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Marc van Opijnen

Cristiana Santos

On the concept of relevance in legal information retrieval

Pamela P. Bailey

Marylou M. Dryer

John P. Piper

Sajjad Ahmad

CASE REPORT Open Access
Chronic cough conundrum: a case report
of a new diagnosis of HIV and pulmonary
Kaposi’s sarcoma
Pamela P. Bailey1, Marylou M. Dryer1*, John P. Piper2 and Sajjad Ahmad3
Abstract
Background: When evaluating a common complaint such as cough, clinicians should rely on a patient’s history and
physical to guide them, but also not diverge from guidelines in screening and testing lest certain diagnoses be overlooked.
Case Presentation: A 44 year old Hispanic male presented to a pulmonologist’s office after failing multiple courses of
antibiotics for chronic cough, now six months in duration. He described intermittent scant hemoptysis and an evanescent
migratory non-pruritic rash occasionally noted on his trunk or limbs. Due to financial concerns, the patient initially agreed
only to limited testing. Eventually bronchoscopy was pursued, but results were pending when the patient presented to the
emergency room with worsening dyspnea, blood-tinged sputum and weight loss. A diagnosis of Kaposi’s sarcoma (KS) of
the lung was confirmed by histopathologic staining and HIV/AIDS was confirmed (HIV1 PCR 70,900 copies/mL, CD4 count
26 cells/mm3). He had repeatedly denied HIV risk factors to all providers, but once the diagnosis was established, he
confirmed sexual promiscuity prior to his marriage greater than 10 years ago. He was started on HAART before initiating
therapy for his KS due to concern for immune reconstitution syndrome worsening his pulmonary status.
Conclusion: Pulmonary Kaposi’s sarcoma is an infrequent diagnosis, yet risk is significantly greater for those with
HIV infection. Diagnosis is difficult, with both symptoms and radiographic findings being nonspecific and not
distinctly different from the appearance of pulmonary opportunistic infections. Without treatment, patients with
pulmonary KS have median survival of months, but with chemotherapy and HAART they may achieve relief from
symptoms and improve survival.
Following recommended screening guidelines and furthering diagnostic evaluation for persistently symptomatic
patients are key to uncovering potentially fatal disease even for patients whose symptoms may seem as common
and benign as an irritating cough.
Keywords: Kaposi’s sarcoma, HIV, Cough
Background
Cough is an incredibly common complaint. Clinicians
should rely on a patient’s history and physical to guide
them, but also not diverge from guidelines in screening
and testing lest certain tests be overlooked which may
reveal a rare cause.
Case Presentation
A 44 year old Hispanic male was referred to a pulmonol-
ogist’s office after failing multiple courses of antibiotics
for chronic cough, now 6 months in duration. He de-
scribed intermittent scant hemoptysis and an evanescent
migratory rash that was non-pruritic occasionally noted
on his trunk or limbs (Fig. 1). His physical exam was
otherwise unremarkable, including no adventitious lung
sounds. Due to financial concerns, the patient initially
agreed only to basic laboratory testing and imaging
which was nonspecific (Fig. 2). His initial white blood
cell count was 4.7 cells/nL, hemoglobin 13.9 grams/dL,
platelet 209 cells/nL; his initial chest x-ray showed bilat-
eral hazy nodular opacities. Eventually bronchoscopy
was pursued, which was also unrevealing. No lesions
were appreciated throughout the examined upper airway
and lungs. Pathologic results and cultures were still
* Correspondence: MDryer@ChristianaCare.org
14755 Ogletown-Stanton Road, Suite 2E70, Newark, DE 19718, USA
Full list of author information is available at the end of the article
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Bailey et al. BMC Pulmonary Medicine  (2017) 17:52 
DOI 10.1186/s12890-017-0395-5
pending when the patient presented to the emergency
room with worsening dyspnea, blood-tinged sputum and
weight loss. A diagnosis of Kaposi’s sarcoma (KS) of the
lung was confirmed by histopathologic staining and
HIV/AIDS was confirmed (HIV1 PCR 70,900 copies per
mL, CD4 count 26 cells/mm3). He had repeatedly denied
HIV risk factors to all providers, but once the diagnosis
was confirmed, he reported sexual promiscuity prior to
his marriage greater than 10 years ago. He was started
on HAART before initiating therapy for his KS due to
concern for immune reconstitution syndrome worsening
his pulmonary status. He subsequently initiated chemo-
therapy for his KS and was maintaining overall good
health.
Discussion
Kaposi’s sarcoma is an uncommon diagnosis, yet risk of
KS is 10,000 times greater among those with HIV infec-
tion [1]. In the United States between 1980 and 2007,
there were an estimated 83,252 cases of KS for which
AIDS was a contributing factor in 82% of cases.
Incidence of KS peaked between 1990 and 1995 with
subsequent decline after the introduction of HAART in
1996 [2, 3] since HHV8 (human herpesvirus 8, or Kapo-
si’s sarcoma associated-herpes virus) which causes KS
can be better controlled with a stronger immune system.
Especially in the absence of characteristic skin and
mucosal findings, diagnosis of KS may be hindered by
nonspecific symptoms and radiographic findings making
it difficult to distinguish from opportunistic infections.
The disease is commonly associated with a violaceous or
erythematous eruption that is generally papular or plaque-
like on the skin and mucous membranes as originally
described by the dermatologist after which Kaposi’s sar-
coma is named [4]. In retrospect, presence of a rash in our
patient is suspicious for possible association to his KS
diagnosis, but was not classical in appearance and was not
later able to be biopsied since it was transient. His rash is
more likely to have been directly related to his HIV
disease as an idiopathic pruritus has been reported with
higher prevalence in patients with viral loads higher than
55,000 copies/mL [5].
Because pulmonary KS tends to progress from the sube-
pithelial layer to invade the mucosal surfaces, broncho-
scopic inspection is considered to be a highly sensitive
method for diagnosis [6, 7]. As an example, in Pozniak’s
cohort in Africa in 1992, only 1 patient of 47 with con-
firmed KS has a normal bronchoscopy; the others had the
expected reddish, flat nodules [8]. The traditional endo-
bronchial lesions in KS are maculopapular, reddish-purple
in color, concentrated at airway bifurcations and parallel
to the tracheal rings though can be seen throughout the
tracheobronchial tree [8, 9]. These are vascular lesions
making it difficult to weigh the risks and benefits of per-
forming a biopsy which carries an approximate 30% risk
for clinically significant hemorrhage [6, 7]. Additionally,
the ability bronchoscopic biopsies to impact diagnosis is
relatively low because of patchy submucosal involvement
with diagnostic yield ranging from 7 to 60% [6, 8–10].
Once again, despite abnormal bronchoscopy in Pozniak’s
cohort, only 2 of 29 biopsies showed KS [8]. Yet, despite
these commonly reported findings and nonspecific bilat-
eral hazy nodular opacities on his chest x-ray (Fig. 2), our
patient did not have any characteristic lesions on exam or
Fig. 1 Evanescent migratory non-pruritic rash in patient found to
have new diagnosis of HIV/AIDS and Kaposi’s Sarcoma
Fig. 2 Upright AP Chest x-ray with bilateral, diffuse, airspace opacities
was read as consistent with multilobar pneumonia possibly due to TB,
MAI, aspergillosis or recurrent aspiration. The patient was ultimately
determined to have pulmonary Kaposi’s sarcoma
Bailey et al. BMC Pulmonary Medicine  (2017) 17:52 Page 2 of 4
bronchoscopy. The entire examined tracheobronchial tree
was free of lesions and, despite multiple biopsies having
been taken, the patient did not have any significant
bleeding.
Although our patient did not present with classic skin
or mucosal lesions, he did have lymphopenia which is
commonly associated with the KS [11, 12]. In the emer-
gency department, his white blood cell count was mea-
sured as normal at 4.7 cells/nL (normal range 3.9–10.6
cells/nL) and had a slight neutrophil predominance of
69.4% (normal range 50–60%) but did also demonstrate
lymphopenia with an automated count of 16.5% (normal
range 25–40%). Records from his prior limited evaluation
were unavailable for review or comparison to determine
the duration of this finding. Reduced leukocyte and
lymphocyte counts are associated with advanced stages of
KS [12], but case reports of patients with KS who did not
demonstrate typical immunologic deficiencies have also
been made [13].
As a 44 year old man in America, our patient should
have undergone routine screening for HIV which may
have prevented delay in his diagnosis. In 2013, the CDC
estimated that 1.2 million persons in the US are living
with HIV and approximately 13%, or 1 in 8 individuals,
didn’t know they had HIV. CDC guidelines advocate for
routine HIV screening as a normal part of general med-
ical practice for all patients aged 13–64 years unless they
opt out of testing. The CDC also reports that voluntary
HIV screening is cost-effective even in settings where
HIV prevalence is low. In fact, the CDC advocates for
routine HIV testing to reduce the stigmas associated
with testing due to risk behaviors; many people do not
perceive themselves at risk or do not disclose their risky
behaviors to clinicians [14]. This patient had denied risk
factors multiple times and it was not until the KS diag-
nosis was confirmed and the HIV test was positive that
he was willing to discuss high risk sexual behaviors
which had reportedly occurred more than 10 years prior.
Identification of HIV infection and AIDS-defining KS
disease is meaningful for affected patients since the 5-
year survival rate has improved from an estimated 10%
in the pre-HAART era to approximately 72% with treat-
ment including chemotherapy and HAART [15].
Conclusion
Pulmonary KS is an uncommon diagnosis, though it pre-
sents with common symptoms of dyspnea and cough,
occasionally with hemoptysis. Without treatment, patients
with pulmonary KS have median survival of months, but
with chemotherapy and HAART, they may achieve relief
from symptoms and improve survival. Screening guide-
lines should be followed and diagnostic evaluation pur-
sued for persistently symptomatic patients, even if their
symptoms may seem as common as a cough.
Abbreviations
AIDS: Acquired immunodeficiency syndrome; HHV8: Human herpesvirus 8;
HIV: Human immunodeficiency virus; KS: Kaposi’s sarcoma.
Acknowledgements
Not applicable.
Funding
Not applicable as no funds were procured or used for the purpose of any
research or manuscript writing related to this case report.
Availability of data and materials
Data sharing is not applicable to this article as no datasets were generated
or analyzed.
Authors’ contributions
All authors participated in the care of this patient. PB drafted the text and
completed research for supporting and background data. MD contributed in
writing and editing the manuscript. JP and SA were attending physicians
caring for this patient and helped to guide diagnosis and treatment which
also allowed them to critically evaluate the manuscript. All authors read and
approved the final manuscript.
Authors’ information
PB and MD are resident physicians in training; JP and SA are attending
specialist physicians who dedicate their time to mentoring trainees.
Competing interests
The authors declare that they have no competing interests.
Consent for publication
Written informed consent for publication of their clinical details and/or
clinical images was obtained from the patient. A copy of the consent form
is available for review by the Editor of the journal.
Ethics approval and consent to participate
Not applicable.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
14755 Ogletown-Stanton Road, Suite 2E70, Newark, DE 19718, USA. 2Omega
Professional Center, C-78-80 Omega Drive, Newark DE 19713, USA. 34745
Ogletown-Stanton Road, MAP 1, Suite 220, Newark, DE 19713, USA.
Received: 3 December 2016 Accepted: 14 March 2017
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with AIDS, 1980–2007. JAMA. 2011;305(14):1450–9.
3. Engels EA, et al. Cancer risk in people infected with human
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highly active antiretroviral therapy: An institutional urban clinic experience.
J Am Acad Dermatology. 2006;54(Issue 4):581–8.
6. Friedland GH, et al. Case 29–2013: A 32-year-old HIV-Positive African Man
with Dyspnea and Skin Lesions. NEJM. 2013;369(12):1152–61.
7. Yoo DJ, et al. Clinical and bronchoscopic findings in Ugandans with
pulmonary Kaposi’s sarcoma. Korean J Intern Med. 2005;20:290–4.
8. Pozniak AL, et al. Pulmonary Kaposi’s sarcoma in Africa. Thorax. 1992;47:730–3.
9. Pitchenik AE, et al. Kaposi’s sarcoma of the tracheobronchial tree: clinical,
bronchoscopic, and pathologic features. Chest. 1985;87:122.
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10. Aboulafia DM. The epidemiologic, pathologic, and clinical features of AIDS-
associated pulmonary Kaposi’s sarcoma. Chest. 2000;177:1128–45.
11. Santelli G et al. Urinary neopterin and immunological features in patients
with Kaposi’s sarcoma. Eur J Cancer Clin Oncol. 1988;241391–1396
12. Stratigos AJ, et al. Association of Clinical Progression in Classic Kaposi’s
Sarcoma With Reduction of Peripheral B Lymphocytes and Partial Increase
in Serum Immune Activation Markers. Arch Dermatol. 2005;141(11):1421–6.
13. Ballard HS. Disseminated Kaposi’s sarcoma without lymphocyte
abnormalities. Arch Intern Med. 1985;145(3):547.
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Bailey et al. BMC Pulmonary Medicine  (2017) 17:52 Page 4 of 4


Chronic cough conundrum: a case report of a new diagnosis of HIV and pulmonary Kaposi’s sarcoma

Reforms in pedagogy and the Confucian tradition: looking below the surface

Anirudh Damughatla

Brian Raterman

Orlando P Simonetti

Travis Sharkey-Toppen

Ning Jin

Richard D White

Arunark Kolipaka

POSTER PRESENTATION Open Access
MR elastography as a method to estimate aortic
stiffness and its comparison against MR based
pulse wave velocity measurement
Anirudh Damughatla1*, Brian Raterman2, Orlando P Simonetti2,3, Travis Sharkey-Toppen3, Ning Jin4,
Richard D White2, Arunark Kolipaka2,3
From 16th Annual SCMR Scientific Sessions
San Francisco, CA, USA. 31 January - 3 February 2013
Background
Arterial (aortic) stiffness is a well-recognized pathophysio-
logical change that plays a significant role in the determi-
nation of risk factors for various cardiovascular diseases
[1]. Measurement of arterial stiffness using pulse wave
velocity (PWV) is the gold standard among non-invasive
modalities. Recently, a novel non-invasive MRI based tech-
nique known as magnetic resonance elastography (MRE)
was developed to determine the stiffness of the aorta[2].
The aim of the study is to compare the abdominal aortic
stiffness obtained using MRI based PWV stiffness mea-
surements against MRE based stiffness measurements.
1Biomedical Engineering, The Ohio State University, Columbus, OH, USA
Full list of author information is available at the end of the article
Figure 1 Healthy Volunteer. A: Sagittal magnitude image with contour (red line) delineating abdominal aorta. B-E: Snap shot of four phases of
propagating waves. F: The stiffness map from x, y, and z encoding directions with a mean stiffness of 5.5 kPa.
Damughatla et al. Journal of Cardiovascular Magnetic
Resonance 2013, 15(Suppl 1):P240
http://www.jcmr-online.com/content/15/S1/P240
© 2013 Damughatla et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Methods
In-vivo aortic MRE and MRI was performed on 8 healthy
volunteers (Ages 18-35yrs). All imaging was performed
using a 3T-MRI Scanner (Tim-Trio, Siemens Healthcare,
Germany). The volunteers were positioned in the supine
position and placed head first in the scanner. 60Hz
mechanical waves were introduced in to the aorta using a
pneumatic diver[2]. A GRE-MRE and phase contrast
(PC)-MRI sequences were performed to obtain wave and
velocity data on a sagittal slice of the aorta. The imaging
parameters for MRE included: TE/TR=21.3/25ms, matrix
=128x64, FOV=40cm, a =16, and a motion encoding gradi-
ent of 60Hz was applied separately in the x, y, and z direc-
tion to encode motion. The imaging parameters for the
PC-MRI included: TE/TR=2.1/9.15ms, venc=150,175cm/s;
matrix=192x144, FOV=30x40cm2, a =15, #cardiac
phases=128. The sagittal images were masked to obtain the
major portion of the aorta for both MRE and PC-MRI data
analysis. Then, MRE wave images were analyzed using
MRE-Lab (Mayo Clinic Rochester, MN) to obtain the stiff-
ness of the aorta[3]. PC-MRI phase images were analyzed
using in house custom built software in Matlab (Math-
works, Natic, MA) to obtain the PWV measurements, and
the stiffness was calculated by using Moens-Korteweg
equation[4].
Results
Figure 1A-E shows the sagittal magnitude image with the
contours used for segmenting the abdominal aorta and
corresponding snap shots of wave propagation in one of
the volunteers. Figure 1F shows the weighted stiffness map
from 3 encoding directions with a mean stiffness value of
5.5±1.3kPa. Figure 2 shows the plot of stiffness values
obtained using MRE and PWV Vs. age indicating no trend
in this data set. Furthermore, the MRE stiffness (range 4-
6.7kPa) and PWV (range 4.2-5.2m/s) values obtained from
all volunteers were in the normal range[2,5].
Conclusions
This study demonstrated the feasibility of comparing
MRE based stiffness estimates and PWV based stiffness
estimates in the same imaging plane of the aorta.
Funding
Author details
1Biomedical Engineering, The Ohio State University, Columbus, OH, USA.
2Radiology, The Ohio State University Wexner Medical Center, Columbus,
OH, USA. 3Internal Medicine, The Ohio State University Wexner Medical
Center, Columbus, OH, USA. 4Siemens Medical Solutions Inc., Columbus, OH,
USA.
Published: 30 January 2013
References
1. Agabiti-Rosei, et al:. Vasc Health Risk Manag 2009, 5:353-60.
2. Kolipaka A, et al:. JMRI 2012, 35(3):582-86.
3. Manduca A, et al:. Med Image Anal 2001, 5(4):237-54.
4. J. of Cardiovasc. Trans. Res 2012, 5:243-255.
5. Ibrahim, et al:. J Cardiovasc Magn Reson 2010, 12(1):26.
doi:10.1186/1532-429X-15-S1-P240
Cite this article as: Damughatla et al.: MR elastography as a method to
estimate aortic stiffness and its comparison against MR based pulse
wave velocity measurement. Journal of Cardiovascular Magnetic Resonance
2013 15(Suppl 1):P240.
Figure 2 Plot of shear stiffness obtained using MRE and PWV as a function of age.
Damughatla et al. Journal of Cardiovascular Magnetic
Resonance 2013, 15(Suppl 1):P240
http://www.jcmr-online.com/content/15/S1/P240
Page 2 of 2


MR elastography as a method to estimate aortic stiffness and its comparison against MR based pulse wave velocity measurement

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