Abstract Respiratory failure remains one of the most common reasons for ICU admission in patients with advanced HIV/AIDS, typically secondary to opportunistic infections. Pulmonary Kaposi Sarcoma (KS) is an uncommon and often fatal cause of respiratory failure, and diagnosis can be easily delayed due to overlapping clinical and radiologic features. We report a case of pulmonary KS complicated by Mycobacterium avium complex (MAC) infection and pulmonary alveolar proteinosis (PAP), resulting in severe ARDS requiring VV-ECMO, with eventual recovery following chemotherapy. A 23-year-old man with recently diagnosed AIDS presented with a three-week history of worsening cough and dyspnea. Initial presentation was pertinent for tachypnea and hypoxia, with diffuse interstitial and nodular infiltrates on imaging. Empiric treatment for Pneumocystis jirovecii pneumonia(PJP) and bacterial infection was initiated, however his respiratory status deteriorated, requiring intubation and ICU admission. Bronchoalveolar lavage was negative for Pneumocystis and malignant cells, while cultures later grew Mycobacterium avium. Chest CT revealed numerous irregular nodules and consolidations throughout both lungs. On day 4, given lack of improvement, a video-assisted thoracoscopic (VATS) lung biopsy was performed, which demonstrated Kaposi Sarcoma and pulmonary alveolar proteinosis, negative for fungi or PJP. On day 9, the patient experienced aspiration with subsequent cardiac arrest, from which he was successfully resuscitated. He developed worsening hypoxemia despite maximal ventilatory support and was placed on veno-venous extracorporeal membrane oxygenation (VV-ECMO). On day 23, following hematologic stabilization and exclusion of tuberculosis, weekly paclitaxel chemotherapy was initiated while on ECMO, along with triple therapy for MAC. His course was further complicated by cytopenias requiring 76 blood products for transfusion support during the prolonged course. Over the following weeks, gradual improvement in oxygenation and lung compliance was observed. He was eventually weaned from ECMO(Day 53), underwent tracheostomy decannulation, and completed 6 weeks of chemotherapy and an intensive pulmonary rehabilitation program. The patient was discharged home off supplemental oxygen and continued on antiretroviral, antimycobacterial, and paclitaxel therapy with sustained recovery. Pulmonary KS rarely presents as fulminant respiratory failure and carries a historically poor prognosis, with median survival of approximately 3 to 10 months. Diagnosis is often delayed due to overlap with opportunistic infections and ARDS-like presentations.This case underscores the potential reversibility of even severe pulmonary KS when early chemotherapy and aggressive supportive measures including ECMO are employed. Early identification and multidisciplinary management of pulmonary Kaposi Sarcoma can lead to meaningful recovery in cases once thought uniformly fatal. This abstract is funded by: None
Thakkar et al. (Fri,) studied this question.