Kaposi's Sarcoma and Pneumocystis Pneumonia Among Homosexual Men — New York
City and California
Source: Morbidity and Mortality Weekly Report , July 3, 1981, Vol. 30, No. 25 (July 3,1981), pp. 305-308
Published by: Centers for Disease Control & Prevention (CDC)
Stable URL: http://www.jstor.com/stable/23300179
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CENTERSCENTERS FOR
FORDISEASEDISEASECONTROLCONTROL

July
July 3,3, 1981
1981//Vol.
Vol.30/No.
30/No.
2525
Epidemiologic Notes and Reports

305 Kaposi's Sarcoma and Pneumocystis
Pneumonia Among Homosexual Men —New York City and California
308 Cutaneous Larva Migrans in American
Tourists — Martinique and Mexico
314 Measles — U.S. Military

MORBIDITY AND MORTALITY WEEKLY REPORT

Epidemiologic
EpidemiologicNotes
Notes
andandReports
Reports
Kaposi's
Kaposi'sSarcoma
SarcomaandandPneumocystis
Pneumocystis
Pneumonia
Pneumonia
Among
AmongHomosexual
Homosexual
Men
Men— New— NewYorkYork
City Cityand California
and California
DuringDuringthe
thepastpast
3030
months,months,
Kaposi's
Kaposi's
sarcomasarcoma(KS), an(KS),uncommonly
an uncommonly
reportedreported
malig
malig
nancy
nancyin
inthe
theUnited
UnitedStates,States,has hasbeenbeen
diagnosed
diagnosed
in 26 homosexualin 26 homosexualmen (20 menin New(20Yorkin New York

City
City [NYC],[NYC],6 6inin
California).
California).
TheThe26 patients
26 patientsrangerange
in age infromage26-51
fromyears
26-51(meanyears
39 (mean 39years).
years).Eight
Eightofof
thesethesepatientspatients
dieddied(7 in(7NYC,in NYC,
1 in California)—all
1 in California)—all
8 within824
withinmonths24 months
after KS was diagnosed. The diagnoses in all 26 cases were based on histopathologicalexamination of skin lesions, lymph nodes, or tumor in other organs. Twenty-five of the26 patients were white, 1 was black. Presenting complaints from 20 of these patients areshown in Table 1.

Skin or mucous membrane lesions, often dark blue to violaceous plaques or nodules,
were present in most of the patients on their initial physician visit. However, theselesions were not always present and often were considered benign by the patient and hisphysician.
A review of the New York University Coordinated Cancer Registry for KS in men
under age 50 revealed no cases from 1970-1979 at Bellevue Hospital and 3 cases in thisage group at the New York University Hospital from 1961-1979.
Seven KS patients had serious infections diagnosed after their initial physician visit.

Six patients had pneumonia (4 biopsy confirmed as due to Pneumocystis carinii [PC]),and one had necrotizing toxoplasmosis of the central nervous system. One of the patientswith Pneumocystis pneumonia also experienced severe, recurrent, herpes simplex infec

tion; extensive candidiasis; and cryptococcal meningitis. The results of tests for cyto
megalovirus (CMV) infection were available for 12 patients. All 12 had serological evi
dence of past or present CMV infection. In 3 patients for whom culture results wereavailable, CMV was isolated from blood, urine and/or lung of all 3. Past infections withamebiasis and hepatitis were commonly reported.

TABLE 1. Presenting complaints in 20 patients with Kaposi's sarcoma
Presenting complaint

Number (percentage) of patients

Skinlesion(s) onlySkin
lesion(s) only 10 (50%)
10 (50%)4 (20%)
Skin
Skin
lesions
lesions
plus lymphadenopathy
plus lymphadenopathy 4 (20%)
1 (5%)
Oral
Oral
mucosalmucosallesion only
lesion only 1 (5%)
1 (5%)
Inguinal
Inguinal
adenopathy
adenopathy
plus perirectal
plus perirectal
abscess
abscess 1 (5%)
WeightWeightloss and feverloss and fever 2 (10%)
2 (10%)
WeightWeightloss, loss,fever, andfever,pneumonia
and pneumonia 2 (10%)
2 (10%)(one(onedue due
to Pneumocystis
to Pneumocystiscarinii)
carinii)

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306

MMWR

Kaposi'sJuly

Sarcoma3,—1981

Continue

Since the previous report offrom Los Angeles (/), 10 addBay area) of biopsy-confirm
the state. Two of the 10 pat
cystis cases among homosex
range in age from 25 to 46 y
Reported by A Friedman-Kien, MD, L Laubenstein, MD, M Marmor, PhD, K Hymes, MD, J Green,MD, A Ragaz, MD, J Gottleib, MD, F Muggia, MD, R Demopoutos, MD, M Weintraub, MD, D Williams,MD, New York University Medical Center, NYC; R Oliveri, MD, J Marmer, MD, NYC; J Wallace, MD,/ Halperin, MD, JF Gillooley, MD, St. Vincent's Hospital and Medical Center, NYC; N Prose, MD,Downstate Medical Center, NYC; E Klein, MD, Roosevelt Hospital, NYC; J Vogel, MD, B Safai,MD, P Myskowski, MD, C Urmacher, MD, B Koziner, MD, L Nisce, MD, M Kris, MD, D Armstrong,MD, J Gold, MD, Sloan-Kettering Memorial Institute, NYC; D Mildran, MD, Beth Israel Hospital,NYC; M Tapper, MD, Lenox Hill Hospital, NYC; JB Weissman, MD, Columbia Presbyterian Hospital,NYC; R Rothenberg, MD, State Epidemiologist, New York State Dept of Health; SM Friedman, MD,Acting Director, Bur of Preventable Diseases, New York City Dept of Health; FP Siegal, MD, Deptof Medicine, Mount Sinai School of Medicine, City College of New York, NYC; J Groundwater,MD, J Gilmore, MD, San Francisco; D Coleman, MD, S Follansbee, MD, J Gullett, MD, SJ Stegman,MD, University of California at San Francisco; C Wofsy, MD, San Francisco General Hospital, SanFrancisco; D Bush, MD, Franklin Hospital, San Francisco; L Drew, MD, PhD, Mt. Zion Hospital, E

Braff, MD, S Dritz, MD, City/County Health Dept, San Francisco; M Klein, MD, Valley Memorial
Hospital, Salinas; JK Preiksaitis, MD, Stanford University Medical Center, Palo Alto; MS Gottlieb, MD,
University of California at Los Angeles; R Jung, MD, University of Southern California MedicalCenter, Los Angeles; J Chin, MD, State Epidemiologist, California Dept of Health Services; J Goedert,MD, National Cancer Institute, National Institute of Health; Parasitic Diseases Div, Center for Infec
tious Diseases, VD Control Division, Center for Prevention Services, Chronic Diseases Div, Center for
Environmental Health, CDC.

Editorial Note: KS is a malignant neoplasm manifested primarily by multiple vascular
nodules in the skin and other organs. The disease is multifocal, with a course ranging fromindolent, with only skin manifestations, to fulminant, with extensive visceral involvement (2).
Accurate incidence and mortality rates for KS are not available for the United States,
but the annual incidence has been estimated between 0.02-0.06 per 100,000; it affects
primarily elderly males (3,4). In a series of 92 patients treated between 1949 and 1975 at
the Memorial Sloan-Kettering Cancer Institute in NYC, 76% were male, and the mean
age was 63 years (range 23-90 years) at the time of diagnosis (5).
The disease in elderly men is usually manifested by skin lesions and a chronic clinicalcourse (mean survival time is 8-13 years) (2). Two exceptions to this epidemiologic
pattern have been noted previously. The first occurs in an endemic belt across equatorial
Africa, where KS commonly affects children and young adults and accounts for up to
9% of all cancers (3). Secondly, the disease appears to have a higher incidence in renaltransplant recipients (6-9) and in others receiving immunosuppressive therapy (10-12).
The occurrence of this number of KS cases during a 30-month period among young,homosexual men is considered highly unusual. No previous association between KS andsexual preference has been reported. The fulminant clinical course reported in manyof these patients also differs from that classically described for elderly persons.
The histopathologic diagnosis of KS may be difficult for 2 reasons. Changes in somelesions may be interpreted as nonspecific, and other cutaneous and soft tissue sarcomas,
such as angiosarcoma of the skin, may be confused with KS (13,14).
That 10 new cases of Pneumocystis pneumonia have been identified in homosexual
men suggests that the 5 previously reported cases were not an isolated phenomenon (1).

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Vol.

30/No.

Kaposi's

25

MMWR

Sarcoma

307—ContiInaddition,
CDC
hasa
regressive,
perianal
herpesciencies. Three died, 1 with systemic CMV infection. The fourth patient is currently
undergoing therapy. It is not clear if or how the clustering of KS, Pneumocystis, andother serious diseases in homosexual men is related. What is known is that the patientswith Pneumocystis pneumonia described in the previous report showed evidence ofimpaired cellular immunity and previous or current CMV infection (1). Furthermore,
serologic evidence of past CMV infection and active shedding of CMV have been shown
to be much more common among homosexual men than heterosexual men attending
a sexually transmitted disease clinic (15). A specific serologic association with CMV
infection has been demonstrated among American and European patients with KS (16,17) and herpes-type virus particles have been demonstrated in tissue culture cell lines
from African cases of KS (18). It has been hypothesized that activation of oncogenic
virus during periods of immunosuppression may result in the development of KS (19). A1-*
though immunosuppression often results in CMV infection, it is not yet clear whether
CMV infection precedes or follows the above-mentioned disorders.
Although it is not certain that the increase in KS and PC pneumonia is restricted tohomosexual men, the vast majority of recent cases have been reported from this group.
Physicians should be alert for Kaposi's sarcoma, PC pneumonia, and other opportunistic
infections associated with immunosuppression in homosexual men.
References
1.

23.
4.

CDC. Pneumocystis pneumonia — Los Angeles. MMWR 1981;30:250.
Safai B, Good RA. Kaposi's sarcoma: a review and recent developments. CA 1981 ;31:1 -12.
Oettle AG. Geographical and racial differences in the frequency of Kaposi's sarcoma as evidenceof environmental or genetic causes. Acta Un Int Cancr 1962;18:330-63.
Rothman S. Remarks on sex, age, and racial distribution of Kaposi's sarcoma and on possible

6.

pathogenetic factors. Acta Un Int Cancr 1962;18:326-9.
Safai B, Mike V, Giraldo G, Beth E, Good RA. Association of Kaposi's sarcoma with second
primary malignancies: possible etiopathogenic implications. Cancer 1980;45:1472-9.
Harwood AR, Osoba D, Hofstader SL, et al. Kaposi's sarcoma in recipients of renal transplants.

7.

Am J Med 1979;67:759-65.
Stribling J, Weitzner S, Smith GV: Kaposi sarcoma in renal allograft recipients. Cancer 1978;

5.

42:442-6.
8.
9.
10.
11.
12.

Myers BD, Kessler E, Levi J, Pick A, Rosenfeld JB, Tikvah P. Kaposi sarcoma in kidney transplant recipients. Arch Intern Med 1974;133:307-11.
Penn I. Kaposi's sarcoma in organ transplant recipients: report of 20 cases. Transplantation
1979,27:8-11.

Gange RW, Jones EW. Kaposi's sarcoma and immunosuppressive therapy: an appraisal. Clin Exp
Dermatol 1978;3:135-46.
Klepp O, Dahl O, Stenwig JT. Association of Kaposi's sarcoma and prior immunosuppressive
therapy: a 5-year material of Kaposi's sarcoma in Norway. Cancer 1978;42:2626-30.
Hoshaw RA, Schwartz RA. Kaposi's sarcoma after immunosuppressive therapy with prednisone.
Arch Dermatol 1980:116;1280-2.

13.
14.
15.

Girard C, Johnson WC, Graham JH. Cutaneous angiosarcoma. Cancer 1970;26:868-83.
Rosai J, Sumner HW, Kostianovsky M, Perez-Mesa C. Angiosarcoma of the skin. A clinicopatho
logic and fine structural study. Hum Pathol 1976;7:83-109.
Drew WL, Mintz L, Miner RC, Sands M, Ketterer B. Prevalence of cytomegalovirus infection
in homosexual men. J Infect Dis 1981;143:188-92.

16.

Giraldo G, Beth E, Kourilsky FM, et al. Antibody patterns to herpesvirus in Kaposi's sarcoma:
serologic association of European Kaposi's sarcoma with cytomegalovirus. Int J Cancer 1975;

17.

Giraldo G, Beth E, Henle W, et al. Antibody patterns to herpesvirus in Kaposi's sarcoma. II.
serological association of American Kaposi's sarcoma with cytomegalovirus. Int J Cancer 1978;

15:839-48.

22:126-31.

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1:ffff:ffff:ffff:ffff:ffff on Thu, 01 Jan 1976 12:34:56 UTC
All use subject to https://about.jstor.org/terms

308

MMWR

Kaposi's

July3,Sarcoma

1981—Continu

18. Giraldo G, Beth E, Haguenau F. Herpes-type virus particles in tissue culture of Kaposi's sarcoma
from different geographic regions. J Natl Cancer Inst 1972;49:1509-26.
19. Kapadia SB, Krause JR. Kaposi's sarcoma after long-term alkylating agent therapy for multiple
myeloma. South Med J 1977;70:1011-3.

Cutaneous Larva Migrans in
American Tourists — Martinique and Mexico
Since October 19, 1980, the Parasitic Diseases Division, Center for Infectious Diseases,
has received reports that 7 American tourists, who had vacationed briefly at Club Med
iteranee seaside resorts in both Martinique and Mexico, returned with cutaneous larva
migrans. The patients, 5 men and 2 women ranging in age from 33 to 38 years, resided
in Massachusetts, Pennsylvania, Georgia, and Ohio, and were exposed on different dates.
(Continued on page 313)

TABLE
Summary— casesof specified
notifiablenotifiablediseases. UnitedStates United States
TABLEI. I.
Summary— casesof specified
diseases.
[Cumulative[Cumulativetotals
totalsincludeincluderevisedrevisedand delayed
and reports
delayedthroughreports
previousthroughweeks.]
previous weeks.]
25th WEEK ENDINGDISEASE

Aseptic meningitis
Brucellosis

Chicken poxDiphtheria
Encephalitis: Primary (arthropod-borne & unspec.)

June 21
1980

133
3107

107

5

6

3,801

4,577

--

Post-infectious

Hepatitis, Viral: Type B
Type A
Type unspecified

CUMULATIVE, FIRST 25 WEEKSMEDIAN
1976-1980

June 27
1981

20

8

2

4

404

364
579
214

430

185

4,353

June 27
1981

1,859
73
157,6903June 21
1980

1,619

82

144,4652

144,465
35
287
102
7,262
14,023
4,253
265

18
4

360
44

282

9,425
11,981
5,367

7,977
12,945
5,296
853

178
19924

1,126

82

317
595

MEDIAN

1976-1980

98

Malaria

4358

Measles (rubeola)85

Meningococcal infections: Total

48

463
50

46

49

40
39

2

1
158

1422

30

26
82

4

4

27

524
2,756
29

505

613
7

1689

12,863

12,672

13,778

87
224
436

70
171

62

Civilian

Military

Mumps

54

Pertussis

23

Rubella (German measles)
Tetanus

Tuberculosis
Tularemia

8

7

Typhoid fever
Typhus fever, tick-borne (Rky. Mt. spotted)

11,224
1,522

26

2,009
12
2,665
482

362

1,443

4

10
39

57

634

2,292
2,021

8
48

1,533
11

6,382

20,679
1,357
1,299
21
11,698
524

9,753
29

171
299

318

Venereal diseases:

Gonorrhea: Civilian

18.174

Military579

20,192368
488

610
Syphilis, primary & secondary: Civilian

Military
Rabies in animals

6162

20,192

5

136

495
452
573

463,413
13,731
14,248452,245
12,756

178

12,387
151

3,479

3,250

452,245
12,844
11,575146
1,509

TABLE II. Notifiable diseases of low frequency. United States
CUM. 1981
Anthrax-Botulism

29

Cholera1

Congenital rubella syndrome♦

Leprosy
Leptospirosis (Ark. 2)
Plague(Upstate103
N.Y.

195CUM. 1981

Poliomyelitis: TotalParalyticPsittacosis (Mass. 1, Ohio 1, La. 1, Tex. 1, Cok>. 1)
Rabies in man

Trichinosis (Conn. 1)
1)
Typhus fever, flea-borne (endemic, murine) (Tex. 1)

All delayed reports and corrections will be included in the following week's cumulative totals.

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16