Pulmonary Kaposi Sarcoma in Advanced HIV With Flame-Like Opacities on Chest CT

October 6, 2026

Annals Of Internal Medicine: Clinical Cases

Overview

A 61-year-old man with advanced HIV, progressive dyspnea, productive cough, and violaceous skin lesions had bilateral flame-shaped peri-bronchovascular opacities on chest CT. An initial scant biopsy suggested adenocarcinoma but was discordant with the clinical and imaging findings; repeat sampling demonstrated HHV-8 latent nuclear antigen-1 positivity and confirmed pulmonary Kaposi sarcoma (KS).

Background

Pulmonary KS is a visceral manifestation of KS in people with HIV and may present with respiratory symptoms and characteristic peri-bronchovascular abnormalities on CT. Flame-shaped opacities are not specific to KS and can also occur with opportunistic infections, including Pneumocystis jirovecii pneumonia, invasive fungal infection, and mycobacterial infection. In this case, concurrent Mycobacterium avium complex and Cryptococcus neoformans infections were treated, adding diagnostic context. Histopathologic confirmation with HHV-8 immunohistochemistry established the diagnosis after the initial tissue-limited biopsy was inconclusive.

Data Highlights

Case feature	Finding
Age and HIV status	61 years; advanced HIV, CD4 nadir below 50 cells/µL
Presentation	Progressive dyspnea, productive cough, and violaceous cutaneous lesions
Chest CT	Innumerable bilateral, asymmetric nodular opacities with indistinct margins and flame-like morphology along peri-bronchovascular regions, predominantly on the left
Initial biopsy	Scant fibrotic tissue with atypical glandular proliferation concerning for adenocarcinoma; HHV-8 negative
Repeat biopsy	Left lower lobe and lingula samples showed spindle-cell vascular proliferation and HHV-8 latent nuclear antigen-1 positivity, confirming KS
Concurrent infections and treatment	Mycobacterium avium complex treated with azithromycin/ethambutol; Cryptococcus neoformans treated with fluconazole

Key Findings

The patient had advanced HIV with a CD4 nadir below 50 cells/µL, progressive respiratory symptoms, and violaceous skin lesions.
CT showed bilateral, asymmetric, flame-shaped nodular opacities along the peri-bronchovascular regions, predominantly on the left.
The initial left-lung core biopsy was scant and suggested adenocarcinoma, with cytokeratin AE1/3, thyroid transcription factor-1, and Napsin A positivity; HHV-8 staining was negative.
Repeat CT-guided sampling from the left lower lobe and lingula showed spindle-cell vascular proliferation and HHV-8 latent nuclear antigen-1 positivity, confirming pulmonary KS.
The source case notes that similar imaging findings can occur with opportunistic infections, including Pneumocystis jirovecii pneumonia, invasive fungal infection, and mycobacterial infection.
The case report states that repeat tissue sampling should be pursued when pathology conflicts with the clinical and radiographic picture, incorporating HHV-8 immunohistochemistry.

Clinical Implications

In this case, the initial tissue-limited biopsy did not resolve the diagnosis and was inconsistent with the clinical and radiographic findings; repeat CT-guided sampling established KS. The case report advises repeat tissue sampling with HHV-8 immunohistochemistry when pathology conflicts with the clinical and imaging picture.

Conclusion

Pulmonary KS was confirmed by repeat biopsy after an initial scant specimen suggested adenocarcinoma. The case links flame-shaped peri-bronchovascular CT opacities with confirmatory histopathology and emphasizes reassessment when biopsy findings are discordant.