AIDS and Kaposi sarcoma pre­1979

By Robert Root-Bernstein
The Lancet 21 April 1990

Sir, - Professor Freidman­Kien and colleagues (Jan 20, p.168) describe cases of Kaposi sarcoma (KS) in HlV­negative homosexual men and seek information on other cases. My review of publications on KS, done in light of the Centers for Disease Control criteria for diagnosing AIDS has revealed a large number of cases hat may fit Freidman­Kien's description.

Kamer and Pankey (1) have reviewed 28 cases of KS among previously healthy men under the age of 60 that were reported in the United States and Europe between 1902 and 1966 and which resulted in death in less than 2 ½ years. Dutz and Stout (2) record another 23 cases of KS not associated with other diseases or treatments among European and American children under the age of 16 for the years 1908­50. 6 of those children died in less than 2 years. These childhood cases represent about 4% of the total cases of KS reported for that period, and the cases identified by Kamer and Pankey represent an equivalent proportion. These historical cases of KS might have qualified as AIDS cases under the current definition.

Kaposi himself described the earliest known cases of this now eponymous sarcoma in 1872. Of 5 patients 2 were men in their 40s. A sixth case, diagnosed by Billroth, was a boy of 10. (3) No underlying or associated diseases are mentioned. A decade later de Amici described 12 more cases, all in males; 2 patients were in their 30s, 3 in their 40s, 1 in his 50s, and 1 was a 5­year­old.(4) 3 of the younger men, including the boy, had penile lesions and died within a year with fulminating disease or respiratory failure accompanying high fever and possibly pneumonia. There are other examples of series of KS in the pre­AIDS era, with short survival at a young age -for instance, the patients reported from the US Armed Forces Institute of Pathology in 1959, 16 of whom were under 60; (5) the 23 patients reported from Stockholm between 1915 and 1939, of whom 3 were under 50, the tumours being more malignant in younger patients, as is typical of AIDS; (6) and Degosand colleagues' 28 cases in France between 1954 and 1964, 8 of whom contracted the disease before the age of 50. (7)

My review of these and other reports suggests that 15­20% of KS cases published before 1979 were of the type described above. Since the incidence of KS in the United States was 0.36 per 100 000 for the years 1973­80, (8) the number of AIDS­like cases of KS that went unrecognised before 1979 may have 100 or more per year.

There was no test for HIV until 1984 but if we accept that HIV is a new retrovirus that entered North America and Europe in the past two or three decades, then all of the cases listed above must have been HIV­free. If so, several hypotheses must be entertained (9,10) -that AIDS is not new; that HIV is only one of several possible causes of AIDS; or that HIV is itself a new, opportunistic infection that takes advantage of previously immunosuppressed individuals. (11) If, however, one argues that KS in otherwise healthy young men is always associated with HIV, these historical cases would indicate that HIV is not a new disease agent, and it would follow that AIDS is not a new disease and that the current epidemic is due not to the introduction of a new virus but to changes in lifestyle creating new populations of susceptible individuals and/or extending modes of transmission.

The existence of HIV­free AIDS cases requires us to re­evaluate the theory that AIDS is a new disease and that HIV is the necessary and sufficient cause. Incidentally, my review of the history of pneumocystis pneumonia, cryptococcosis, disseminated cytomegalovirus and candida infections, and the other opportunistic diseases associated today with AIDS is revealing the same pattern of unrecognised AIDS­like cases.

I thank Heather Conlee for tracking down many of the references.

ROBERT S. ROOT-BERNSTEIN

Department of Physiology.
Michigan State University
East Lansing Michigan 48824 USA

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