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1/23. AIDS presenting with cutaneous Kaposi's sarcoma and bacillary angiomatosis in the bone marrow mimicking Kaposi's sarcoma.

    Kaposi's sarcoma (KS) and bacillary angiomatosis (BA) may be histologically similar. A precise diagnosis is required because of the different management of these diseases. KS or BA involving bone marrow is rare in patients with and without acquired immune deficiency syndrome (AIDS). We report the case of a 40-year-old human immunodeficiency virus (HIV)-positive homosexual male who presented with small KS lesions in the skin and BA in the bone marrow that histologically were similar. Laboratory evaluation revealed anemia and thrombocytopenia; CD4 count was 103/mm3, and the viral load was 750,000 hiv-1 mRNA copies per milliliter in plasma. bartonella henselae, the etiologic agent of BA, was isolated from a blood culture. dna sequences of human herpesvirus-8 (HHV-8), the putative etiologic agent of KS, were identified by polymerase chain reaction (PCR) in skin and bone marrow specimens, but antibody anti-HHV-8-encoded protein ORF73, localized signals only in the skin-KS lesion. The patient received clarithromycin and cefotetan for the BA, and antiretroviral therapy for the HIV infection. The skin lesions gradually regressed, the hiv-1 mRNA copy number decreased to less than 400 per milliliter and the cd4 lymphocyte count increased to 665/mm3. In conclusion, vascular lesions of BA and KS may be clinically and histologically similar, both may be associated with advanced AIDS, and an accurate diagnosis is required because of their different management.
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ranking = 1
keywords = angiomatosis
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2/23. Upper gastrointestinal bacillary angiomatosis causing hematemesis: a case report.

    A 38-year-old HIV-positive woman presented with massive hematemesis on initial admission to hospital. endoscopy revealed ulcerated nodular lesions in the esophagus, stomach, and duodenum. The clinical impression was of Kaposi's sarcoma. The stomach was biopsied when the patient re-presented, and another endoscopy was performed. The biopsy showed mucosal ulceration with a proliferation of vascular channels associated with neutrophils and clumps of purplish, granular bacterial colonies, which were highlighted by a Warthin-Starry stain. The histopathological features were typical of bacillary angiomatosis. This case highlights bacillary angiomatosis involving the gastrointestinal tract at multiple sites, the cause of massive upper gastrointestinal hemorrhage that was the initial presentation of an HIV-positive patient, and the occurrence of visceral bacillary angiomatosis in the absence of cutaneous lesions.
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ranking = 1.4
keywords = angiomatosis
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3/23. Clinical vignette in antiretroviral therapy: jaundice.

    HIV caregivers face many challenges following initiation of ART. The development of jaundice is uncommon but worrisome. In this case, two distinct and contrasting episodes of jaundice were observed. In the first instance, isolated elevation of the indirect bilirubin without elevation of the alkaline phosphatase was noted. The normal PT and serum aminotransferase levels indicate the absence of intrinsic liver dysfunction. Elevations in the indirect bilirubin may result from either impaired uptake/conjugation or excess production. The latter, usually from acquired hemolysis, may be a complication of an occult NHL. A work-up for this AIDS-related malignancy was not initiated since the caregivers recognized jaundice as a complication of IDV, which inhibits UDP-glucuronyl transferase and produces a Gilbert's-like syndrome. physicians can expect to encounter this syndrome even more frequently with ATV. Experienced patients given RTV-boosted ATV have experienced elevations of unconjugated hyper-bilirubinemia in up to 45 percent of cases in clinical trials. However, such elevations do not reflect liver dysfunction and symptomatic jaundice requiring dosage reduction that occurred infrequently (7 to 8 percent of study patients). counseling patients about this syndrome may promote adherence and prevent self-directed interruptions of ATV that compromise efficacy. The second case of jaundice provides a more formidable diagnostic challenge. The triad of LFT abnormalities (mild elevation of aminotransferases, normal PT, and marked cholestatic jaundice) implies an acute process that is mildly toxic to hepatocytes without affecting their synthetic function. The subacute nature of the patient's cholestatic jaundice suggests either intrahepatic infiltrative disease of the liver or extrahepatic obstruction of the biliary tree, most likely due to the patient's relatively modest level of pain and lack of fever. Despite LFT abnormalities occurring 17 months after a switch in his ART, cumulative drug-related toxicities must still be considered. ritonavir can produce significant elevations in the AST/ALT, especially with pre-existing chronic liver disease as with hepatitis c virus coinfection. The NRTIs can produce hepatic steatosis, a result of mitochondrial toxicity and impaired fatty acid oxidation. However, jaundice and cholestasis are not typical of the latter syndrome. With a negative contrast CT that excludes parenchymal liver disease, investigation of the biliary tree to assess the presence of AIDS-related cholangitis was the next step. Performing a sphincterotomy or stent placement, and obtaining brushings or biopsy specimens to determine the extent of extrahepatic obstruction may help define a pathogen and be life-saving. The negative results of the ERCP justify the final diagnostic step, a liver biopsy to evaluate microscopic infiltrative disease that might not have been detected on contrast abdominal CT. Examples might include granulomatous disease (MAC), fungal etiologies (histoplasmosis), carcinomatosis (lymphoma, hepatoma, cholangiocarcinoma), and microvascular disease (bacillary angiomatosis). The failure to observe granulomatous inflammation in the liver does not exclude MAC infection, as MAC may involve other peri-aortic or mesenteric lymph nodes. This form of iris is unlikely given the abdominal CT findings, lack of systemic complaints, and extended persistence of liver aminotransferases. The nonspecific results of the liver biopsy are a common outcome in advanced AIDS patients with elevated alkaline phosphatase levels. Despite not having identified a pathogen, the biopsy establishes chronic liver disease and prompts re-evaluation and change of treatment to NFV. The subsequent normalization of the patient's aminotransferase levels suggests a prior adverse effect of LPV/r in the setting of unexplained, chronic liver disease. Most importantly, this case highlights the importance of HIV caregivers to review ART for safety when noting chronic liver dysfunction. patients need to be counseled to minimize acetaminophen use, to consume alcohol in moderation, and to avoid behavior with risk for hepatitis c. Finally, all HIV patients should receive appropriate vaccination against hepatitis a and B if serology shows lack of protective immunity.
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ranking = 0.2
keywords = angiomatosis
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4/23. Polypoid endobronchial lesions. A manifestation of bacillary angiomatosis.

    Polypoid endobronchial lesions occurred in a patient with acquired immunodeficiency syndrome (AIDS) with recent fever, skin lesions, lymphadenopathy, lung infiltrates, and pleural effusions. His condition improved with antimicrobials and vincristine. After therapy ceased, skin lesions recurred and gastroesophageal mucosal lesions developed. Bacillary angiomatosis was identified during retrospective analysis of skin and endobronchial biopsy specimens.
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ranking = 1
keywords = angiomatosis
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5/23. Rochalimaea henselae causes bacillary angiomatosis and peliosis hepatis.

    BACKGROUND--Recent studies have demonstrated that a newly described agent of persistent bacteremia, Rochalimaea henselae, and the agent of bacillary angiomatosis are both closely related to Rochalimaea quintana. Bacillary peliosis hepatis seemed likely to have the same etiologic agent as bacillary angiomatosis. We sought these pathologic changes in patients from whom R henselae was cultivated. methods--For two patients whose histopathologic findings we reviewed, additional light and electron microscopy were performed. Their bacterial isolates were compared by electrophoretic patterns of outer membrane proteins, restriction endonuclease digestion patterns of dna, and reaction with murine antiserum. RESULTS--A previously reported human immunodeficiency virus-infected man with persistent bacteremia due to R henselae was found to have bacillary peliosis hepatis. Rochalimaea henselae was also isolated from the spleen of a woman receiving immunosuppressive therapy after allogeneic renal transplantation. She had developed fever, liver and spleen nodules, and periaortic lymphadenopathy. Bacillary peliosis of her liver and spleen, as well as bacillary angiomatosis of liver, spleen, and a lymph node, were found. The bacterial isolates had comparable electrophoretic patterns of outer membrane proteins and of restriction endonuclease-digested dna, which differed from the respective patterns of R quintana. Murine antisera raised to the first isolate reacted strongly with the second by means of immunoblot and immunofluorescence techniques, while reacting only weakly with R quintana. CONCLUSION--Rochalimaea henselae, recently recognized to cause persistent fever and bacteremia in immunocompetent and immunocompromised persons, also causes bacillary angiomatosis and parenchymal bacillary peliosis.
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ranking = 1.6
keywords = angiomatosis
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6/23. Bacillary angiomatosis in a pregnant patient with acquired immunodeficiency syndrome.

    Bacillary angiomatosis, a cutaneous lesion newly recognized to affect patients with AIDS, may resemble Kaposi sarcoma. It is presumed to be an infectious process caused by the gram-negative bacilli associated with cat-scratch fever. We present a case of bacillary angiomatosis in a pregnant AIDS patient.
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ranking = 1.2
keywords = angiomatosis
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7/23. Bacillary epithelioid angiomatosis involving the liver, spleen, and skin in an AIDS patient with concurrent Kaposi's sarcoma.

    The simultaneous findings of bacillary epithelioid angiomatosis and Kaposi's sarcoma of the skin with visceral hepatosplenic bacillary epithelioid angiomatosis is reported in a patient with acquired immune deficiency syndrome. liver biopsy showed periportal peliotic spindle cell foci that initially were misinterpreted as Kaposi's sarcoma. After antibiotic therapy induced rapid clinical improvement, repeated liver biopsy showed resolution of the previously noted lesions. Although the violaceous skin lesions all appeared similar clinically, some resolved completely and some progressed. One of the latter was biopsied and had the histologic features of Kaposi's sarcoma. The differential diagnosis is discussed.
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ranking = 1.2
keywords = angiomatosis
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8/23. Hepatic peliosis (bacillary angiomatosis) in AIDS: CT findings.

    patients with acquired immunodeficiency syndrome are at risk of developing opportunistic infections and aggressive tumors. Computed tomographic examination is the usual method of evaluating the abdomen and pelvis in these patients. Although this technique is reasonably sensitive in detecting pathology, findings are often nonspecific. A case of hepatic peliosis (bacillary angiomatosis) in a patient with acquired immunodeficiency syndrome is presented.
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ranking = 1
keywords = angiomatosis
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9/23. Bacillary angiomatosis associated with pseudoepitheliomatous hyperplasia.

    Bacillary angiomatosis is an opportunistic bacterial infection caused by either bartonella henselae or B. quintana. The classic histologic presentation of bacillary angiomatosis involves three components: a lobular proliferation of capillaries with enlarged endothelial cells, neutrophilic debris, and clumps of finely granular material identified as bacteria with staining techniques. Pseudoepitheliomatous hyperplasia is a histologic reaction pattern characterized by epithelial proliferation in response to a variety of stimuli, including mycobacterial, fungal, and bacterial infections. We describe a case of bacillary angiomatosis associated with pseudoepitheliomatous hyperplasia in an immunocompromised patient with acquired immunodeficiency syndrome. Histologic examination of a finger lesion demonstrated a capillary proliferation with neutrophilic debris and characteristic amorphous granular deposits. Warthin-Starry and Giemsa staining revealed clumps of coccobacilli. Cervical lymph node tissue also revealed organisms identified as Bartonella with PCR techniques. Stains and cultures for acid fast bacilli, fungus, and bacteria were negative. To our knowledge, there has been only one other report of bacillary angiomatosis presenting with pseudoepitheliomatous hyperplasia. We conclude that the differential diagnosis of entities associated with pseudoepitheliomatous hyperplasia should be expanded to include bacillary angiomatosis.
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ranking = 1.8
keywords = angiomatosis
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10/23. Bacillary angiomatosis presenting as a soft-tissue tumor without skin involvement.

    A patient with human immunodeficiency virus infection presented with a soft-tissue mass which histologically and clinically mimicked an angiosarcoma. Ultrastructural study, however, revealed bacteria identical to those seen in cutaneous bacillary angiomatosis, but the patient had no skin lesions. To our knowledge, this represents the first report of soft tissue involvement by bacillary angiomatosis without the presence of skin lesions.
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ranking = 1.2
keywords = angiomatosis
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