Derm Cases · Dermatology / HIV medicine / Oncology
OSCE — purple palate and skin nodules: Kaposi sarcoma, HHV-8 and ART pathway
An 8-minute OSCE station on Kaposi sarcoma recognition, four epidemiologic variants, HHV-8 aetiology, biopsy, ART-first management in AIDS-KS, systemic therapy triggers, and transplant/IRIS considerations.
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Target exams
NEET-PGINICETUSMLEPLABMRCP
Prompt
An 8-minute OSCE station on Kaposi sarcoma recognition, four epidemiologic variants, HHV-8 aetiology, biopsy, ART-first management in AIDS-KS, systemic therapy triggers, and transplant/IRIS considerations.
Brief (to candidate)
A 34-year-old man with newly diagnosed HIV (CD4 80) presents with purple-brown macules and nodules on the trunk and a purple plaque on the hard palate. He is not yet on ART. You have 8 minutes to diagnose Kaposi sarcoma, link HHV-8, plan confirmation, and outline ART-centred management with systemic therapy triggers.
[3]Candidate instructions
- Recognise cutaneous/mucosal Kaposi sarcoma (KS).
- Name HHV-8 / KSHV as the causal virus and list four epidemiologic variants.
- Plan biopsy and HIV staging bloodwork.
- Prioritise ART initiation/optimisation for AIDS-KS.
- Indicate when systemic chemotherapy (e.g. liposomal doxorubicin) is needed.
- Mention transplant KS (sirolimus) and KS-IRIS concepts.
Examiner checklist (mark each domain / 10)
| Domain | Key actions expected |
|---|---|
| Recognition | Purple/red/brown macules → plaques → nodules; classic oral site hard palate; AIDS-defining illness in HIV context[1][6] |
| Aetiology / variants | Caused by HHV-8 (KSHV); four variants: classic, endemic (African), iatrogenic (transplant), epidemic (AIDS-KS) — histology shared[1][5] |
| Diagnosis | Skin/mucosal biopsy (spindle cells, slit-like vessels, HHV-8 LANA IHC); HIV VL/CD4; evaluate for visceral disease if pulmonary/GI symptoms; note related KSHV diseases (e.g. multicentric Castleman) when systemic inflammatory features present[3][6][2] |
| First-line HIV pathway | Start/optimise ART promptly — cornerstone of AIDS-KS control; multidisciplinary HIV-oncology care |
| Systemic therapy | Extensive cutaneous, visceral (lung/GI), or progressive disease despite ART → systemic therapy such as pegylated liposomal doxorubicin (or other specialist regimens)[3] |
| Special contexts | Transplant KS: reduce immunosuppression if safe; switch to sirolimus (mTOR) when appropriate; early ART may trigger KS-IRIS — do not stop ART; manage with specialist support |
| Communication | Explain viral oncogenesis simply; stigma-sensitive counselling; urgent linkage to HIV care |
Model key actions
- Diagnose probable AIDS-KS (skin + hard palate) and confirm with biopsy + HHV-8 IHC context.[1][6]
- Start ART as the foundation; add systemic chemo for extensive/visceral disease.[3]
- Safety-net for pulmonary/GI KS symptoms and IRIS after ART start.
Common errors
- Treating only with local cryotherapy while delaying ART.
- Missing oral KS examination.
- Stopping ART for KS-IRIS.
- Ignoring visceral symptoms (haemoptysis, GI bleeding).
- Forgetting HHV-8 aetiology and variant classification.
References6ShowHide
- [1]Cesarman E, Damania B, Krown SE, et al. Kaposi sarcoma. Nature Reviews Disease Primers, 2019.PMID 30705286
- [2]Carbone A, Borok M, Damania B, et al. Castleman disease. Nature Reviews Disease Primers, 2021.PMID 34824298
- [3]Patel R, Lurain K, Yarchoan R, et al. Clinical management of Kaposi sarcoma herpesvirus-associated diseases: an update on disease manifestations and treatment strategies. Expert review of anti-infective therapy, 2023.PMID 37578202
- [4]Xiao Q, Liu Y, Li T, et al. Viral oncogenesis in cancer: from mechanisms to therapeutics. Signal transduction and targeted therapy, 2025.PMID 40350456
- [5]Iftode N, Rădulescu MA, Aramă ȘS, et al. Update on Kaposi sarcoma-associated herpesvirus (KSHV or HHV8) - review. Romanian journal of internal medicine = Revue roumaine de medecine interne, 2020.PMID 32681788
- [6]Radu O, Pantanowitz L. Kaposi sarcoma. Archives of pathology & laboratory medicine, 2013.PMID 23368874