- San Francisco doctors have reported a cluster among gay
men of unusual cases of Kaposi's sarcoma, the cancer-like skin disease
whose disfiguring purple lesions were a terrifying signature of a bygone
era of the AIDS epidemic.
-
- All 15 patients under treatment for the condition are
long-term survivors of HIV whose infections are firmly under control with
antiviral drugs. So far, none of them appears to be in any danger.
-
- The new cases of Kaposi's sarcoma have not been aggressive,
invasive or lethal - the way the disease behaved in patients with uncontrolled
HIV during the 1980s.
-
- Still, the lesions are unsightly, difficult to treat
and raise uncomfortable questions about what weaknesses might lurk in the
immune systems of thousands of aging survivors of the epidemic.
-
- The re-emergence of this classic AIDS illness in these
outwardly healthy patients is an unsettling echo from the past and a warning
that this 26-year-old plague still has the capacity to surprise.
-
- "This could either be the canary in the coal mine,
or it could just be a collection of rare events that will continue to occur
when people are given what appears to be effective treatment," said
Dr. Jeffrey Martin, a San Francisco General Hospital epidemiologist and
Kaposi's sarcoma expert.
-
- Kaposi's sarcoma was one of the first visible manifestations
of the HIV epidemic. At the time, it was popularly known as "gay cancer."
About 80 percent of early AIDS patients suffered from it, and when it migrated
to the lungs, lymph nodes and throat, many died.
-
- With the widespread use of combinations of antiviral
drugs beginning in 1995, however, the lesions disappeared, and AIDS-related
Kaposi's sarcoma has seldom been seen in the United States except among
impoverished patients whose HIV is untreated.
-
- Today, the disease is still rampant in Africa, where
only one in four people who need AIDS drugs to survive has access to them.
"KS is the most common malignancy among adults in sub-Saharan Africa,"
said Martin, who travels to the region frequently.
-
- So it was highly unusual, and a little spooky, when the
KS cases among long-term HIV survivors in San Francisco began to stack
up in the past three years.
-
- "I'm of an age to remember when, if a purple lesion
showed up on your face, it meant you were going to die," said Matt,
a 42-year-old San Francisco man who has controlled his HIV infection since
1995.
-
- Matt, who asked that his last name not be used, said
he was startled three years ago when a pea-sized purple spot appeared on
his waist. Before long, he had a dozen lesions, including two on his face.
"It was extremely scary," he said. "I got something out
of the blue and totally unexpected."
-
- The nodules on his skin were not painful or itchy, but
they were embarrassing. Mostly, they generated fear.
-
- Matt acknowledged that Kaposi's sarcoma bears a stigma
as a visible mark of AIDS that is still difficult to overcome. Treatments
have caused most of the lesions to fade. Some were removed like warts by
freezing with liquid nitrogen; others responded to direct injections of
chemotherapy drugs.
-
- Always conscious about his appearance, Matt said he dreaded
the prospect of Kaposi's sarcoma when he was first diagnosed with HIV,
and was relieved in those early years that he never came down with it.
He was stunned to see the lesions appear so much later. "It was jarring,"
he said. "I never thought I would have to face this."
-
- Although Matt's anxiety eased as time went by, and his
KS remained stable, he could not help reliving some of the darker days
of the AIDS epidemic. "I've had the experience of people saying, 'What's
that on your face?' " he said. "It is like something out of the
movie, 'Philadelphia.' I'd thought those days were over."
-
- Most of the new Kaposi's sarcoma patients are in their
40s and 50s and have been living with HIV for nearly two decades. Their
lives were spared by the introduction of antiviral drug combinations in
the mid-1990s. Their HIV is suppressed below the level of detection in
standard tests, and they have plenty of infection-fighting white blood
cells.
-
- "The normal treatment for KS among HIV patients
is to treat the virus and boost the immune system. But in these patients,
their immune system is already boosted," said Dr. Toby Maurer, chief
of dermatology at San Francisco General Hospital.
-
- Maurer and colleagues revealed a cluster of nine cases
of Kaposi's sarcoma in a brief letter published in the Sept. 27 issue of
the New England Journal of Medicine. The patients described in the report
were diagnosed from November 2004 through January 2006.
-
- The total number of cases has since grown to 15, with
several more suspected but not confirmed, Maurer said. Since she published
her letter in the prestigious medical journal, more reports have come her
way. "Every day, I am getting stories from around the world,"
she said.
-
- These new cases are more of a nuisance than a threat
to life. They resemble the Kaposi's sarcoma cases first described in medical
textbooks in the 19th century. The patches of purple skin - caused by a
proliferation of blood vessel growth - are painless and have not spread
to internal organs. It's a kind of Kaposi's sarcoma that is relatively
common in countries surrounding the Mediterranean, with one exception:
Classic KS is a disease of old men, but the average age of Maurer's patients
is 51.
-
- Columbia University researchers proved in 1994 that Kaposi's
sarcoma is caused by a herpes virus, dubbed HHV-8. Both the rampant AIDS-related
Kaposi's sarcoma, and the more benign Mediterranean variety, are caused
by the same virus. In the case of uncontrolled HIV infection, the Kaposi's
sarcoma virus takes off because the patient's immune system is destroyed.
In the case of the Mediterranean men, their immune system is simply old.
-
- "This is an infection of 70-year-old guys, and I'm
seeing it at 50. What does it mean?" Maurer asked.
-
- "The big question," she added, is that if the
HHV-8 virus can't be controlled, does that mean other things won't be controlled
in these patients, as their immune system ages? That's why we are following
this very closely."
-
- Dr. Marcus Conant was a dermatologist catering to a gay
clientele in the early 1980s when the first cases of deadly Kaposi's sarcoma
began to appear. Since then, he built one of the largest private AIDS practices
in the nation. After the arrival of effective AIDS drugs, KS cases plummeted,
but he has seen about a dozen of these mild cases among patients who have
their HIV under control. None has developed the fulminant Kaposi's sarcoma
that killed so many during the 1980s and early 1990s.
-
- "I believe some other virus, or infection, is stimulating
HHV-8 to replicate," he said.
-
- An eyewitness to the epidemic since its earliest days,
Conant is not alarmed by the new Kaposi's sarcoma cases. "This is
nothing like what we saw 25 years ago," he said.
-
- Kaposi's sarcoma
-
- Frequently asked questions about Kaposi's sarcoma
-
- What is Kaposi's sarcoma?
-
- It is a cancer-like skin disease that is triggered by
a virus, which causes blood vessels to grow out of control. Patients develop
purple spots on their skin.
-
- Is it dangerous?
-
- It can be. Until AIDS drugs became effective in the mid-1990s,
Kaposi's sarcoma was a major killer of people infected with HIV. It is
still the leading malignancy in sub-Saharan Africa, where most people with
AIDS have no access to drugs. But historically, KS was a skin tumor found
mostly in old men in the Mediterranean region. They didn't die of it.
-
- Why did the AIDS drugs help?
-
- The drugs lower the level of HIV in the bloodstream and
boost the number of infection-fighting white blood cells that naturally
control HHV-8, the virus that causes Kaposi's sarcoma.
-
- What's different about these new KS cases?
-
- They are occurring in gay men who have been controlling
their HIV with antiviral drugs for years. It also appears to be a milder
form of Kaposi's sarcoma, like the kind that affected the old men.
-
- Why is this happening?
-
- Doctors are trying to figure that out. It could be that
some other virus is triggering an outbreak of latent HHV-8 infection, much
as stress can trigger a cold sore. It could be that as treated AIDS patients
age, their immune systems weaken faster.
-
- How worrisome is this?
-
- There are only 15 confirmed cases in San Francisco, and
none of these patients appear to be in danger. It is nevertheless unsettling
for something unpredictable to occur among vulnerable AIDS patients, and
it dredges up memories of the terrible toll Kaposi's sarcoma once took.
-
- E-mail Sabin Russell at srussell@sfchronicle.com.
-
- http://sfgate.com/cgi-bin/article.cgi?f=/c/a/2007/10/12/MNEESOFRG.DTL
-
- This article appeared on page A - 1 of the San Francisco Chronicle
-
- Help yourself to FREE treats served up daily at the Messenger
Café. Stop by today!
-
- Alan Cantwell M.D.
- alancantwell@sbcglobal.net
-
- <http://www.ariesrisingpress.com>http://www.ariesrisingpress.com
-
- author of, THE CANCER MICROBE
-
- and FOUR WOMEN AGAINST CANCER
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