Harris-Love Michael O, Shrader Joseph A
VA Medical Center, Washingon DC, USA.
J Orthop Sports Phys Ther. 2009 Aug;39(8):612-7. doi: 10.2519/jospt.2009.2961.
Resident's case problem.
Kaposi's sarcoma (KS) is the most common form of cancer in patients with human immunodeficiency virus (HIV) infection. Although KS is often initially asymptomatic, this neoplasm may progress to affect multiple organ systems, including structures of the musculoskeletal system, which can produce symptoms similar to those associated with common orthopaedic conditions. This resident's case problem describes the evaluation and differential diagnosis of a 45-year-old male with HIV and KS, referred to physical therapy with an initial diagnosis of radiographic osteoarthritis (OA) and patellofemoral pain syndrome (PFPS) of the left knee. His primary complaint was knee pain during end range knee flexion.
The history, systems review, and examination suggested a source of pain of a nonorthopaedic origin. Differential examination ruled out clinical OA, PFPS, ligament/cartilage derangement, and tendonitis. Avascular necrosis of the medial femoral condyle was also considered as a possible source of pain. Recent blood tests indicated a high viral load and low CD4 count, which might have increased susceptibility to opportunistic infections or KS tumor progression. The patient was referred back to his physician for additional follow-up. Magnetic resonance imaging (MRI) of the knees were consistent with a systemic inflammatory process such as KS. A true-cut biopsy was subsequently scheduled, which confirmed KS lesions at the left knee.
Physical therapists who manage orthopaedic conditions should be aware of the disablement that may result from acquired immunodeficiency syndrome-related KS. A thorough joint-specific examination, with a broad differential diagnosis, should be employed for patients having known systemic diseases.
Differential diagnosis, level 4.
住院医师病例问题。
卡波西肉瘤（KS）是人类免疫缺陷病毒（HIV）感染患者中最常见的癌症形式。尽管KS通常最初无症状，但这种肿瘤可能进展并影响多个器官系统，包括肌肉骨骼系统结构，可产生与常见骨科疾病相关的类似症状。该住院医师病例问题描述了一名45岁HIV合并KS男性患者的评估和鉴别诊断，该患者因初步诊断为左膝影像学骨关节炎（OA）和髌股疼痛综合征（PFPS）而转诊至物理治疗科。他的主要诉求是膝关节终末屈曲时疼痛。
病史、系统回顾和检查提示疼痛来源非骨科。鉴别检查排除了临床OA、PFPS、韧带/软骨紊乱和肌腱炎。股骨内侧髁缺血性坏死也被认为是可能的疼痛来源。近期血液检查显示病毒载量高且CD4计数低，这可能增加了机会性感染或KS肿瘤进展的易感性。患者被转回其医生处进行进一步随访。膝关节磁共振成像（MRI）结果与KS等全身性炎症过程一致。随后安排了切取活检，证实左膝存在KS病变。
处理骨科疾病的物理治疗师应意识到与获得性免疫缺陷综合征相关的KS可能导致的功能障碍。对于患有已知全身性疾病的患者，应进行全面的关节特异性检查，并进行广泛的鉴别诊断。
鉴别诊断，4级。
