The cutaneous manifestations of HIV infection

Mucocutaneous Manifestations of People Living with HIV in Current Antiretroviral Therapy Era

OBJECTIVE

It has been reported that approximately 90% of patients who are infected with human immunodeficiency virus (HIV) have various cutaneous symptoms that are related to the virus. This study aims to describe the cutaneous disorders that have developed in HIV-infected patients and to investigate the factors that may be related, such as relationships to drug use and CD4 counts.

METHODS

This cross-sectional study included people who were living with HIV and being followed by our hospital's infectious diseases clinic after they had been referred to the dermatology clinic because of skin lesions. These patients had been diagnosed with HIV by enzyme-linked immunosorbent assay tests and were included in the study if they were older than 18 years and had agreed to participate. Findings from detailed dermatological examinations were recorded, along with the patients' CD4 counts, the durations of their illnesses, and the treatments they received.

RESULTS

144 patients were included in the study. The most common mucocutaneous manifestation was seborrheic dermatitis, at 28.5% (n = 41). The mean CD4 count was 607.1 (min-max = 10.6-1982).The CD4 counts were divided into three groups in the study as follows: 22 (15.3%) patients with <200, 35 (24.3%) patients between 200 and 500, and 87 (60.4%) patients with >500. There were no statistical differences between these groups in terms of dermatological findings. Nevertheless, the highest rate of patients with three or more dermatological conditions was found among those with CD4 counts <200 (n = 11.50%).

CONCLUSION

Skin manifestations are common in patients who are HIV-positive; however, many skin disorders can be seen in HIV/acquired immunodeficiency syndrome (AIDS) patients whatever CD4 cell counts of these patients are.

Chronic non-healing ulcers as presenting sign of acquired immunodeficiency syndrome

Atypical forms of herpes simplex virus (HSV) infections, which indicate severe impairment of cellular immunity can be challenging to diagnose. In this paper, we report the case of an atypical HSV infection presenting as chronic nonhealing wounds, which are the first sign of HIV, in a 50-year-old female patient. The lesions had emerged as two large, chronic, and painful ulcerations on the left buttock and labia major 8 months prior. The skin biopsy revealed multinucleated keratinocytes with ground glass nuclei and intranuclear Cowdry type A viral inclusions. A serologic test for HIV-1 was positive. Her CD4⁺ T-cell count was 42/mm³. Clinicians should be familiar with the dermatologic manifestations of HIV, as they are occasionally key to correctly suspecting an underlying HIV infection, allowing for early diagnosis and treatment.

Effects of CD4 cell count and antiretroviral therapy on mucocutaneous manifestations among HIV/AIDS patients in Yunnan, China

BACKGROUND

The affecting factors of mucocutaneous manifestations in human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) patients remain unclear in China.

METHODS

A retrospective analysis was conducted among HIV/AIDS patients in Yunnan, China. The demographic data, mucocutaneous manifestations, CD4 cell counts, and antiretroviral therapy (ART) regimens were collected. The effects of CD4 cell count and ART on the spectrum of mucocutaneous manifestations were evaluated.

RESULTS

Among 508 HIV/AIDS patients, 86.0% of cases showed mucocutaneous manifestations. The average CD4 cell count (176 cells/μl) of the patients with manifestations was significantly lower than those without manifestations (328 cells/μl) (P < 0.001). Diseases such as herpes zoster, oral candidiasis, condyloma acuminatum, genital herpes, oral leukoplakia, talaromycosis, cryptococcosis, and HIV-PPE (pruritic papular eruption) were represented quite frequently in patients with CD4 cell count <200 cells/μl (P < 0.05), but eczema was suffered by those with CD4 cell count ≥200 cells/μl (P < 0.05). ART could decline the incidence of herpes zoster, oral candidiasis, condyloma acuminatum, genital herpes, oral leukoplakia, talaromycosis, and cryptococcosis (P < 0.05).

CONCLUSIONS

Mucocutaneous manifestations are closely related to the CD4 cell count and can be used as early predictors of HIV/AIDS and immune status in clinic. ART could reduce the incidence of certain mucocutaneous manifestations.

Cutaneous manifestations associated with HIV infections: A great imitator

HIV is associated with an increased incidence of mucocutaneous disorders, with the overwhelming majority of HIV-infected individuals being afflicted with skin diseases during the course of the infection. Skin diseases in HIV patients are rarely fatal, but they have a significant effect on the quality of life. The immunologic stage of the infection and the use of highly active antiretroviral therapy (HAART) are the main elements that determine the spectrum of the mucocutaneous involvement. Many skin diseases may occur simultaneously in HIV patients, and the course of these diseases may or may not be different than it is in HIV-negative individuals. The unusual, severe, and different presentations of the mucocutaneous involvement make HIV one of the great imitators in dermatology.

Study of prevalence of dermatophytes among human immunodeficiency virus/AIDS patients in Shadan Institute of Medical Sciences and Teaching Hospital and Research Centre, Hyderabad, Telangana, India

Introduction:

The objective of the study was to evaluate the prevalence of dermatophytoses in human immunodeficiency virus (HIV) patients as well as to analyze the influence of CD4+ T-cell level in the Dermatology and STD Outpatient Department of Shadan Institute of Medical Sciences Teaching Hospital and Research Centre, Himayat sagar road, Hyderabad (Telangana state). The patients were tested for dermatophytic infections, as well as for the CD4+ T-cell counts. A total of 120 HIV-seropositive patients were included in this study, among which 38 were diagnosed of dermatophytosis. A majority of patients were in the 21–30 years’ age group. Tinea cruris was seen in majority of the cases, with Trichophyton rubrum being the most common culprit.

Background:

Cutaneous fungal infections have been reported worldwide as being one of the most common human infectious diseases in clinical practice. Dermatophytoses in individuals with HIV infection seem to manifest with atypical, multiple, or extensive lesions more frequently.

Aims:

The aim of this study was to determine the prevalence of dermatophytic infections among HIV-seropositive patients and their relation with CD4 count.

Materials and Methods:

This single-center prospective study was conducted in all HIV-seropositive patients (by double ELISA methods) who attended the Dermatology and STD Outpatient Department of Shadan Institute of Medical Sciences Teaching Hospital and Research Centre, Himayat sagar road, Hyderabad (Telangana state), from March 2015 to September 2016. They were screened for cutaneous fungal infections and those who tested positive were recruited for this study.

Results:

A total of 120 HIV-seropositive patients were included in this study, among which 38 were diagnosed of dermatophytosis. Most patients were in the 21–30 years’ age group. Tinea cruris was the most common variant, and T. rubrum was the most common offending pathogen. It was also found that the CD4+ T-cell count does not influence the occurrence of dermatophytoses.

Conclusion:

Superficial fungal infections are a common yet significant problem in HIV infection. They are characterized by the diversity of clinical aspects; the lesions are mostly caused by T. rubrum. It is essential that optimum treatment should be administered.

Dermatologic manifestations among human immunodeficiency virus patients in Morocco and association with immune status

OBJECTIVE

The objective was to determine if the type and number of skin diseases can be clinical indicators of underlying immune status in HIV1 disease by estimating and correlating with the CD4 count and CDC stage.

MATERIALS AND METHODS

This was a retrospective cross-sectional descriptive study. All consecutive patients infected with HIV1 followed at the Dermatology Department of Rabat Military Hospital between January 2008 and January 2017 were studied for dermatological manifestations, CD4 count and CDC clinical stage.

RESULTS

A total of 170 patients with 304 dermatological manifestations were included. The most common dermatoses were fold dermatophytic infections (67%), genital warts (43%), herpes zoster (21%), xerosis (21%), and oral candidiasis (12%). The number of dermatologic manifestations was significantly greater in patients with CD4 count less than 200/mm³ or in stage C of the CDC classification. Five types of skin diseases (dermatophyte infections of the folds, genital warts, shingles, oral candidiasis, and seborrheic dermatitis) were significantly associated (P < 0.05) with CD4 count <200/mm³ . Seborrheic dermatitis was the only one skin disease significantly associated with AIDS stage. In multivariate analysis, genital warts (OR = 0.3, 95% CI 0.10-0.92) are independently associated with CD4 count less than 200 CD4/mm³ .

CONCLUSIONS

Skin manifestations not only act as markers but also reflect the underlying immune status. Seborrheic dermatitis and genital warts appear to be a marker of immune status, and seborrheic dermatitis appears to be associated with CDC stage C, especially in their chronic and severe forms.

Inflammatory dermatoses in human immunodeficiency virus

Various inflammatory dermatoses have been described in association with human immunodeficiency virus (HIV) infection. These either present in the usual way or in varied atypical presentations. This article gives a brief review about the etiopathogenesis and clinical presentation of the common inflammatory dermatoses associated with HIV such as psoriasis, reactive arthritis, seborrheic dermatitis, eosinophilic folliculitis, pruritic papular eruption, photosensitivity disorders prurigo nodularis, atopic dermatitis, and ichthyosis.

Treatment of Dermatological Conditions Associated with HIV/AIDS: The Scarcity of Guidance on a Global Scale

Background. Skin diseases associated with Human Immunodeficiency Virus (HIV) infection are associated with significant morbidity and mortality. In resource-limited settings, nondermatologists and lay health care providers on the front line of HIV care provide much of the treatment for these conditions. Objective. To evaluate guidelines for treatment of HIV-related skin conditions and assess their accessibility, comprehensiveness, and quality of evidence employed. Methods. A review was undertaken of all national and society guidelines which included treatment information on the ten highest burden HIV-related skin conditions. The search strategy included gray and peer-reviewed literature. Results. Of 430 potential guidelines, 86 met inclusion criteria, and only 2 were written specifically to address HIV-related skin diseases as a whole. Treatment information for HIV-related skin conditions was embedded within guidelines written for other purposes, primarily HIV/AIDs treatment guidelines (49%). Development of guidelines relied either partially or completely on expert opinion (62%). Only 16% of guidelines used gradation of evidence quality and these were primarily from high-income countries (p = 0.001). Limitations. Due to the nature of gray literature, not all guidelines may have been identified. Conclusion. This review highlights the need for evidence-based summary guidelines that address treatment for HIV-related skin conditions in an accessible format.

Dermatophytosis and immunovirological status of HIV-infected and AIDS patients from Sao Paulo city, Brazil

Over the past decades, more people became infected with human immunodeficiency virus (HIV) and developed acquired immunodeficiency syndrome (AIDS). Because of that the incidence of fungal infections rose dramatically. It happened because this virus can modify the course of fungal diseases, leading to altered clinical pictures. The aim of this study was to evaluate epidemiological and biological aspects of dermatophytosis in HIV-positive and AIDS patients living in the city of São Paulo, Brazil. A total of 84 (44 HIV-positive and 40 AIDS) patients were enrolled in this study. The patients were tested for dermatophyte infections, as well as for the CD4(+) /CD8(+) and HIV viral load counts. Tinea unguium was most frequently observed in AIDS patients, whereas Tinea pedis was mostly observed in HIV-positive patients. The most frequent dermatophyte species was Trichophyton rubrum. CD4(+) counts and CD4(+) /CD8(+) ratios were not associated with a higher risk for dermatophytosis. On the other hand, viral load higher than 100 000 copies/ml was associated with a higher frequency of dermatophytosis. The results suggest to that although dermatophytosis is common in HIV-positive and AIDS patients, the degree of immunosuppression does not seems to correlate with increased risk of this fungal infection. In addition, high viral load as a predictive risk factor for dermatophyte infection should be subject of further evaluations.

Systemic mycoses in immunodepressed patients (AIDS)

Infectious and noninfectious skin diseases are observed in about 90% of HIV patients, and their incidence increases and is more severe as the immune system weakens. Cutaneous manifestations are considered good clinical predictors for the immunological condition of the patient with AIDS and the introduction of highly effective antiretroviral therapy totally changed the prognosis of the mycoses, among other diseases associated with AIDS, permitting longer survival and acceptable level of quality of life for these patients. This contribution describes the systemic mycoses that are more frequent in the seropositive population, that is, patients with HIV/AIDS, which are cryptococcosis, histoplasmosis, coccidioidomycosis, blastomycosis, paracoccidioidomycosis, sporotrichosis, penicilliosis, and aspergillosis. Their causative agents, mode of transmission, clinics, laboratorial diagnosis and therapy, in the aspects related to immunodepressed patients, are reviewed.

Rapid detection and typing of Molluscum contagiosum virus by FRET-based real-time PCR

A fluorescence resonance energy transfer (FRET)-based real-time PCR (RT-PCR) was developed for very sensitive and specific detection of Molluscum contagiosum virus (MCV), as well as reliable differentiation of the two MCV subtype genetic lineages, MCV1 and MCV2, in a single reaction. The assay employs modified primers specific for the viral MC021L gene and uses two novel FRET hybridization probes to detect polymorphisms specific for each of the two subtypes. The sensitivity of the assay at a 95% detection level for both MCV subtypes was 3.3 DNA copies/reaction and the dynamic range was nine orders of magnitude, discriminating 10-10(9) viral genome equivalents/reaction. Post-amplification probe-specific dissociation analysis differentiated the two viral subtypes reliably in all tested concentrations. Testing of 43 tissue specimens clinically diagnosed as MCV lesions showed complete agreement with the results obtained with previously described MCV specific MC080R Taqman RT-PCR and MC021L whole gene sequencing. The novel assay is simple, robust and easy to perform, and may be of great value for clinical and epidemiological studies of MCV infections and related conditions.

Toxic exanthems in the adult population

Frequently the internist is confronted with the nonspecific exanthematous eruption. While often a sign of a benign and self-limiting process, an exanthem also might herald the development of a more severe systemic syndrome. Infections, immune-mediated processes, drug reactions, a neoplasm, and familial syndromes with poor prognoses might all manifest initially with an exanthem. A thorough history and complete physical examination should be performed on all patients who present with an exanthem. Characterization of the exanthem morphology, other physical examination findings, and review of systems can help guide laboratory testing and ensure prompt diagnosis and early treatment of potentially life-threatening conditions. This article provides a brief overview of the conditions that must be considered in the evaluation of an ill patient with an exanthem.

Dermatologic Manifestations of Underlying Infectious Disease among Illicit Injection-Drug Users

Background:

Drug use patterns and serious bloodborne infections commonly have dermatologic manifestations among illicit injection-drug users (IDUs).

Objective:

To assess how self-reported skin conditions of IDUs may correlate with underlying infectious diseases after adjustment for drug use patterns.

Methods:

Prospective analysis of factors associated with self-reports of skin rashes, cellulitis, oral lesions, and lymphadenopathy obtained from 1,065 IDUs enrolled in a large cohort study. Variables potentially associated with each outcome were evaluated using multivariate generalized estimating equations.

Results:

In multivariate analyses, drug use patterns were associated with cellulitis, whereas human immunodeficiency virus (HIV) infection and hepatitis C (HCV) were not. HCV infection was independently associated with skin rashes (odds ratio [OR] 1.85; 95% Cl 1.17–2.94). HIV infection was independently associated with lymphadenopathy (OR 2.00; 95% CI 1.52–2.63), skin rash (OR 2.12; 95% CI 1.57–2.86), and oral lesions (OR 14.95; 95% CI 9.41–23.76).

Conclusions:

Self-reports of IDUs, which could easily be obtained as part of a functional inquiry in a clinical setting, correlate with specific drug use patterns and underlying bloodborne infections.

Identification and genotyping of molluscum contagiosum virus from genital swab samples by real-time PCR and Pyrosequencing

BACKGROUND

Laboratory diagnosis of molluscum contagiosum virus (MCV) is important as lesions can be confused with those caused by Cryptococcus neoformans, herpes simplex virus, human papillomavirus, and varicella-zoster virus.

OBJECTIVES

To develop a rapid method for identifying patients infected with MCV via swab sampling.

STUDY DESIGN

Two dual-labeled probe real-time PCR assays, one homologous to the p43K gene and one to the MC080R gene, were designed. The p43K PCR was designed to be used in conjunction with Pyrosequencing for confirmation of PCR products and discrimination between MCV1 and MCV2.

RESULTS

Both PCR assays were optimized with respect to reaction components, thermocycling parameters, and primer and probe concentrations. The specificities of both PCR assays were confirmed by non-amplification of 38 known human pathogens. Sensitivity assays demonstrated detection of as few as 10 copies per reaction. Testing 703 swabs, concordance between the two real-time PCR assays was 99.9%. Under the developed conditions, Pyrosequencing of the p43K PCR product was capable of providing enough nucleotide sequence to definitively differentiate MCV1 and MCV2.

CONCLUSIONS

These real-time PCR assays can be used for the rapid, sensitive, and specific detection of MCV and, when combined with Pyrosequencing, can further discriminate between MCV1 and MCV2.

Prevalence and factors associated with dry skin in HIV infection: the FRAM study

OBJECTIVE

Complaints of dry skin in HIV-infected individuals were reported after the advent of HAART. The objective of the study was to evaluate the prevalence of dry skin and associated factors in HIV-infected and control subjects.

DESIGN

Cross-sectional.

METHODS

A total of 1026 HIV-infected subjects and 274 controls [from the Coronary Artery Risk Development in Young Adults (CARDIA) study, a population-based study of cardiovascular risk assessment] in the Study of Fat Redistribution and Metabolic Change in HIV infection (FRAM) had skin assessed by self-report and examination. Multivariable logistic regression identified factors associated with dry skin.

RESULTS

Self-reported dry skin was more prevalent in HIV-infected subjects than controls. In multivariable analysis, HIV infection was associated with self-reported dry skin. In HIV-infected men, current indinavir use, CD4 cell count less than 200 cells/microl and recent opportunistic infections were associated with dry skin. Indinavir use had an elevated risk in men with CD4 cell counts of 200 cells/microl or greater but not with CD4 cell counts less than 200 cells/microl. In HIV-infected women, a CD4 cell count less than 200 cells/microl was associated with dry skin; indinavir use did not reach statistical significance but, as in men, indinavir use had an elevated risk in those with higher CD4 cell counts than in those with CD4 cell counts less than cells/microl.

CONCLUSION

Dry skin is more common in HIV-infected individuals than controls. In HIV-infected individuals, low CD4 cell counts and indinavir use in those with higher CD4 cell counts are associated with dry skin.

Skin Disease in HIV-Positive Persons Living in Puerto Rico

OBJECTIVES

To determine the frequency of skin disease in persons infected with the human immunodeficiency virus (HIV), to validate the agreement of self-reported skin condition(s) versus objective data obtained by physical examination, and to describe the characteristics of HIV-positive persons with skin disease in Puerto Rico.

DESIGN

Descriptive correlational design.

SETTING AND PARTICIPANTS

Ninety-five HIV-positive adults in San Juan, Puerto Rico. Ninety-five adults who were HIV-positive participated.

RESULTS

Ninety (94.7%) participants had skin disease and/or signs or symptoms suggestive of disease. Diseases most often reported were onychomycosis (n=16; 17.8%) and nongenital warts (n=11; 12.2%). Signs and symptoms reported were dryness (n=59; 65.6%), itch (n=58; 64.4%), erythema (n=30; 33.3%), induration (n=13; 14.4%), postinflammatory hyperpigmentation (n=9; 10.0%), and excoriation (n=9; 10.0%). Kappa index confirmed the relationship between self-reported skin condition or signs and symptoms and the diagnosis of a skin disease by the physician (k=.42). Positive predictive value was 97.7% (95% confidence interval [CI], 94.7%-100%). Condyloma acuminata was associated with male gender (chi2=4.09, P=.043). Tinea pedis (P=.0215), excoriations (P=.002), and prurigo nodularis (P=.0096) were associated with having a low CD4 cell count.

CONCLUSIONS

This study shows that persons infected with HIV can identify significant skin manifestations that are associated with the diagnosis of a skin disease. This validates the use of self-reporting of skin conditions in these patients and points to the importance of educating patients and providers to report patient skin problems. Although the high prevalence of skin disease found in this study population supports a need for improving dermatologic care in HIV-infected patients, the findings of such prevalent cutaneous disease can also provide caretakers with ample evidence to suspect and, therefore, test for HIV infection.

Inflammatory Noninfectious Dermatoses of HIV

Since the advent of HIV/AIDS, a variety of inflammatory noninfectious skin conditions have been described in HIV-infected patients. This review will discuss a group of inflammatory, noninfectious dermatoses that, although not exclusive to HIV/AIDS, are commonly observed in HIV-infected patients and pose an apparent paradox in a disease that supposedly involves suppression of cellular immunity.

Cutaneous markers of HIV infection

Despite the development of laboratory methods, dermatological symptoms are a basic index of the presence and physical course of HIV infection. HIV infection usually undergoes a long latent period, proceeds to a period of immunodeficiency-related symptoms, and ends in an advanced immunodeficiency state characterized by opportunistic infections and neoplasms. Occasionally, dermatological manifestations can be the first signs of asymptomatic disease, indices of advanced immunodeficiency, or symptoms of opportunistic infections or neoplasms. The variety of symptoms and signs for the skin during the course of HIV infection is a consequence of the progressing immunodeficiency and therefore indicates the underlying disorder. The use of these manifestations is a challenge for clinical praxis.

Cutaneous Manifestations of HIV: A Primer

PURPOSE

To provide physicians and nurses with an overview of the characteristics and treatments for skin lesions associated with HIV/AIDS.

TARGET AUDIENCE

This continuing education activity is intended for physicians and nurses with an interest in identifying and managing skin lesions in patients with HIV/AIDS.

OBJECTIVES

After reading the article and taking the test, the participant will be able to: 1. Identify the characteristics of skin lesions associated with HIV/AIDS. 2. Identify treatment options for skin lesions associated with HIV/AIDS.

Osseous Kaposi sarcoma in an HIV-positive patient

A case of osseous Kaposi sarcoma in a 35-year-old man is described. The patient (HIV-positive for 8 years) suffered from cutaneous Kaposi sarcoma and presented with right-sided chest pain. He underwent a chest CT scan that revealed three osteolytic lesions involving rib and vertebra with large soft tissue masses, without cutaneous lesions at these sites. CT-guided core needle biopsy led to a histological diagnosis of Kaposi sarcoma.