The diagnosis and management of HIV infection

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.

HIV in pregnancy

Pregnancy in individuals infected with HIV has become an important problem because of a fourfold rise of infection in women of childbearing age in the developed world. The incidence of vertical transmission varies in different continents and is highest in Africa. Transmission may occur in utero (antepartum), during delivery (intrapartum), or after birth (postpartum), occurring during the latter period, in many cases, through breastfeeding. Maternal viral burden around the time of delivery is the strongest determinant of the risk of disease transmission. While breastfeeding may account for up to one-third of cases of vertical transmission in Africa, the benefits of breastfeeding outweigh its risks, even in HIV infection, and breastfeeding is recommended in those areas. Treatment of the mother with antiretroviral agents significantly decreases the risk of vertical transmission.

Managing sexually transmitted diseases in adolescents

Control of sexually transmitted diseases (STDs) in adolescents is a primary responsibility of health care providers. Using the tools of history and physical examination, and drawing on the awareness of different stages of adolescent development, health care providers can define at-risk for STDs. This article discusses screening practices, disease control through reporting and preventive counseling, and treatment guidelines for common STD syndromes.

The pediatrician and the sexually active adolescent. A primer for sexually transmitted diseases

Sexual activity is a common practice among young adolescents, placing them at high risk for STDs, many of which have long-term consequences. Early diagnosis and treatment are essential to limit both the consequences and the spread of these infections. The clinician has a responsibility to the adolescent patient to recognize and treat these diseases. Using history and physical examination, the clinician should be able to determine an adolescent's risk for an STD, and, based on this risk, undertake the appropriate evaluations. Patient treatment, follow-up, and management of sex partners are then guided by the results of either presumptive or definitive diagnostic tests.