passages.id: PMC-1852096-sec-05__text
passages.type: sec
passages.text: Case Presentation
  The patient is an 80 year old male with diabetes mellitus and hypertension, who at age 74 (March 2001) had received a living non-related donor kidney transplant. At that time he was discharged with a double immunosuppressive therapy consisting of prednisone 20 mg/day and mophetil mycophenolate 1.5 gr/day. No calcineurin inhibitor was administered. His prednisone dose was further decreased to 5 mg/day and mophetil mycophenolate doses sustained. In November 2001 he developed cutaneous purple elevated lesions in his lower limbs that were diagnosed as KS by skin biopsy. He received 19 administrations of vincristine (1 mg) and bleomycin (15 mg) weekly that resulted in flattening and fading of the lesions. Treatment was discontinued for two months, and KS recurred, with pain and edema in both legs.
  On July 2002, with an almost 100% involvement of his lower limbs skin with KS but no visceral involvement he received 50 mg of liposomal-adriamycin. In addition, he was then prescribed valganciclovir 450 mg BID (corrected for creatinine clearance) [7] and three additional administrations of liposomal-adriamycin, up to December 2002. He showed 40% response again with early relapse. On January 2003 the patient developed disseminated herpes zoster, which was treated with IV acyclovir.
  In May 2003 KS progression was observed and received radiotherapy with no benefit Figure 1. In August 2003 he started oral etoposide at 50 mg QD for two weeks followed by two weeks off until May 2004 achieving a very slow 50% response. Tolerance was good and serum creatinine remain stable at around 1,4 mg/dl. Mophetil mycophenolate dose was reduced to 1 g/day and prednisone to 2.5 mg/day.
  Figure 1
  Kaposi's sarcoma progressions after chemotherapy withdrawal, both lower limbs were completely covered with Kaposi's Sarcoma (June 2003).
  On May 2004 the patient requested a second opinion and was prescribed Imatinib 200 mg qd for two weeks followed by 400 mg qd. After four weeks of Imatinib, his health deteriorated rapidly, he developed anasarca, worsening of KS, his serum creatinine increased from 1.4 mg/dl to 2.3 mg/dl and he developed grade 4 granulocytopenia (Figure 2). The patient was hospitalized with fever and was started on IV antibiotics and daily G-CSF for four days after which his WBC count normalized. Two weeks later the creatinine level returned to 1.5 mg/dl. On February 2005 he was started on 30 mg of paclitaxel IV every three weeks. After three courses with no clinical benefit he developed a skin rash that prompted discontinuation.
  Figure 2
  Patient developed anasarca with rapid progression of Kaposi's Sarcoma after four weeks of taking Imatinib (June 2004).
  On April 2005, he was started on Sirolimus 2 mg a day, and after 8 weeks escalated to 4 mg a day. Three weeks later mophetil mycophenolate and prednisone were discontinued. Sustained and significant KS regression was evident after 16 weeks, but he developed a basal cell carcinoma and pneumonia that required hospital admission; Sirolimus dose was lowered to 2 mg a day. Thereafter his clinical course has been satisfactory with continuous and progressive regression of KS lesions (Figure 3). His serum creatinine has remained under 1.6 mg/dl and he has not developed new infectious episodes.
  Figure 3
  Extensive regression of Kaposi Sarcoma after immune-suppression was changed to Sirolimus, (14 months later), he only has hyperpigmented areas at knee levels, skin looks thin and delicate and easily bruised (July 2006).
  