Homme rouge and the acquired immunodeficiency syndrome

Cutaneous malignancy and human immunodeficiency virus disease

Certain skin cancers occur with increased frequency or altered course in patients infected with HIV. Malignant melanoma and squamous cell carcinoma are examples of cutaneous malignancies that have a more aggressive course in patients with HIV. Others, such as basal cell carcinoma, appear more frequently in this population but do not appear to be more aggressive. The incidence of HIV-associated Kapsosi's sarcoma has markedly decreased since the advent of HIV antiretroviral therapy. Our understanding of the pathogenesis of this malignancy and its unique management issues are fully reviewed. Cutaneous T-cell lymphoma (CTCL) is rare in this population. Other types of cutaneous lymphoma and HIV-associated pseudo-CTCL are discussed. This article addresses prevention, treatment, and follow-up strategies for this at-risk population.

LEARNING OBJECTIVE

At the completion of this learning activity, participants should be familiar with the unique epidemiology, clinical course, and management of cutaneous malignancy in patients infected with HIV.

Erythroderma: a comparison between HIV positive and negative patients

Background Erythroderma has protean underlying causes. There have been isolated case reports suggesting an association between erythroderma and the human immunodeficiency virus (HIV).

OBJECTIVE

To describe and characterize further the prevalence, etiology, and metabolic sequelae of erythroderma in HIV positive and negative patients. In a subset of patients, clinicopathologic correlation was performed.

METHOD

One hundred and thirty-eight consecutive patients were prospectively recruited over a one and a half year period at the skin clinic of King Edward VIII Hospital. Demographic, clinical, biochemical, and histologic data were recorded.

RESULTS

Seventy-five per cent of the patients were black, 22.5% Indian, and 2.5% white. The men to women ratio was 1.9 : 1. The mean age was 34. 7 years (range, 1 month to 85 years). Forty-three per cent of patients were HIV positive, of whom 90% were black. The commonest causes of erythroderma in the total sample were atopic dermatitis (23.9%), psoriasis (23.9%), and drug reactions (22.5%). The commonest cause in the HIV positive group was drug reactions (40.6%), the commonest being ethambutol (30.8%). HIV positive patients had a significantly lower (P < 0.05) white cell count (7.6 vs. 10.5 x 109 /L), hemoglobin (11.1 vs. 12.6 g/dL), platelets (278.3 vs. 378.0 x 109 /L), and albumin (25.4 vs. 28.7 g/L) and significantly higher serum urates (0.6 vs. 0.4 mM/L) than HIV negative patients. HIV positive patients did not have a significant increase in the number of episodes of erythroderma. Clinicopathologic correlation was greatest with psoriasis in the HIV negative group and with psoriasis and drug reactions in the HIV positive group.

CONCLUSIONS

A large proportion of erythrodermic patients in this study were HIV positive. Inflammatory dermatoses were the commonest cause of erythroderma in all the patients studied. Drug reactions were the commonest cause in HIV positive patients. In the young black patient, erythroderma may be a marker for HIV infection.

Update on the cutaneous manifestations of HIV infection. Clinical and pathologic features

Skin is the most commonly affected organ in patients with HIV. As such, cutaneous manifestations of HIV infection have been the subject of intense scrutiny as well as the topic of many articles. A broad range of infectious and noninfectious skin lesions may develop during the course of the disease. This article discusses the clinical and pathological cutaneous manifestations of HIV infection.

Atypical cutaneous lymphoproliferative disorder in patients with HIV infection

BACKGROUND

An inflammatory pruritic eruption which is characterized histologically by CD8+, atypical lymphocytes has been described in human immunodeficiency virus (HIV)-infected patients. This disorder has been described as "pseudo-Sezary" or a "cutaneous T cell lymphoma (CTCL)-simulant", however, as these patients do not resemble CTCL clinically, and the relationship between this entity and CTCL is unclear, a more descriptive term is "atypical cutaneous lymphoproliferative disorder" (ACLD). The purpose of this study is to categorize the clinical, histologic, and immunophenotypic features of 16 HIV-infected patients with this skin disorder seen at the New York Department of Veterans Affairs Medical Center.

METHODS

A retrospective chart review was conducted on 16 HIV-infected patients with a histologic diagnosis of an atypical cutaneous lymphoproliferative infiltrate on skin biopsy. Skin biopsies were reviewed, and histologic features noted. Immunophenotyping was performed on 14 out of 16 samples; electron microscopy was performed on samples from five patients. Clinical manifestations, disease course, medication history, and response to treatment were noted.

RESULTS

The patients presented with a pruritic, persistent, generalized, papular eruption. Pigment changes, including hyperpigmentation and hypopigmentation were common. Histologically, lesional biopsies were characterized by a superficial and deep polymorphous infiltrate with atypical lymphocytes which were CD8+ predominant, Ki-1 negative, and occasionally CD7 antigen depleted. Sezary-like cells were present in the infiltrate in four out of five patients by electron microscopy. None of the patients has systemic manifestations of lymphoma; however, one of the 16 patients eventually developed frank CTCL.

CONCLUSIONS

HIV-infected patients can present with a pruritic, widespread disorder, often with pigment changes characterized by an atypical cutaneous lymphocytic infiltrate. This clinicopathologic disorder is a rare, reactive inflammatory condition which generally occurs in late stage HIV infection and rarely progresses to frank lymphoma.

Update on cutaneous manifestations of HIV infection

The skin is affected in virtually all patients with HIV infection. Many articles and several books have been published that deal with these disorders for a number of reasons. First, cutaneous disease may serve as the initial or only problem that the patient suffers for much of the course of the HIV infection. Second, serious opportunistic infections may present for the first time in the skin, so that a skin lesion may be a harbinger of the patient's having a life-threatening illness. Third, skin disorders in these patients may appear unusual and hence may not be accurately diagnosed by clinical inspection alone. Furthermore, response to treatment may be poorer than expected. Thus, skin diseases in the HIV-infected patient are important and, in some cases, may be the most debilitating element of the patient's condition.

Spontaneous regression of granulomatous mycosis fungoides in an HIV positive patient

The development of mycosis fungoides in HIV-positive patients is uncommon. We describe the granulomatous type of mycosis fungoides in an HIV-positive patient whose cutaneous lesions regressed without treatment. In addition to HIV seropositivity and mycosis fungoides, he had a long history of pulmonary sarcoidosis. Immunophenotyping of the cutaneous lymphoid infiltrates revealed a predominance of CD4+ T cells, and monoclonality was demonstrated by T-cell gene rearrangement studies. The regression of mycosis fungoides in this patient was associated with a falling peripheral blood CD4 T-cell count.

Cutaneous T-cell lymphoma associated with HIV infection

BACKGROUND

Mycosis fungoides-type cutaneous T-cell lymphoma is uncommon in association with human immunodeficiency virus type 1 (HIV-1) infection. Reported patients have a high incidence of CD8+ T-cell lymphomas and erythroderma, are usually severely immunocompromised, and rapidly die. Chronic, more typical patch-plaque mycosis fungoides-type cutaneous T-cell lymphoma in association with HIV-1 infection has not been reported.

OBJECTIVE

We report two cases of stage 1B epidermotropic mycosis fungoides-type cutaneous T-cell lymphoma in HIV-1-infected men with no history of the acquired immunodeficiency syndrome.

METHODS

Clinical and laboratory data, including lesional immunophenotypic and immunogenotypic findings of two patients with HIV-1-associated cutaneous T-cell lymphoma, were studied.

RESULTS

Immunohistochemical analysis of skin determined the lesional infiltrate of one patient to be CD8+ (Leu-2+), CD7- (Leu-9-), and Leu-8- with germline lesional skin and blood T-cell receptor genes. The other was CD4- (Leu-3+), CD2- (Leu-5-), CD7- (Leu-9-), and Leu-8- with beta-chain T-cell receptor gene rearrangement in lesional skin and blood. Circulating Sézary cells were not detected in either patient. Peripheral CD4/CD8 T lymphocyte numbers did not appear to correlate with cutaneous disease activity or the predominant lesional T-cell subtype. Both patients were responsive to standard therapies and have experienced prolonged survival in excess of that generally reported for HIV-1-associated systemic peripheral and cutaneous T-cell lymphomas.

CONCLUSION

In the absence of severe immunodeficiency, HIV-1-infected patients with concomitant cutaneous T-cell lymphoma may follow a more typical slowly progressive course.