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Clinical concept of Kaposi sarcoma

Case Scenario:

28 y/o Caucasian female presented to the ED with main c/o a mouth sore that occurred about

two weeks ago, associated with pain, unable to eat or drink for the last three days. As well,

complaints of abdominal upset stomach and poor appetite. Does report nausea, vomiting, and

denies diarrhea. Patient complaints as well of SOB at rest and with exertion not relieve by anymeasures with occasional chest pain. States that pain is located at center of the chest wall with

no radiation, pain 8/10. More concern with a rash that developed a couple days ago bluish red

in color with elevated papules along her back and arms. States that she was diagnosed with

HIV + about eight months ago. Has not taken any prescribed medications or followed up with

physician recently. Continues with unhealthy habits such as smoking and drug abuse. Upon

examination lab results reveal a CD4 count of 150/mm3, CXR images revealed pleural effusion

and vascular congestion, WBC 20,000, and physician has given a diagnosis of r/o Kaposis

sarcoma-associated herpes virus (KSHV).

Diane: A Case of Physician Assisted Suicide

Diane was a patient of Dr. Timothy Quill, who was diagnosed with acute myelomonocytic

leukemia. Diane overcame alcoholism and had vaginal cancer in her youth. She had beenunder his care for a period of 8 years, during which an intimate doctor-patient bond had been

established. It was Dr. Quill's observation that "she was an incredibly clear, at times brutally

honest, thinker and communicator." This observation became especially cogent after Diane

heard of her diagnosis. Dr. Quill informed her of the diagnosis, and of the possible treatments.

This series of treatments entailed multiple chemotherapy sessions, followed by a bone marrow

transplant, accompanied by an array of ancillary treatments. At the end of this series of

treatments, the survival rate was 25%, and it was further complicated in Diane's case by the

absence of a closely matched bone-marrow donor. Diane chose not to receive treatment,

desiring to spend whatever time she had left outside of the hospital. Dr. Quill met with her

several times to ensure that she didn't change her mind, and he had Diane meet with a

psychologist with whom she had met before. Then Diane complicated the case by informing Dr.Quill that she be able to control the time of her death, avoiding the loss of dignity and discomfort

which would precede her death. Dr. Quinn informed her of the Hemlock Society, and shortly

afterwards, Diane called Dr. Quinn with a request for barbiturates, complaining of insomnia. Dr.

Quinn gave her the prescription and informed her how to use them to sleep, and the amount

necessary to commit suicide. Diane called all of her friends to say goodbye, including Dr. Quinn,

and took her life two days after they met.

PROSTATE CANCER

Carlos Aquino, a 63 year old Filipino male with hormone-refractory prostate cancer is your clinic

patient. Mr. Aquino was diagnosed with benign prostatic hypertrophy (BPH) several years ago and was

taking alpha blockers for this condition.

A year ago, his BPH symptoms worsened despite maximal therapy. At that time you performed adigital rectal exam and noted that he had a new hard nodule (1cm x 1cm) in the right lobe of hisprostate and a PSA of 2.4 (PSA in the year prior to that was 2.2). A prostate biopsy revealed high-grade adenocarcinoma in 5/5 R lobe biopsy specimens with Gleason's score of 4+5, and 2/5 of L lobebiopsies. A bone scan showed a small focal abnormality in the lumbar spine at the level of the L2vertebra. The prostate cancer was staged as T2b.

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