Università degli Studi di Siena, Istituto di Reumatologia, Policlinico Le Scotte, Siena 53100, Italy
SIR, We read with great interest the case report by Burnet and McNeil [1], which describes the onset of Kaposi's sarcoma (KS) in a patient with rheumatoid arthritis following an intra-articular corticosteroid injection. To date, iatrogenic KS is considered an unusual, although recognized complication of immunosuppressive therapy, including steroid treatment [24]. However, in rheumatological clinical practice it is very rare for patients to develop such a complication in spite of the large number of patients who receive immunosuppressive therapy. This observation supports the hypothesis that the development of KS may require further ethnic, geographical, genetic or environmental predisposing factors, such as infectious agents [5]. Here we report an additional case of KS in an elderly female patient with a history of long-standing destructive psoriatic arthritis (PsA). The patient, aged 75 yr, had been affected by PsA for approximately 30 yr. In previous years she had been treated with topical steroids, keratolytic agents and non-steroidal anti-inflammatory agents (NSAIDs); in 1995 she had also received a short course of low-dose i.m. methotrexate, which was subsequently withdrawn because of liver toxicity. From 1996 onwards, she had been taking sulphasalazine (2 g daily) and 6-methylprednisolone (4 mg i.m.) with moderate improvement of the arthritis. In December 1996 the patient developed progressively enlarging purple nodules on the left forefoot, followed by similar skin lesions on the scalp, shins and forearms. KS was diagnosed on the basis of the typical histopathological changes found in a skin sample obtained by excision biopsy. Corticosteroids were stopped, and treatment with argon laser photocoagulation was commenced. The treatment proved partially effective. In 2001, the patient was admitted to our clinic complaining of a flare of polyarticular joint pain and swelling affecting the wrists, hands, shoulders and knees. Physical examination revealed swelling of the knees and wrists, diffuse psoriatic plaques, and multiple, widespread nodular purplish lesions, some of which were ulcerating. At that time, the patient was taking only sulphasalazine and NSAIDs, but not steroids, apart from the odd intra-articular triamcinolone acetonide injection. Histological examination of a biopsy specimen from a leg nodule confirmed the diagnosis of KS. Laboratory data showed only markedly increased acute-phase reactants and mild anaemia (haemoglobin 11 g/dl). Serological screening for infectious agents, including HIV and herpesvirus 8, was negative; extensive imaging studies were unremarkable apart from the findings related to the underlying arthropathy. The patient did not consent to receiving specific treatment for KS.
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Notes
Correspondence to: E. Selvi. E-mail: eselvi{at}katamail.com
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