Colonic Kaposi's sarcoma as the first clinical manifestation of undiagnosed HIV.

A 52-year-old male, without significant past medical history, is referred for new onset constipation, hematochezia and significant weight loss. Blood tests were unremarkable. A colonoscopy was performed, showing reddish, hematocystic and friable mucosa in a circumferential pattern in the rectum, with similar patches throughout the whole colon, one of them infiltrating the ileocecal valve. Biopsies were obtained and revealed spindle cell proliferation immunoreactive for CD34 and herpesvirus 8 (HHV-8), compatible with Kaposi's sarcoma (KS). HIV serologies were subsequently done, with a positive result, the patient then reporting previous heterosexual unprotected sexual activities. He was started on highly active antiretroviral therapy (HAART) and chemotherapy with liposomal doxorubicin, with a favorable outcome to this date. KS is a low-grade tumor of the vascular endothelium that requires infection with HHV-8. HIV-related KS is more commonly diagnosed in homosexual males with uncontrolled HIV infection and is associated with a variable clinical course. The gastrointestinal tract is involved in up to 51% of patients, but since the majority is clinically silent (70%), visceral involvement is probably underestimated. The treatment goal is symptomatic relief, and may range from HAART alone to a combination with systemic chemotherapy, depending on disease extent. We present this case given its endoscopic exuberance, with biopsies showing an HIV-defining condition, in a patient unaware of his diagnosis.

Case of acute hepatitis E with concomitant signs of autoimmunity.

Sporadic cases of acute viral hepatitis E have been described in developed countries, despite the more common occurrence in endemic areas and developing countries. We present the case of a 58 years old Portuguese female, with no epidemiological relevant factors, admitted with acute hepatitis with positive anti-nuclear antibodies, anti-smooth muscle antibody and high serum gamma globulin (> 1.5 fold increase). Serologies for hepatitis A virus, hepatitis B virus, hepatitis C virus, Epstein-Barr virus, cytomegalovirus, hereditary sensory neuropathy and varicella zoster virus were negative. Liver biopsy histology revealed changes compatible with autoimmune hepatitis. Prednisolone and azathioprine was started. She tested positive for immunoglobulin M anti hepatitis E virus (HEV) with detectable viremia by reverse transcription polymerase chain reaction (RT-PCR) technique. HEV-RNA was confirmed through RT-PCR in a liver specimen, establishing the diagnosis of acute hepatitis E. Immunosuppression was stopped. She clinically improved, with resolution of laboratory abnormalities. Therefore, we confirmed acute hepatitis E as the diagnosis. We review the literature to elucidate about HEV infection and its autoimmune effects.