kaposi 's sarcoma ( ks ) is the most common malignancy among patients with acquired immune deficiency syndrome . the precise origin of this pathology is still unclear , but the current investigation is the narrow link between the appearance of the kaposi 's sarcoma and the infection by human herpes virus 8 . the initial lesion of aids - associated ks generally develops on the trunk , face , or oral mucosa . a 34-year - old heterosexual man with co - infection of hiv and hcv for 5 years was referred to our center due to fever , dyspnea , weight loss , and icterus . he had been taking highly active anti - retroviral therapy ( haart ) ( zidovudine 300 mg / bid , lamivudine 300 mg / bid , efavirenz 600 mg / d ) regularly since a year prior to his admission . he had a history of intravenous drug abuse with a norgesic substance ( buprenorphine plus dexamethansone ) , which stopped 5 years ago . in addition , he was hospitalized 1 year ago because of the pulmonary tuberculosis with continuation of anti - tuberculosis drugs for 6 months . on admission to our hospital , he was toxic , dyspneic and febrile with oral temperature 40c , respiratory rate 24 per / min , pulse rate 134 per / min , and blood pressure 110/60 mg / hg . peripheral blood leukocyte count was 4000/ul , hemoglobin 6 g / dl , platelet count 34000/ul , total bilirubin 15 mg / dl and direct 10 mg / dl , alanine aminotransferase 31 iu / l , aspartate aminotransferase 22 iu / l , and lactate dehydrogenase 512 the patient was severely immunosuppressed with cd4 lymphocyte counts 79/mm , plasma hiv viral load 395722 iu / ml , and hcv viral load was 21900 iu / ml . on physical examination , there were multiple purplish - black plaques on his arms and feet . also , several small violaceous macules ranged from 2 mm to 1 cm were observed on the glans and shaft of the penis , which had started gradually over the last year [ figure 1 ] . violaceous macules localized on the glans and shaft of the penis sonography study demonstrated hepatosplenomegaly , and spiral computed tomography scan of the thorax was shown bilateral pleural effusion with consolidation in the upper lobe of the right lung . finally , sputum mycobacteriological examination was positive for mycobacterium tuberculosis ; therefore , a relapse of pulmonary tuberculosis was diagnosed . a modified anti - tuberculosis medication ( ethambutol 800 mg / d , amikacin 500 mg / d , and ofloxacin 600 mg / d ) was started in this patient due to abnormal liver function . ultimately , skin biopsy of the lesions of foot and penis was performed for histopathologic examination . hematoxylin and eosin - stained sections revealed a marked dermal neovascularization with spindle cells proliferation and also nuclear atypia compatible with kaposi 's sarcoma [ figure 2 ] . moreover , nested polymerase chain reaction ( pcr ) for human herpes virus-8 ( hhv8 ) was also positive in the penile tissue [ figure 3 ] . penile lesion ; irregular vascular spaces , and spindle - shaped cells with extravasated rbcs ( h and e , 40 ) electrophoresis of the nested pcr products for detection of hhv-8 . line 1 : 100 bp ladder marker , line 2 : whole blood sample of studies case , line 3 : plasma sample of studied case , line 4 : negative control ( human dna ) , line 5 and 6 : penile biopsy tissue of studies case , line 7 : non - template control ( double distilled water ) , line 8 : positive control our patient was referred for chemotherapy treatment with vinblastine , but he deferred it and discharged himself from hospital . kaposi 's sarcoma can be categorized into 4 distinct forms : endemic , classic , iatrogenic , and aids- associated . penile ks is uncommon ; majority of reports are from hiv - negative patients , especially who were homosexual and appears to have an aggressive behavior . the areas more often involved on the penis are glans , foreskin , coronal sulcus , frenulum , and urethral meatus . however , involvement of the shaft of penis is extremely unusual , and it is typically associated with lesions located on the glans or coronal sulcus . the majority of the previous reported penile ks have been located on the glans , especially in hiv - negative patients and are also limited to the genitalia area . our patient was notable due to the involvement of the shaft of the penis in addition to the glans . also , it was not limited to the genitalia and simultaneously involved to the upper and lower extremities . the differential clinical diagnosis includes balanitis , bowen 's disease , molluscum contagiosum , and condiloma acuminate . the decisive diagnosis is established by biopsy that the histological pattern is similar to that of kaposi 's sarcoma seen in other sites of the body . recent data showed a correlation between all types of ks and infection with hhv-8 , known as ks - associated herpes virus ( kshv ) . it assumes that the route of hhv-8 transmission might be both sexual and non - sexual . the detection of hhv-8 antibodies in children and nuns without sexual activity proposes the non - sexual route ; on the other hand , high hhv-8 seroprevalence in individuals with high - risk sexual activity represents the sexual route . additionally , it was reported that saliva could be a potential source of spread of hhv-8 in the general population . there have been several studies documented complete remission of ks with haart medication and support its efficacy as a first step of therapy in the management of this malignancy in hiv patients . alternatively , for the advanced disease , additional therapy is needed , for instance , chemotherapy with the liposomal forms of doxorubicin and daunorubicin . hiv suppression with anti - retroviral therapy is believed to be crucial and is considered the best factor of response . this might be related to the consequent suppression of hhv-8 replication and a reduction in the hiv - associated tat protein , which is angiogenic and anti - apoptotic . report of this case highlights the importance of cutaneous lesions in patients with hiv infection . although the penile kaposi 's sarcoma is relatively uncommon among hiv - positive men , clinicians should consider its possibility . usually , histopathologic evaluation is necessary to establish the diagnosis . in patients with hiv infection , kaposi 's sarcoma may involve shaft and glans of penis and concurrent lesions may be found in extremities .
kaposi 's sarcoma ( ks ) is a malignant proliferation of the endothelial cells . 
 it typically presents with several vascular nodules on the skin and other organs . 
 the penile localization of ks , particularly on the shaft area , is exceptional . 
 we report an hiv - positive 34-year - old man who had multiple purplish - black plaques on his extremities and several small violaceous macules on the glans and shaft of the penis . 
 kaposi 's sarcoma was diagnosed by histopathology .