Noninfectious Inflammatory Skin Diseases in HIV-Infected Individuals

Vasculite cutânea de pequenos vasos: subtipos e tratamento - Parte II

Vasculite cutânea de pequenos vasos refere-se a grupo de doenças geralmente caracterizado por púrpura palpável, causada por vasculite leucocitoclástica das vênulas pós-capilares. Vasculites podem variar em gravidade, podendo manifestar-se como doença autolimitada, com acometimento de único órgão, ou como doença sistêmica, acometendo múltiplos órgãos, e evoluir para quadro de falência de múltiplos órgãos e sistemas. Esse grupo de doenças apresenta-se como desafio para o dermatologista, incluindo classificação e diagnóstico, avaliação laboratorial, tratamento e a necessidade de seguimento cuidadoso. Neste artigo são revistos os subtipos de vasculites cutâneas dos pequenos vasos e as opções atuais de tratamento; apresenta-se também abordagem detalhada para o diagnóstico e o tratamento do paciente com suspeita de vasculite cutânea e sistêmica.

Prurigo nodularis: A review

Prurigo nodularis is a chronic condition characterized by a papulonodular pruriginous eruption of unknown aetiology. This condition is a difficult disease to treat and causes frustration to both the patient and the treating doctor. A variety of systemic conditions have been reported to be associated with prurigo nodularis. The mechanism by which these disorders may trigger prurigo nodularis is unknown. Nerve growth factor has been implicated in the pathogenesis of prurigo nodularis. Calcitonin gene-related peptide and substance P immunoreactive nerves are markedly increased in prurigo nodularis when compared with normal skin. These neuropeptides may mediate the cutaneous neurogenic inflammation and pruritus in prurigo nodularis. Topical or intralesional glucocorticoids are the treatment of choice. Other topical treatments such as topical vitamin D3, and topical capsaicin have also been reported to be effective. Oral treatments such as cyclosporin and thalidomide have been shown to improve both appearance of the skin and pruritus. We review the clinical features, associations, pathology, pathogenesis and treatment of prurigo nodularis.

Cutaneous vasculitis update

The classification of cutaneous vasculitis and its general principles, including clinical patterns, pathogenesis, and causes, are reviewed in this article. Several types of cutaneous vasculitis are discussed in detail, including Henoch-Schonlein purpura, erythema elevatum diutinum, and cutaneous polyarteritis nodosum. The approach to treatment for cutaneous vasculitis also is reviewed.

Cutaneous mucinoses and HIV infection

In the last few years cutaneous mucinoses have been reported with increased frequency in HIV patients. We report the occurrence of scleredema, reticular erythematous mucinosis and lichen myxoedematosus in three different HIV-infected patients, review the literature and discuss the possible relationship between mucin deposits and HIV infection. This is the first report of scleredema and the second of reticular erythematous mucinosis in an HIV-infected patient. Only the association of HIV infection with lichen myxoedematosus seems to be more than coincidental.

Cutaneous small-vessel vasculitis

Cutaneous small-vessel vasculitis (CSVV) refers to a group of disorders usually characterized by palpable purpura; it is caused by leukocytoclastic vasculitis of postcapillary venules. CSVV can be idiopathic or can be associated with a drug, infection, or underlying systemic disease. Initially, the pathogenesis of CSVV is immune complex related, but in its later stages different pathogenetic mechanisms may intensify the reaction and lymphocytes may predominate in the infiltrate. Cure requires elimination of the cause (ie, drugs, chemicals, infections, food allergens) when possible, as well as therapy with nonsteroidal antiinflammatory agents, corticosteroids, dapsone, potassium iodide, fibrinolytic agents, aminocaproic acid, immunosuppressive agents (ie, cyclophosphamide, azathioprine, methotrexate, cyclosporine) or even monoclonal antibodies, depending on disease severity.

Eosinophils are not a clue to the pathogenesis of granuloma annulare

Eosinophils are variably present in biopsy specimens of granuloma annulare (GA). A retrospective study of 77 biopsy specimens from 73 patients with GA was performed to quantitate eosinophils and correlate the findings with both histologic and clinical features. Specimens were divided into absent, low (10 > x > or = 1 eosinophils per 3 sections), and high (x > or = 10 eosinophils per 3 sections) eosinophil groups and evaluated for eight histologic and 11 clinical features. Eosinophils were identified in 66% (51/77) of biopsy specimens, with 51.9% (40/77) and 14.3% (11/77) in the low and high eosinophil groups, respectively. Clinically, patients in the high eosinophil group were found to be significantly younger with a propensity towards nonannular, localized disease. These patients also did not have diabetes or use systemic medications. Histologically, the presence of eosinophils was strongly associated with palisaded architectural pattern and the presence of necrobiosis. Eosinophils were not present in areas of necrobiosis but were found predominantly perivascularly. A moderate to marked lymphocytic infiltrate at the periphery of the granulomas and reactive vessel changes were common in all three groups, but vasculitis was not identified. In summary, this study showed eosinophils to be commonly present in GA but was unable to correlate their presence with specific clinical or histologic features supportive of an allergic precipitant. A cell-mediated immune mechanism is likely involved in GA, with eosinophils recruited nonspecifically by mediators released during granuloma formation.

Simultaneous occurrence of two rare cutaneous markers of poor prognosis in myelodysplastic syndrome: erythema elevatum diutinum and specific lesions

We report the concomitant occurrence of erythema elevatum diutinum and specific skin lesions in a patient with a myelodysplastic syndrome (MDS). This patient's course, and review of other reported cases, support the opinion that neutrophilic dermatoses are associated with a poor prognosis of MDS. The simultaneous appearance of these manifestations could be the consequence of a particular chemotactism of myeloid cells, expressed after acute transformation.

Cutaneous sarcoid-like granulomas in primary immunodeficiency disorders

We report the occurrence of cutaneous sarcoid-like granulomas in one patient with common variable immunodeficiency and another with 'thymoma and hypogammaglobulinaemia'. To our knowledge, this is the first time that such skin lesions have been described in patients with primary immunodeficiency. These granulomas may be attributed to a combination of interleukin-2 deficiency and a profound CD4 lymphopenia. The lesions are similar to the non-infectious 'papular eruption' associated with human immunodeficiency virus infection, and might reflect a common pathogenic mechanism.

The spectrum of vasculitis in human immunodeficiency virus-infected patients. A clinicopathologic evaluation

OBJECTIVE

To delineate the different types of inflammatory vascular diseases (IVD) occurring in patients with human immunodeficiency virus (HIV) infection.

METHODS

Muscle, nerve, or skin biopsy specimens from 148 symptomatic HIV-infected individuals were reviewed, and subgroups of vasculitis were identified using the American College of Rheumatology (ACR) 1990 clinicopathologic criteria for the classification of vasculitis.

RESULTS

IVD was documented in 34 patients (23%) and included necrotizing arteritis (3 patients), non-necrotizing arteritis (1 patient), neutrophilic IVD (7 patients), mononuclear IVD (17 patients), and other small vessel inflammatory changes (6 patients). According to the ACR criteria, 11 patients could be classified as having a distinct category of vasculitis, including polyarteritis nodosa (4 patients), Henoch-Schönlein purpura (1 patient), and drug-induced hypersensitivity vasculitis (6 patients), and 23 were classified in the group "other vasculitis, type unspecified." One patient had hepatitis B virus surface antigenemia, 2 had cryoglobulinemia, and 2 were coinfected by human T lymphotropic virus type I. Cytomegalovirus inclusions and antigens were found in endothelial cells in 1 patient. HIV antigens and genome were detected in perivascular cells of 2 of the 3 patients with necrotizing arteritis; in 1, HIV-like particles were seen by electron microscopy. Immune deposits were found in small vessel walls in 5 skin biopsy samples showing small vessel vasculitis and in the muscle of the 3 patients with necrotizing arteritis.

CONCLUSION

A wide range of inflammatory vascular diseases may occur in HIV-infected individuals. Vascular inflammation appears multifactorial and may result from HIV-induced immunologic abnormalities and exposure to a variety of xenoantigens, such as HIV itself, other infectious agents, and drugs.