대한흉부영상의학회 Weekly Chest Cases

Case No : 1305 Date 2022-10-24

Courtesy of Min Kyung Jung, Jeong Min Ko, Hyun Jin Park / Department of Radiology, College of Medicine, St. Vincent’s Hospital, The Catholic University of Korea
Age/Sex 52 / M
Chief ComplaintDyspnea for 2 weeks HIV positive

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Figure 2
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Figure 5

Diagnosis With Brief Discussion

Diagnosis: acquired immunodeficiency syndrome (AIDS)–related Kaposi sarcoma
Radiologic Findings: Fig 1. Chest radiograph shows bilateral ill-defined nodular and linear infiltrates with a perihilar and basal distribution. There are bilateral small pleural effusions.

Fig 2. Lung window setting of the chest CT scan shows peribronchovascular and interlobular septal thickening with nodularity in both lower lobes. Small nodular opacities with bilateral and symmetrical perilymphatic and peribronchovascular distribution in both lower lobes.

Fig 3 and 4. Contrast-enhanced mediastinal window setting of chest CT scan shows irregular bronchial wall thickening and enhacement along the both main bronchi. There are peribronchovascular and interlobular septal thickening with enhancement and nodularity in B lungs, especially B lower lobes. There are small enhancing lymph nodes in bilateral mediastinum. There are bilateral small pleural effusions.

Fig 5. Bronchoscopy shows red macular lesions in the distal trachea.

He underwent bronchoscopic biopsy and pathologic result was spindle cell proliferation with vascular space in submucosal layer, consistent with Kaposi sarcoma. Human herpes virus type 8 was positive.

Contrast-enhanced mediastinal window setting of chest CT scan shows multiple small hypodense peripheral portal nodules in liver.
Duodenoscopy shows nodular red to purple involvement of stomach.
Brief Review: Kaposi sarcoma (KS) is a low-grade vascular tumor that typically manifests as one of four variants: classic KS, endemic (African) KS, iatrogenic (organ transplant–related) KS, or acquired immunodeficiency syndrome (AIDS)–related KS. KS is the most common tumor among AIDS patients, affecting a high percentage of these individuals, and is considered to be an AIDS-defining illness. Multiple organs can be involved by AIDS-related KS. KS has been linked with human herpes virus type 8 infection and other cofactors.
Thoracic disease is found in about 45% of patients with cutaneous AIDS-related KS. Manifestations include parenchymal, tracheal, lymphatic, pleural, and chest wall abnormalities. Common clinical symptoms include chronic cough, dyspnea, fever, and hemoptysis. The typical purplish endoscopic appearance of tracheobronchial KS is helpful in developing the differential diagnosis. A characteristic CT finding in AIDS-related KS is the presence of bilateral and symmetric ill-defined nodules in a peribronchovascular distribution (flame-shaped lesions), usually exceeding 1 cm in diameter. Ground-glass opacities may be seen surrounding the nodules (“halo sign”). Other common findings include peribronchovascular and interlobular septal thickening, fissural nodularity, mediastinal adenopathies (eg, axillary, mediastinal, and hilar), and pleural abnormalities (eg, bilateral pleural collections and, rarely, pleural implants).
AIDS-related KS of the liver is the most common intrahepatic neoplasm in patients with AIDS. Baseline CT findings include hypoattenuating nodules and irregular enlargement of the hilum and peripheral portal branches. After the injection of iodine-based contrast material, more hypoattenuating nodular lesions and periportal tissue can be visualized, most of which exhibit enhancement on delayed scans (4 –7-minute delay). Nodular lesions may appear iso- or hyperattenuating on delayed images and may be indistinguishable from multiple hemangiomas.
Gastrointestinal AIDS-related KS compromise is the most common visceral involvement in disseminated disease, being seen in up to 50% of patients. AIDS-related KS can affect any level of the gastrointestinal tract from the oropharynx to the rectum, including the gallbladder. The duodenum is the most frequently affected site. The red-purple endoscopic appearance of lesions is helpful in developing the differential diagnosis, which may include lymphoma, opportunistic infections, hematogenous metastasis, polyps, and Crohn disease. Endoscopic biopsy may be negative because of the submucosal location of the tumor.
References: RadioGraphics 2006; 26:1169 –1185
Keywords

No. of Applicants : 87

▶ Correct Answer : 50/87, 57.5%

- , Japan KYOKO NAGAI
- Showa General Hospital , Japan MASAFUMI KAIUME
- Shiga University of Medical Science , Japan AKITOSHI INOUE
- Hpital du Sacr Coeur , Canada Andrea Ojanguren
- McGill University Health Center , Canada ALEXANDRE SEMIONOV
- CHCB , France LE GUEN RAPHAEL
- NIMS, HYDERABAD , India BHASKAR K
- National Center of Neurology and Psychiatry , Japan MOTO NAKAYA
- , Italy PAOLO BALDASSARI
- Chungbuk National University Hospital , Korea (South) JIYUN KANG
- Vita Hospital , Brazil DIOGO LAGO PINHEIRO
- Other , Korea (South) SEONGSU KANG
- , Korea (South) JIN YOUNG LEE
- Oita University, Faculty of Medicine , Japan FUMITO OKADA
- Seoul Medical Center , Korea (South) HYUK GI HONG
- Osaka University , Japan AKINORI HATA
- , Japan HIKARI FUKUI
- Ajou University Hospital , Korea (South) HAEIN LEE
- Osaka Metropolitan University , Japan HIROTAKA TAKITA
- Shimada General Medical Center , Japan HAYATO NOZAWA
- Ajou University Hospital , Korea (South) HYUNSEUNG LEE
- The University of Tokyo Hospital , Japan TOSHIHIRO FURUTA
- Ajou University Hospital , Korea (South) MINJI KIM
- , India JAHNAVI GADUPTI
- Gifu University Hospital , Japan Yo Kaneko
- , Japan KENTARO KOTANI
- Kyoto University Hospital , Japan YASUHISA KURATA
- Ajou University Hospital , Korea (South) YOU NA KIM
- Osaka Metropolitan University Hospital , Japan SHU MATSUSHITA
- Jichi Medical University, School of Medicine , Japan MITSURU MATSUKI
- University of Tsukuba, Dept of Radiology , Japan MANABU MINAMI
- Eskisehir Sehir Hastanesi , Turkey MURAT SAHIN
- Osaka metropolitan university Hospital , Japan TATSUSHI OURA
- Chonnam National University Hwasun Hospital , Korea (South) JEONG YEOP LEE
- Manipal hospital Hebbal ,Bengaluru , India PRAVIN KUMAR M
- Ulsan University Hospital , Korea (South) SUNGMIN KIM
- Other , Korea (South) KYU-CHONG LEE
- , Japan KENSUKE DOMAE
- Paras hospital, Panchkula , India SHALEEN RANA
- Nishida Hospital , Japan SHOJI OKUDA
- Seoul National University Bundang Hospital , Korea (South) YOONAH DO
- Chonbuk National University Hospital , Korea (South) MINJEE KIM
- Pusan National University Yangsan Hospital , Korea (South) JI HWAN KIM
- Toranomon Hospital , Japan KAORU SUMIDA
- Ichinomiya Nishi Hospital , Japan Takao Kiguchi
- , Japan YUMI MAEHARA
- , Japan YUKI HAYASHI
- , Korea (South) HM PARK
- the first affiliatited hospital of nanjing medical univercity , China HAI XU
- Jiangsu province hospital , China WANGJIAN ZHA

▶ Correct Answer as Differential Diagnosis : 15/87, 17.2%

- Saitama-Sekishinkai Hosptal , Japan MIHOKO YAMAZAKI
- Jichi Medical University Hospital , Japan JUN KANZAWA
- Affilitated Hospital of Jining Medical college , China JIANG SHENG HUA
- Chonnam National University Hwasun Hospital , Korea (South) SEONGWOO CHO
- Tiger Gate Hospital , Japan SHIN-ICHI CHO
- Soonchunhyang University Hospital Bucheon , Korea (South) HYEJOO PARK
- , Japan YUKIKO USUI
- Inje University Pusan Paik Hospital , Korea (South) JIYEON HAN
- Chungbuk National University Hospital , Korea (South) MIHYEON PARK
- , Qatar NABIL SHERIF MAHMOOD
- Dokkyo Medical University , Japan HIROAKI ARAKAWA
- Kyoto University Hospital , Japan SATOSHI IKEDA
- Yonsei University,Severance Hospital , Korea (South) SEO BUM CHO
- Chonnam Hospital , Korea (South) JAEHYUN PARK
- Hanyang University Hospital , Korea (South) SEUNG JIN YOO

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 1305 Date 2022-10-24

Discussion

No. of Applicants : 87