New insights into HIV-1-primary skin disorders

Psoriasis associated with idiopathic CD4+ T-cell lymphopenia: a regulatory T-cell defect?

Idiopathic CD4(+) lymphocytopenia (ICL) is a rare immunodeficiency syndrome of unknown origin for which the increased risks of opportunistic infections and of malignancies have been well established; however, skin dysimmune diseases, including psoriasis, have been scarcely reported up to now. We report herein the severe course of psoriasis in four patients with ICL, and show evidence for a defect in the skin recruitment of regulatory CD4(+) FoxP3(+) T cells. These data raise the apparent paradigm of the occurrence of a severe immunomediated disease together with a profound T-cell defect, a model that might also apply to other immune deficiencies associated with psoriasis.

A Case of Severe HIV-Associated Psoriasis Successfully Treated with Acitretin Therapy

Psoriasis is a chronic inflammatory skin disease that involves immune-mediated cutaneous inflammation and keratinocyte hyperproliferation. Psoriasis in patients with HIV responds poorly to treatment and has a high morbidity rate, thus posing a challenge to clinicians. Until now, there have been no documented cases of acitretin therapy for HIV-associated psoriasis in Korea. Here, we report a case of safe and successful therapy with acitretin in a 52-year-old man with HIV-associated psoriasis that responded poorly to previous treatments including steroids and ultraviolet B phototherapy. We also review the relevant literature.

A novel community health worker tool outperforms WHO clinical staging for assessment of antiretroviral therapy eligibility in a resource-limited setting

The accuracy of a novel community health worker antiretroviral therapy eligibility assessment tool was examined in community members in Blantyre, Malawi. Nurses independently performed World Health Organization (WHO) staging and CD4 counts. One hundred ten (55.6%) of 198 HIV-positive participants had a CD4 count of <350 cells per cubic millimeter. The community health worker tool significantly outperformed WHO clinical staging in identifying CD4 count of <350 cells per cubic millimeter in terms of sensitivity (41% vs. 19%), positive predictive value (75% vs. 68%), negative predictive values (53% vs. 47%), and area under the receiver-operator curve (0.62 vs. 0.54; P = 0.017). Reliance on WHO staging is likely to result in missed and delayed antiretroviral therapy initiation.

Serum selenium and skin diseases among Nigerians with human immunodeficiency virus/acquired immune deficiency syndrome

Background

The role of selenium as an antioxidant micronutrient has garnered the unprecedented focus of researchers in recent times. No clinical study has related serum selenium concentration to skin diseases in human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) patients.

Methods

In this study, 134 newly diagnosed HIV patients that satisfied the inclusion criteria were included. Skin diseases were clinically diagnosed and fasting venous blood was taken for assessment of serum selenium using an atomic absorption spectrophotometer.

Results

The mean age of HIV subjects with and without skin disease were not significantly different: 32.72 ± 9.21 versus 35.86 ± 8.55 years, P = 0.077, respectively. The mean of serum selenium (0.51 ± 0.48 versus 0.81 ± 0.39), CD4+ count (228.06 ± 212.89 versus 446.41 ± 182.87), and body mass index (BMI; 21.09 ± 3.58 versus 23.53 ± 3.35) were significantly lower (P < 0.001) for HIV/AIDS participants with skin disease than those without skin disease. We found significant clustering of symptoms and signs: fever (P = 0.037), weight loss (P = 0.009), oral candidiasis (P = 0.038), pallor (P = 0.037) among HIV/AIDS subjects with skin diseases than those without. Low serum selenium concentration was significantly associated with primary skin disease of HIV/AIDS, such as pruritic papular eruption of AIDS (P = 0.003), xeroderma (P = 0.030), fluffy hair (P = 0.021), blue-black nail hyperpigmentation (P = 0.033) and secondary skin disease, such as oral candidiasis (P = 0.002). There was a significant association between low serum selenium concentration and increasing frequency of skin diseases (P = 0.002), but serum selenium was not significantly related to extents of distribution of skin diseases (P > 0.05).

Conclusion

serum selenium concentration was lower among HIV subjects with skin diseases than those without skin disease. Pruritic papular eruption, xeroderma, fluffy hair, blue-black nail hyper pigmentation, and oral candidiasis were significantly associated with low serum selenium concentration.

Disseminated atypical molluscum contagiosum as a presenting symptom of HIV infection

Atypical forms of molluscum contagiosum may be challenging to diagnose and are found in immunocompromised patients where they indicate severe impairment of cellular immunity. We report a case of disseminated atypical molluscum contagiosum which was the first sign of HIV infection and AIDS disease in a 38-year-old male patient. The lesions – painless, flesh-colored and violaceous papules and nodules – spread systematically for previous 3 years. They were located on the face, forearms, in the groins and in the genital region. Serologic tests for HIV-1 and hepatitis C virus were positive. CD4+ T–cells count was 80/mm³. The skin biopsy showed intracytoplasmic molluscum bodies. Atypical, recalcitrant, disseminated or facial molluscum contagiosum requires immediate HIV testing. In our patient, both the opportunity for early diagnosis and the institution of effective therapy were missed.

Endogenous retrovirus-K promoter: a landing strip for inflammatory transcription factors?

Humans are symbiotic organisms; our genome is populated with a substantial number of endogenous retroviruses (ERVs), some remarkably intact, while others are remnants of their former selves. Current research indicates that not all ERVs remain silent passengers within our genomes; re-activation of ERVs is often associated with inflammatory diseases. ERVK is the most recently endogenized and transcriptionally active ERV in humans, and as such may potentially contribute to the pathology of inflammatory disease. Here, we showcase the transcriptional regulation of ERVK. Expression of ERVs is regulated in part by epigenetic mechanisms, but also depends on transcriptional regulatory elements present within retroviral long terminal repeats (LTRs). These LTRs are responsive to both viral and cellular transcription factors; and we are just beginning to appreciate the full complexity of transcription factor interaction with the viral promoter. In this review, an exploration into the inflammatory transcription factor sites within the ERVK LTR will highlight the possible mechanisms by which ERVK is induced in inflammatory diseases.

Toxic epidermal necrolysis and Stevens-Johnson syndrome in South Africa: a 3-year prospective study

BACKGROUND

Toxic Epidermal Necrolysis (TEN) and Stevens-Johnson syndrome (SJS) remain feared medication-related reactions. HIV infection and tuberculosis predispose to drug eruptions, yet there is a paucity of data on TEN/SJS in populations with high prevalences of both diseases.

AIM

The aim of this prospective observational study was to describe the features and outcomes of patients admitted with TEN/SJS at a large academic hospital in South Africa. We aimed to identify poor prognostic indicators and to validate the use of the TEN-specific severity-of-illness score (SCORTEN) in this population.

METHODS

All patients admitted with TEN/SJS over a 3-year period were enrolled. Disease severity was graded according to percentage skin involved and SCORTEN. Co-morbid diagnoses, clinical features, investigations, complications and outcomes were noted.

RESULTS

75 patients (39.9 ± 10.6 years, 16 males, 59 HIV positive) were classified as TEN (n  = 42), TEN/SJS overlap (n = 11) and SJS (n = 22). Twenty-four percent died, most from refractory septic shock. Non-survivors had a higher mean SCORTEN on Days 1 and 3 (1.89 vs. 1.04, P = 0.006 and 2.27 vs. 0.90, P < 0.001). A SCORTEN ≥2 on Days 1 and 3 predicted non-survival (OR = 2.94, P = 0.047; OR = 7.45, P < 0.001). Other predictors of non-survival included HIV infection (OR = 6.01, P = 0.058), HIV-tuberculosis co-infection (OR = 8.5, P < 0.001), ≥40% skin involvement (OR = 20.27, P < 0.001), anaemia (OR = 4.68, P = 0.005), hypoalbuminemia (OR = 8.5, P = 0.001) and severe sepsis (OR = 71.09, P < 0.001).

CONCLUSION

Most patients with TEN/SJS were HIV positive and female. We validated the use of SCORTEN and identified several prognostic indicators, most significant being HIV-tuberculosis co-infection, ≥40% skin involvement and severe sepsis.