AIDS is no longer a death sentence
When I was a physiotherapist, I held a steadfast belief, instilled by my training in the scientific method, that diseases could always be conquered. However, my perspective changed when I encountered autoimmune deficiency disorder (AIDS), a formidable and elusive challenge.
As I transitioned to becoming a doctor, I realized that this was just the beginning. Other persistent infections such as herpes simplex and hepatitis have been referred to as the “diamonds” of infectious diseases because they linger indefinitely. This led me to delve deeper into the skin manifestations associated with theses conditions, which are often overlooked or misunderstood.
Years ago, when the global awareness of AIDS was burgeoning due to its deadly nature and mode of transmission, I had a memorable experience with a patient.
Let us call him Benjamin. It was the mid-1980s and AIDS was spreading rapidly. I had the opportunity to work in a US hospital as a physiotherapist where I encountered several patients with this devastating disease. One patient, in particular, stands out in my memory—a middle-aged, handsome man who had become shockingly emaciated, weak and covered with dark, plum-colored patches, plaques, and nodules from his waist down to his legs.
During one of our sessions, I asked him to share his story. He revealed that initially, his only symptom was some white lesions on his tongue, known as oral hairy leukoplakia. Otherwise, he had no classic signs of HIV infection. He led a normal life, working full days and enjoying social activities. His HIV symptoms did not follow the typical progression associated with the AIDS epidemic at that time. But still, after several laboratory tests were done for his mucosal lesions, he was finally diagnosed with AIDS.
It's important for patients to know and understand the skin manifestations of infectious diseases like AIDS.
He recounted how a doctor had explained the stages of AIDS to him, detailing the correlation between the decline of T cells—critical white blood cells that play a key role in the immune response—and the progression of the disease. This conversation painted a grim picture of his future, including the deterioration of his health and the potential for a shortened lifespan. It was a harrowing hour-and-a-half discussion that left a profound impact on him.
Reflecting on this experience, he realized the importance of understanding and addressing the skin manifestations of infectious diseases like AIDS.
What my patient had when I was already taking care of him is known as Kaposi’s Sarcoma (KS). If you’ve watched the film Philadelphia starring Tom Hanks, that’s how it looks. KS is an angioproliferative disorder that has a viral etiology and a multifactorial pathogenesis hinged on an immune dysfunction. The disease is multifocal, with a course ranging from indolent, with only skin manifestations; to fulminant, with an extensive visceral involvement. In the current view, all forms of KS have a common etiology in human herpesvirus (HHV)-8 infection, and the differences among them are due to the involvement of various cofactors. In fact, HHV8 infection can be considered a necessary but not sufficient condition for the development of KS, because further factors (genetic, immunologic, and environmental) are required as well. The role of cofactors can be attributed to their ability to interact with HHV 8 to affect the immune system, or to act as vasoactive (affecting the diameter of blood vessels, and hence blood pressure).
In this contribution, a survey of the current state of knowledge on many and various factors involved in KS pathogenesis is carried out, in particular by highlighting the facts and controversies about the role of some drugs (quinine analogues and angiotensin-converting enzyme inhibitors) in the onset of the disease. Based on these assessments, it is possible to hypothesize that the role of cofactors in KS pathogenesis (the process to determine how an individual became ill) can move toward an effect either favoring or inhibiting the onset of the disease, depending on the presence of other agents (cofactors) modulating, redirecting or influencing the pathogenesis itself, such as genetic predisposition, environmental factors, drug intake, or lymph flow disorders. It is possible that the same agents may act as either stimulating or inhibiting cofactors according to the patient’s genetic background and variable interactions.
KS has four classifications:
Classic type. This is prevalent among the elderly men of Mediterranean origin, diagnosed worldwide and typically follows a benign course.
African Endemic type. First described in 1914, occurs predominantly among young black men aged 25 to 40 years old.
Lymphadenopathic subvariant (African form). This affects children at a mean age of three years.
Iatrogenic form. In the 1970s, this was associated with immunosuppressant treatment often described among recipients of organ transplantation, patients on long-term steroid use for various disorders, and patients immunosuppressed as a result of other therapeutic regimens, including chemotherapy.
Epidemic form. In 1981, an epidemic of KS among young men who had sex with men in the United States served as the harbinger of a new immunodeficiency syndrome, subsequently identified as being associated with HIV infection (20,000 times higher in this group). As the HIV epidemic progressed, KS was found almost exclusively among homosexual men. Due to epidemiologic data indicating the high incidence of KS among persons at greater risk for sexually transmitted infections, a further independent infectious agent was proposed in the etiology of epidemic KS.
As time passed, my patient Benjamin began to develop more classic signs of AIDS: fatigue, fever, exhaustion, which was accompanied by a decline in his T cells—which fell to a very low, critical level.
These visible signs often provide critical clues about the underlying condition and can significantly affect a patient’s quality of life. This patient’s story was not just a medical case but a powerful reminder of the human element in healthcare and the relentless nature of certain diseases that, if diagnosed early, can help prolong and improve the quality of life. These days though, AIDS is no longer considered a death sentence; due to enhanced treatments, a patient with AIDS can live a normal, unrestricted, fulfilling and, most of all, happy life.
