion is shown in the image below.  Which of the following is the most likely cause of this patient's skin lesion?

Quizplus · Accepted Answer

This patient, with an elliptical violaceous skin lesion, has Kaposi sarcoma (KS). KS is a vascular tumor due to co-infection with HIV and human herpesvirus-8, and is most common in men who have sex with men. KS typically occurs in advanced HIV disease with CD4 cell counts <200/mm³, and is considered an AIDS-defining illness. Commonly involved regions include the legs, face, oral cavity, and genitalia, and KS can also be seen in the gastrointestinal tract and lungs. The lesions typically begin as papules, and later develop into plaques or nodules. The color can change from light brown to violet, and patients often have multiple lesions. Early KS may appear similar to purpura, angiomas, hematomas, nevi, or dermatofibromas. The diagnosis is often made clinically, although biopsy is frequently advised for confirmation. KS will often regress if the underlying HIV disease is treated with antiretroviral therapy. However, severe or refractory KS may require systemic or intralesional chemotherapy. (Choice A) Bacillary angiomatosis, caused by Bartonella species, is characterized by friable papules and plaques in immunocompromised patients. It is often associated with fever and other systemic symptoms and may involve the mucosa and visceral organs. Bacillary angiomatosis (Choice B) Cryptococcus species can cause papular skin lesions in immunocompromised patients. However, skin manifestations are usually seen in disseminated infection, along with involvement of the lungs or central nervous system (meningitis). papular skin lesions (Choice D) Human papillomavirus causes verrucous papules (warts) on the skin or mucous membranes. Certain serotypes are associated with squamous cell carcinoma of the skin, cervix, and other mucosal sites. Human papillomavirus (Choice E) Pneumocystis jiroveci causes pneumonia in patients with AIDS who have CD4 cell counts <200/mm³. Although extrapulmonary disease may present as papules and nodules in the ear canal, it is uncommon. (Choice F) Molluscum contagiosum is due to a poxvirus and causes skin-colored umbilicated papules. (Choice G) Secondary syphilis causes diffuse mucocutaneous lesions associated with systemic symptoms beginning 1-3 months after the initial infection. Tertiary gummatous syphilis can occur years after the initial infection, and is characterized by nodular or ulcerating lesions with necrosis and scarring. Secondary syphilis Educational objective: Kaposi sarcoma (KS) is a vascular tumor due to human herpesvirus-8 that typically occurs in advanced HIV disease. Typical lesions appear as violet papules, nodules, or plaques. KS will often regress if the underlying HIV disease is treated with highly active antiretroviral therapy. References: Kaposi's sarcoma in HIV-positive patients: the state of art in the HAART-era. (http://www.ncbi.nlm.nih.gov/pubmed/24065230)

A 44-Year-Old Man Comes to the Clinic for Evaluation of a "Mole