Dermatoses among Brazilian HIV-positive patients: correlation with the evolutionary phases of AIDS

Nail dermatophytoma in HIV-infected patients in Cali, Colombia

INTRODUCTION

A dermatophytoma is a mass of hyphae that is observed at direct examination, it responds poorly to treatment with antifungal drugs, some authors have proposed that it is actually a biofilm. This pathology is underdiagnosed, and its true incidence is unknown.

OBJECTIVES

This study presents the clinical findings of dermatophytoma in HIV/AIDS patients from Colombia presenting onychomycosis.

MATERIAL AND METHODS

A transversal observational descriptive study was carried out in a third level university hospital. One hundred thirty HIV positive patients diagnosed using ELISA and Western Blot that presented nail lesions on their hands and/or feet compatible with onychomycosis were included. Samples taken from affected nails were observed in direct examination with KOH and seeded onto Sabouraud agar, mycosel agar and dextrose-potato agar. Molds were identified based on macroscopic and microscopic characteristics.

RESULTS

Six (4.6%) individuals presented dermatophytoma. Average age was 43 years (range 33-50); nails more commonly affected (5/6) were on the toes, principally the hallux. Clinical manifestations included a yellow or white, rounded or linear dense area on the nail. Superficial white onychomycosis was present in 83.3% of the patients. Fungal cultures were obtained in only 5 patients; Trichophyton mentagrophytes complex was found in 2 individuals while T. rubrum, T. tonsurans and Epidermophyton floccosum were in the other 3. Average cell count for CD4⁺T lymphocytes was 86.8 cells/mm³ (range 9-282).

CONCLUSIONS

This is the first report in Colombia of dermatophytoma in HIV/AIDS patients, most of them had a CD4+ T lymphocytes count less than 200 cells/mm3. Several clinical forms of onychomycosis were observed, the most frequent was the white superficial onychomycosis.

Prevalence of pruritic papular eruption among HIV patients: A cross-sectional study

Introduction:

Pruritic papular eruption (PPE) remains as one of the most common cutaneous manifestations in HIV-infected patients. Proper knowledge about understanding the risk factors associated with this disease may help to decrease the prevalence of PPE.

Objective:

The present study was conducted to determine the prevalence of PPE in HIV-infected patients and to correlate between the severity of PPE and individual CD4 count.

Materials and Methods:

This was a cross-sectional study, conducted in Palakkad Antiretroviral Therapy Centre, Kerala, between March 2017 and April 2017. A total of 100 HIV patients with evidence of multiple itchy skin lesions of 1-month duration were included in the study. Severity of lesion was evaluated using an objective “rash severity scale” for PPE. Data were coded and analyzed.

Results:

Prevalence of PPE was 11.35% in our study. The mean age of the study population was 41.17 ± 12. Male-to-female ratio was 1:2. In our study, 97% of the patients were giving history of mosquito bite. Most of the patients (40%) had moderate type of PPE. In our study, majority (86%) had a CD4 count of more than 200, and the incidence of PPE was more frequently seen in patients with CD4 count more than 200 cells which was statistically significant.

Conclusion:

PPEs are unique dermatosis, which is having a devastating impact on the quality of life, stigmatizing them in their communities. Thus, recognizing those lesions helps in allowing better treatment of this distressing condition.

Dermatophytosis in patients with human immunodeficiency virus infection: clinical aspects and etiologic agents

Dermatophytosis in individuals with human immunodeficiency virus infection seems to manifest with atypical, multiple, or extensive lesions more frequently. In addition, there are reports of presentations with little inflammation, called anergics. Less common etiologic agents have been isolated in these individuals, such as Microsporum species. To describe clinical aspects and etiologic agents of dermatophytosis in individuals with human immunodeficiency virus (HIV) infection. Patients with clinical diagnosis of dermatophytosis underwent scarification for mycological diagnosis through direct microscopic examination and fungal isolation in culture on Sabouraud dextrose agar. Sixty individuals had a clinical hypothesis of dermatophytosis. In 20 (33.3%) of the 60 patients, dermatophytosis was confirmed through a mycological study. Tinea corporis, diagnosed in 14 patients, was the most frequent clinical form, followed by tinea unguium in 7, tinea cruris in 5, and tinea pedis in 1 patient. Most of the lesions of tinea corporis were anergic. Five patients with tinea unguium had involvement of multiple nails, with onychodystrophy as the predominant subtype. Multiple cutaneous lesions occurred in 3 patients and extensive cutaneous lesions in 4. Regarding the agent, Trichophyton rubrum was the most commonly isolated. The high occurrence of anergic skin lesions and involvement of multiple nails, especially as onychodystrophy, corroborates the hypothesis that atypical, disseminated, and more severe presentations are common in individuals with HIV infection. However, no Microsporum species was isolated even in atypical, extensive, or disseminated cases, in disagreement with previous reports. Therefore, the approach of squamous lesions in HIV-positive patients must include a mycological study, in view of the possibility of anergic dermatophytosis, to promote the introduction of a suitable therapeutic agent.

Factors associated with pruritic papular eruption of human immunodeficiency virus infection in the antiretroviral therapy era

BACKGROUND

Pruritic papular eruption (PPE) of HIV is common in HIV-infected populations living in the tropics. Its aetiology has been attributed to insect bite reactions and it is reported to improve with antiretroviral therapy (ART). Its presence after at least 6 months of ART has been proposed as one of several markers of treatment failure.

OBJECTIVES

To determine factors associated with PPE in HIV-infected persons receiving ART.

METHODS

A case-control study nested within a 500-person cohort from a teaching hospital in Mbarara, Uganda. Forty-five cases and 90 controls were enrolled. Cases had received ART for ≥ 15 months and had an itchy papular rash for at least 1 month with microscopic correlation by skin biopsy. Each case was individually matched with two controls for age, sex and ART duration.

RESULTS

Twenty-five of 45 cases (56%) had microscopic findings consistent with PPE. At skin examination and biopsy (study enrolment), a similar proportion of PPE cases and matched controls had plasma HIV RNA < 400 copies mL(-1) (96% vs. 85%, P = 0·31). The odds of having PPE increased fourfold with every log increase in viral load at ART initiation (P = 0·02) but not at study enrolment. CD4 counts at ART initiation and study enrolment, and CD4 gains and CD8(+) T-cell activation measured 6 and 12 months after ART commencement were not associated with PPE. Study participants who reported daily insect bites had greater odds of being cases [odds ratio (OR) 8·3, P < 0·001] or PPE cases (OR 8·6, P = 0·01).

CONCLUSIONS

Pruritic papular eruption in HIV-infected persons receiving ART for ≥ 15 months was associated with greater HIV viraemia at ART commencement, independent of CD4 count. Skin biopsies are important to distinguish between PPE and other itchy papular eruptions.

Frequency, pattern, and extent of skin diseases in relation to CD4+ cell count among adults with human immunodeficiency virus infection or acquired immunodeficiency syndrome in Osogbo, southwestern Nigeria

BACKGROUND

Skin diseases characterize all stages of human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) and contribute significantly to associated morbidity and mortality.

OBJECTIVES

The aim of this study was to document the prevalences, patterns, and extents (severity) of skin diseases and their relationships with immunologic status in HIV/AIDS patients.

METHODS

A total of 140 HIV/AIDS patients in different stages of HIV infection and 140 controls were recruited. Skin diseases were documented and CD4+ cell counts determined in all subjects. Severity was assessed according to the body surface area affected (using the Wallace rule of nines and the rule of palm) for lesions that tended to be widespread. The number of digits involved was counted for lesions involving the nails. Intensity of pain was graded for specific conditions such as herpes zoster. Chi-squared statistics and Pearson correlations were determined.

RESULTS

Mean±standard deviation age was 35.04±8.83 years in the patient group and 32.21±8.30 years in the control group. The prevalences and patterns of skin diseases in HIV/AIDS patients were similar to those reported in previous studies. Most commonly found dermatoses were oral candidiasis (n=28, 20.0%), pruritic papular eruption (n=27, 19.3%), xeroderma (n=23, 16.4%), dermatophytosis (n=22, 15.7%), and fluffy hair (n=19, 13.6%). The presence of specific skin lesions represented a better correlate with immunosuppression than cutaneous extents. However, the extents of viral warts and multiple blue–black nails correlated significantly with CD4+ cell count. The presence of a lighter hair color phenotype signifies a lower CD4+ cell count than a softer hair phenotype.

CONCLUSIONS

The presence of specific skin lesions correlates more strongly with a low CD4+ cell count than does the extent of their distribution, except in cases of viral warts. The presence of and higher numbers of nails affected with blue–black nail hyperpigmentation suggest severe immunosuppression.

Biologia molecular aplicada às dermatoses tropicais

São apresentados conceitos básicos sobre célula, código genético e síntese protéica, e sobre algumas técnicas de biologia molecular, tais como PCR, PCR-RFLP, seqüenciamento de DNA, RT-PCR e immunoblotting. São fornecidos protocolos de extração de nucleotídeos e de proteínas, como salting out no sangue periférico e métodos do fenol-clorofórmio e do trizol em tecidos. Seguem-se exemplos comentados da aplicação de técnicas de biologia molecular para o diagnóstico etiológico e pesquisa em dermatoses tropicais, com ênfase na leishmaniose tegumentar americana e hanseníase.

Testes de contato e HIV: avaliação comparativa quanto à confiabilidade dos resultados

FUNDAMENTOS: A ocorrência da dermatite de contato alérgica em pacientes soropositivos para o HIV foi pouco estudada até o momento (apenas relatos de caso). Os testes de contato são considerados o exame complementar padrão para a investigação diagnóstica desse tipo de reação alérgica e não foram avaliados cientificamente nesse grupo de pacientes. OBJETIVO: Avaliar a aplicabilidade dos testes de contato em pacientes soropositivos para o HIV. MÉTODO: Estudo transversal, descritivo, com controles. Um grupo com 16 pacientes soropositivos para o HIV foi comparado a um grupo com 32 pacientes com sorologia desconhecida para o HIV com relação à positividade aos testes. Foi realizada análise estatística bivariada com nível de significância p < 0,05. RESULTADOS: Entre o grupo de pacientes soropositivos para o HIV, sete (43,75%) tiveram testes positivos, e, entre o grupo de pacientes que rotineiramente realizaram testes de contato (e com sorologia desconhecida ao HIV), 18 (56,25%) tiveram testes positivos. CONCLUSÕES: Os achados deste trabalho sugerem que, apesar da imunodeficiência, a memória imunológica específica e a capacidade de responder positivamente aos testes podem permanecer. Dessa forma, esse recurso diagnóstico importante para as alergias dermatológicas não perderia validade ao ser aplicado no conjunto de pacientes que convivem com o HIV.

Can response of a pruritic papular eruption to antiretroviral therapy be used as a clinical parameter to monitor virological outcome?

BACKGROUND

A pruritic papular eruption (PPE) is a common skin manifestation observed in 12-46% of persons with HIV infection living in tropical countries.

OBJECTIVE

To determine whether PPE responds to HAART and whether monitoring PPE severity could be used as a clinical marker to predict virological outcome in resource-limited settings where viral load testing is not available.

METHODS

The study enrolled 53 patients with PPE for at least 1 month before starting a first-line HAART regimen as part of a prospective study. CD4 cell count and viral load were measured at enrolment and every 3 months. A scoring system was developed to evaluate the PPE severity by asking two questions. Over the last month how itchy has your skin been? Over the last month how has itching interfered with your sleep?

RESULTS

Median CD4 cell count was 15 cells/mul and median viral load 268 663 copies/ml. All patients initiated a regimen containing a nonnucleoside reverse transcriptase inhibitor. Mean PPE score declined from 3.9 at enrolment to 0.1 at 24 months. In 37 (86%) of the 43 patients with at least 6 months of follow-up data, the PPE disappeared and never returned. Patients with viral load > 400 copies/ml at months 9 and/or 12 had significantly higher PPE scores at months 9 to 12 than the patients with < 400 copies/ml.

CONCLUSIONS

In most patients, PPE disappears during HAART and PPE severity scores were higher in patients whose first-line HAART failed to control plasma viral load.

Pruritic Papular Eruption in HIV

Pruritic papular eruption (PPE) is characterized chronic pruritus and symmetric papular eruptions on the trunk and extremities with the absence of other definable causes of itching in an HIV-infected patient. PPE seems to be much more prevalent in less developed regions of the world. The etiology of this distressing condition is unclear, although an inappropriate response to an exogenous agent, such as arthropod bites, may underlie the pathogenesis. Identifying PPE's association with the immune dysregulation of HIV and distinguishing this condition from other pruritic disorders found in HIV-infected patients is important for optimal management.

Acquired ichthyosis

Acquired ichthyosis (AI) is a nonhereditary cutaneous disorder characterized by dry, rough skin with prominent scaling that involves significant portions of the body. It has been associated with malignancies; autoimmune/inflammatory, metabolic, endocrine, and infectious diseases; and medication use. Most microscopic studies of AI exhibit hyperkeratosis with a reduced or absent granular layer. Because AI has been linked to a variety of conditions, the workup of a patient presenting with this finding can be complex. We present an update on AI to provide clinicians with direction regarding the assessment and treatment of patients presenting with AI. An algorithm for the evaluation of patients presenting with AI is provided.

Pruritic papular eruption associated with HIV-etiopathogenesis evaluated by clinical, immunohistochemical, and ultrastructural analysis

Pruritic Papular Eruption with Human Immunodeficiency Virus infection (PPE-HIV) is characterized by symmetrically distributed papules with pruritus in the skin of patients suffering advanced HIV infection. Although known since 1985, the etiology of this symptomatic dermatitis is unclear. We set out to characterize the phenotype of the infiltrating cells and the cytokine profile in the lesions, as an attempt to contribute to determining its etiopathogenesis. Clinical data and histological, immunohistochemical, and ultrastructural features of skin biopsies from 20 HIV patients with PPE were studied. The histopathological aspects, cell immunophenotypes, and cytokine expressions in the lesions where quantified and compared to perilesional skin, and to those in the clinically normal skin of HIV patients without PPE-HIV (n=11) and those in normal skin samples from HIV negative individuals (n=10). PPE-HIV occurred mainly in HIV patients with mean CD4+ counts of 124.6 +/- 104 lymphocytes/mm3. Furthermore, their eosinophil counts were significantly increased. The skin lesions were characterized by a predominantly perivascular dermal lymphohistiocytic inflammatory infiltrate. Langerhans cells were normally distributed in the epidermis and seen among the cellular components of dermal infiltrates. The density of CD8+ lymphocytes was elevated and the density of CD4+ cells was reduced in dermal infiltrates. Interleukin 5 was the predominant cytokine in the lesions. Electron microscopic analysis didn't disclose HIV or other infectious agents in the lesions. These results refute the hypothesis of an infectious etiology of PPE-HIV. CD8+ lymphocytes and Langerhans cells seem to have roles in the pathogenesis of PPE-HIV. The increased frequency of IL5 was associated with abundant eosinophils in the lesions, suggesting a type Th2 response in this dermatitis.

Dermatoses em pacientes infectados pelo HIV com a contagem de linfócitos CD4

OBJETIVO: Correlacionar a prevalência das doenças dermatológicas entre pacientes infectados pelo HIV com a contagem de linfócitos CD4. MÉTODOS: Estudo de série de casos realizado na região de Caxias do Sul, Estado do Rio Grande do Sul. Os dados foram coletados por meio da revisão de prontuários de pacientes com infecção pelo HIV internados em hospital público (198 pacientes, período de março de 1998 a junho de 2002) ou atendidos no ambulatório central universitário (40 pacientes, período de março a junho de 2002). As variáveis analisadas foram: idade, sexo, contagem de linfócitos CD4, carga viral e doenças dermatológicas apresentadas pelo paciente. Os testes estatísticos utilizados foram o Teste t de Student, o de Spearman e o do qui-quadrado. RESULTADOS: A freqüência de doença dermatológica foi de 67,2% entre os pacientes hospitalizados e de 75,0% entre os pacientes ambulatoriais. Candidíase oral foi a doença dermatológica mais prevalente. Na população hospitalar, a média de células CD4 foi menor entre os pacientes com doença dermatológica dos sem doença dermatológica (142,34 células/mm³ vs 512,35 células/mm³, respectivamente; p=0,018). O mesmo fenômeno foi observado na população ambulatorial (138,88 células/mm³ e 336,21 células/mm³, respectivamente; p=0,001). Verificou-se, em ambas as populações, uma correlação negativa entre a contagem de CD4 e o número total de doenças dermatológicas apresentadas pelo paciente (p=0,000, população hospitalar; p=0,000, população ambulatorial). CONCLUSÕES: As doenças dermatológicas são altamente prevalentes entre os pacientes infectados pelo HIV, sendo que a freqüência e o número dessas manifestações correlacionam-se bem com o status imunológico do paciente e com a progressão da doença.

Human T lymphotropic virus 1 and hepatitis C virus as risk factors for inflammatory dermatoses in HIV-positive patients

BACKGROUND

Dermatoses are common in HIV-infected patients. Infections caused by human T lymphotropic virus 1 (HTLV-1) and hepatitis C virus (HCV) are also associated with dermatoses, and their coinfection with HIV has been described. The aim of this study was to investigate the influence of HTLV-1 and HCV in increasing the frequency of dermatological diseases in HIV-positive patients.

METHODS

This cross-sectional study included patients infected with HIV and dermatoses, who consulted the Service of Dermatology Outpatient Clinic of the Health Department of the State of Rio Grande do Sul, in southern Brazil. Their care included the taking of a history and a physical examination, complementary examinations for diagnostic purposes, HTLV-1 and HCV serology, measurement of CD4 lymphocyte count and HIV viral load, and recording of the use of antiretroviral drugs.

RESULTS

One hundred and five HIV-positive patients with dermatoses were evaluated. Positivity for HTLV-1 occurred in 12 patients (12.5%) and that for HCV in 35 patients (38%). The most frequently found dermatoses were infectious and inflammatory in origin. A significant statistical association was found between HIV and HTLV-1 coinfection, with dermatoses of inflammatory origin (P = 0.03; CI = 1.14-2.83).

CONCLUSIONS

It is important to consider the high rate of positivity for HTLV-1 and HCV in the HIV-positive patients (12.5 and 38%, respectively). A higher risk of inflammatory dermatoses is found in patients who are simultaneously positive for HTLV-1 and HIV, indicating the possible importance of this coinfection in the development or worsening of certain dermatological diseases.

Regressão de psoríase em paciente HIV-positivo após terapia anti-retroviral

A síndrome da imunodeficiência adquirida foi reconhecida pela primeira vez como nova doença em 1981 devido à associação atípica de sarcoma de Kaposi e pneumonia por Pneumocystis carinii em homens. A pele é sede freqüente de doenças conseqüentes a essa infecção. A psoríase é dermatose crônica que afeta proporção que varia de 1,3 a 5% dos pacientes infectados com HIV. Portadores de psoríase que apresentem formas clínicas exacerbadas e dificuldade de resposta terapêutica devem ser investigados para possível infecção pelo HIV. É relatado caso de paciente do sexo masculino, de 44 anos, que iniciou com lesões eritêmato-escamosas no couro cabeludo, nos cotovelos, joelhos, palma das mãos, planta dos pés, além de comprometimento ungueal, após infecção pelo HIV. Confirmado o diagnóstico de psoríase e introduzida a terapia anti-retroviral, houve melhora significativa das lesões.

Alterações dermatológicas em crianças com Aids e sua relação com categorias clínico-imunológicas e carga viral

FUNDAMENTOS: Desde o início da epidemia da Aids as dermatoses têm sido freqüentemente descritas em pacientes com essa doença, com relatos de casos atípicos e estudos de séries de pacientes adultos; no entanto, há poucas publicações sobre alterações cutâneas em pacientes pediátricos com Aids. OBJETIVOS: Estudo prospectivo para avaliar a presença de dermatoses em 40 pacientes pediátricos com Aids. MÉTODOS: Quarenta pacientes, com idade inferior a 13 anos e portadores de Aids, foram estudados por um período de seis meses para avaliação de: número de alterações dermatológicas; suas características clínicas; distribuição conforme as categorias clínico-imunológicas e o valor da carga viral. RESULTADOS: A prevalência de dermatoses foi de 82,4%, na primeira consulta, e, no acompanhamento longitudinal, 92,5% dos pacientes tiveram alterações dermatológicas, com proporção de cinco diagnósticos por doente. As crianças com classificação clínico-imunológica grave e carga viral acima de 100.000 cópias/ml apresentaram maior número de alterações dermatológicas quando comparadas àquelas das categorias clínico-imunológicas leves. A proporção de diagnósticos por paciente na categoria clínica C foi de 6,8 e na A de 3,6; na categoria imunológica grave, de sete, e na leve de 3,7; e na carga viral > 100.000 de 7,3, e na < 100.000 de 4,2 (todos com significância estatística). CONCLUSÃO: As dermatoses foram freqüentes nas crianças com Aids e ocorreram em maior número nos pacientes pertencentes às categorias graves. A elevada freqüência de alterações da pele nos pacientes pediátricos com a doença indica ser imprescindível sua avaliação dermatológica minuciosa e freqüente.

Perfil epidemiológico de infectados pelo vírus HIV com dermatoses em Natal/RN

FUNDAMENTOS: Não há registro de dermatoses em infectados pelo vírus HIV no Rio Grande do Norte, embora haja 899 casos acumulados de AIDS em adultos entre janeiro de 1983 e agosto de 2000 e coeficientes de mortalidade por cem mil habitantes de 3,80 e 2,47, nos anos de 1995 e 1997, respectivamente, coincidindo essa diferença de valores, com o uso de antiretrovirais. OBJETIVOS: Descrever as características epidemiológicas de infectados, a freqüência de dermatoses e suas gravidades em usuários e não usuários de antiretrovirais. MÉTODOS: Foram incluídos 172 pacientes conforme a classificação do CDC/1992; descrevendo-se o uso de antiretrovirais e dermatoses neles presentes. RESULTADOS: A amostra teve 83,72% de homens, com média de idade de 37,17 anos, contaminados por via sexual (96,5%), heterossexuais predominantes (54,7%). As doenças cutâneas mais freqüentes foram as virais, fúngicas e miscelânia. O percentual médio da pele atingida pelas dermatoses foi 12,5%. A média da carga viral foi 109.114,05 cps/ml, e a de linfócitos T CD4+ foi 383,15 céls/mm³, estando 81,4% destes, em uso de antiretrovirais. CONCLUSÕES: O perfil epidemiológico dos infectados pelo vírus HIV no RN não difere das outras regiões brasileiras. Estudos analíticos que minimizem bias de confusão são necessários para aferir o grau de interferência do uso de antiretrovirais nesses indivíduos.

Dermatoses em indivíduos infectados pelo vírus HIV com diferentes graus de imunossupressão

FUNDAMENTOS: A contagem sangüínea de linfócitos T Helper CD4+ e o número de cópias de RNA viral são marcadores laboratoriais da progressão de imunodeficiência induzida pelo vírus HIV. OBJETIVOS: Relacionar os marcadores do grau de imunidade em infectados pelo HIV aos aspectos clínicos das dermatoses neles presentes. MÉTODOS: A amostra compreendeu 172 pacientes, submetidos a quantificações de linfócitos T CD4+ e CD8+, pela técnica de citometria de fluxo; quantificações de RNA viral pela técnica de amplificação de ácidos nucléicos (Nuclisens). Foram classificados em pacientes com e sem imunossupressão acentuada, a partir da classificação clínico-laboratorial da infecção pelo HIV do CDC/1992. RESULTADOS: O percentual médio da pele atingida pelas dermatoses foi 12,5% e a média do número de dermatoses por doente foi 2,08. As dermatoses neoplásicas e do grupo miscelânia predominaram nos indivíduos com valores de linfócitos T CD4+•200 células/mm³, enquanto valores de linfócitos T CD4+>200 células/mm³ em pacientes com infestações por artrópodes. CONCLUSÃO: O número de dermatoses por doente mostrou ser marcador da evolução de imunossupressão (p=0,003). A extensão percentual da pele atingida por dermatoses não se prestou a medir gravidade das dermatoses em infectados pelo HIV (p=0,6058). As contagens de linfócitos T CD4+ e CD8+ e da carga viral foram eficientes medidores do grau de imunossupressão dos infectados com dermatoses (p=0,003).

Cytokines in the pruritic papular eruption of HIV

BACKGROUND

The immunopathogenic mechanism of the pruritic papular eruption (PPE) of patients with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) is poorly understood, and the objective of the present study was to determine the concentration of the serum cytokines interleukin-2 (IL-2), IL-4, IL-5, IL-10, IL-12, and gamma-interferon (gamma-IFN) in an attempt to recognize the pattern of CD4+/CD8+ lymphocytes occurring in this dermatosis.

MATERIALS AND METHODS

The study was conducted on 11 HIV-positive PPE patients, matched for sex and age with eight HIV-infected patients with no dermatosis and 10 healthy HIV-negative individuals. Cytokines were quantified by enzyme-linked immunoabsorbent assay (ELISA) using monoclonal antibodies (R & D Systems) and the data were analyzed by the Mann-Whitney, Kruskall-Wallis, and Spearman correlation tests.

RESULTS

An increased concentration of IL-2 was observed in both the HIV-positive (77.65 pg/mL, P < 0.001) and PPE (20.42 pg/mL, P < 0.05) groups when compared with the HIV-negative group (9.50 pg/mL). The IL-2 concentration was significantly higher (P < 0.05) in the HIV-positive group than in the PPE group. Similarly, the gamma-IFN concentration was higher in the HIV-positive (14.97 pg/mL) and PPE (12.67 pg/mL) groups when compared with the HIV-negative group (8.58 pg/mL). The IL-12 concentration was similar in the PPE and HIV-positive groups (1.82 and 1.68 pg/mL, respectively), but higher than in the HIV-negative group (1.17 pg/mL). The same occurred with IL-5 (17.78, 17.79, and 15.74 pg/mL, respectively). There was no significant difference in IL-4 concentration among the PPE, HIV-positive, and HIV-negative groups (10.95, 7.88, and 10.16 pg/mL, respectively), and the same was observed for IL-10 (22.41, 21.13, and 20.92, respectively). There was a negative correlation between serum gamma-IFN concentration and peripheral CD4+ lymphocyte number (r = - 0.6256) in the PPE group (P < 0.05).

CONCLUSIONS

The lower levels of IL-2 and gamma-IFN and the negative correlation between gamma-IFN and peripheral CD4+ lymphocytes may indicate an early phase of immunosuppression in PPE.

Epidemiology and prevalence of onychomycosis in HIV-positive individuals

BACKGROUND

Patients who are human immunodeficiency virus (HIV) positive are predisposed to the development of infections including tinea pedis and onychomycosis. While smaller studies have been reported, there has been no large study evaluating the prevalence of onychomycosis in HIV-positive individuals, or comparing the development of onychomycosis in a typical temperate area with that in a typical tropical area.

METHODS

HIV-positive individuals were evaluated at five clinics: four in Ontario, Canada and one in Sao Paulo, Brazil. The subjects were asked questions to determine the epidemiology of onychomycosis in HIV-positive individuals. The feet were examined and nail material was obtained for mycologic examination to determine the causative organism of onychomycosis.

RESULTS

A total of 500 subjects were examined (415 men and 85 women; age (mean +/- SE), 39 +/- 0.4 years; 400 Canadian, 100 Brazilian). The racial origins of the Canadian patients were: Caucasian, 83.8%; Asian, 4.3%; African-American, 8.1%; Hispanic, 3.3%; American Indian, 0.3%. The Brazilian origins were: Caucasian, 68.7%; African, 18.1%; mixed race, 13.3%. Abnormal appearing nails and mycologic evidence of onychomycosis were present in 200 (40.0%) and 116 (23.2%), respectively, of 500 subjects. The prevalence of onychomycosis in the Canadian and Brazilian samples was 24.0% (96 of 400) and 20.0% (20 of 100), respectively. The projected prevalence of onychomycosis in HIV-positive individuals in Canada was 19.9% (95% CI: 16.0-23.9%) after taking into account the age and sex distribution of HIV-positive individuals in the population. When nails appeared clinically abnormal, the prevalence of onychomycosis was 50.5% (Canada, 51.3%; Brazil, 45.5%). For comparison, published data indicate that the prevalence of onychomycosis in immunocompetent individuals living in Canada is 6.9%. The clinical presentation of onychomycosis for the whole sample (n=500) was: distal and lateral subungual onychomycosis (DLSO), 20.0%; white superficial onychomycosis (WSO), 3.6%; proximal subungual onychomycosis (PSO), 1.8% (Canadian and Brazilian samples: DLSO 21.2% vs. 15.0%, WSO 3.3% vs. 5.0%, and PSO 1.5% vs. 3.0%). The distribution of the causative fungal organisms was: dermatophytes: Candida species: nondermatophyte molds, 73:2:2 (Canadian and Brazilian samples: dermatophytes 95.5% vs. 90.9%, Candida species 3.0% vs. 0%, and nondermatophyte molds 1.5% vs. 9.0%). The use of protease inhibitors, reverse transcriptase inhibitors, or oral antifungal agents did not make a significant difference in the prevalence of onychomycosis for both the Canadian and Brazilian groups. Patients with onychomycosis were aware of their abnormal appearing nails (chi2(1)=69.7, P<0.001), embarrassed by the appearance of their nails (chi2(1)=29.7, P<0.001), and took measures to hide their nails from other individuals. A higher proportion of individuals with onychomycosis experienced discomfort compared with those without the disease (chi2(1)=9.0, P=0.003). Also, individuals who experienced pain in the nail unit were more likely to have onychomycosis (risk odds ratio (ROR), 2.2; 95% CI: 1.0-4.7, P=0.05).

CONCLUSIONS

The prevalence of onychomycosis in HIV-positive individuals in the sample of 500 patients was 23.2%. In the Canadian (n=400) and Brazilian (n=100) samples, the corresponding figures were 24% and 20%, respectively, with the predominant causative organisms being dermatophytes. The projected prevalence of onychomycosis in HIV-positive Canadians is 19.9%. Predisposing factors include a CD4 count of approximately 370, a positive family history of onychomycosis, a history of tinea pedis, and walking barefoot around pools. Onychomycosis can be symptomatic, a source of embarrassment, and a potential cause of morbidity.

Kininogens and kallikrein in pruritic papular eruption

Pruritic papular eruption (PPE) is a common inflammatory cutaneous lesion observed only in HIV/AIDS patients. Since kinin is an important mediator in inflammation, we evaluated the levels of total kininogen (TKg), low and high molecular weight kininogen (LKg and HKg, respectively) and the activity of kallikrein in plasma of 11 patients (median age = 31.4) with AIDS and PPE (PPE+), eight patients (median age = 31.5) with AIDS without PPE (PPE-) and in 12 control individuals (median age = 32.9) with anti-HIV negative serum. Kininogens were measured by ELISA and expressed in median (m) of BK Equivalent/ml plasma and the kallikrein by its activity upon selective chromogenic substrate, and expressed as U kallikrein/ml of plasma. TKg or LKg concentrations in PPE+ patients (m = 4.11 and 4.5) and in PPE- patients (m = 6.23 and 4.54) were significantly higher when compared to control (m = 2.10 and 1.17). Compared to controls PPE- patients presented similar values of HKg (m = 0.78 and 0.61), whereas PPE+ patients presented undetectable values. Plasma kallikrein activity was significantly decreased in PPE+ and PPE- (m = 0.6 and 0.89, respectively) when compared with control individuals (m = 2.23).

The spectrum of mucocutaneous manifestations during the evolutionary phases of HIV disease: an emerging Indian scenario

Third world countries, including India, lack sophisticated investigations to assess the progression of HIV disease. Hence, this study was undertaken to determine the clinical mucocutaneous markers of HIV disease and to establish its relationship with the stage of the disease. This was an observational institutional study of 75 patients with mucocutaneous disorders and HIV infection recruited over a period extending from September of 1996 to June of 1998. The patients with mucocutaneous lesions were staged according to the Centers for Disease Control classification system for HIV infection (1986). The most frequent mode of acquisition of HIV infection was heterosexual contact (96%). The patients were broadly categorized into two groups. The AIDS group was comprised of patients who were in group IV and the early HIV infection group included patients in group II and III; none were detected in group I. Forty-eight cases belonged to the AIDS group, and 27 belonged to the early HIV infection group. A total of 207 dermatoses were diagnosed and grouped as fungal, viral, bacterial, or miscellaneous. The common mucocutaneous disorders in order of frequency observed in this study were: candidiasis, dermatophytosis, herpes simplex, oral aphthae, xerosis/ichthyosis, scabies, HPV infection, molluscum contagiosum, and psoriasis. Xerosis/acquired ichthyosis and giant molluscum contagiosum were characteristically seen in group IV of HIV disease, whereas oral candidiasis, oral aphthae, papular dermatitis of HIV, and psoriasis were early warning signs. The mean number of dermatoses per patient in group IV was 3.15; in group III, it was 2.41; and in group II, it was 1.5. There was a statistically significant difference between the early HIV infection group and AIDS group with regard to number of dermatoses. Apart from syphilis and human papilloma virus infection, the treatment outcomes were satisfactory.