Common skin and mucosal disorders in HIV/AIDS

Exploring the association between erythema multiforme and HIV infection: some mechanisms and implications

Erythema multiforme (EM) is an immune-mediated mucocutaneous condition characterized by hypersensitivity reactions to antigenic stimuli from infectious agents and certain drugs. The most commonly implicated infectious agents associated with EM include herpes simplex virus (HSV) and Mycoplasma pneumoniae. Other infectious diseases reported to trigger EM include human immunodeficiency virus (HIV) infection and several opportunistic infections. However, studies focusing on EM and human immunodeficiency virus (HIV) infection are scarce. even though the incidence of EM among HIV-infected individuals have increased, the direct and indirect mechanisms that predispose HIV-infected individuals to EM are not well understood. In turn, this makes diagnosing and managing EM in HIV-infected individuals an overwhelming task. Individuals with HIV infection are prone to acquiring microorganisms known to trigger EM, such as HSV, Mycobacterium tuberculosis, Treponema pallidum, histoplasmosis, and many other infectious organisms. Although HIV is known to infect CD4 + T cells, it can also directly bind to the epithelial cells of the oral and genital mucosa, leading to a dysregulated response by CD8 + T cells against epithelial cells. HIV infection may also trigger EM directly when CD8 + T cells recognize viral particles on epithelial cells due to the hyperactivation of CD8 + T-cells. The hyperactivation of CD8 + T cells was similar to that observed in drug hypersensitivity reactions. Hence, the relationship between antiretroviral drugs and EM has been well established. This includes the administration of other drugs to HIV-infected individuals to manage opportunistic infections. Thus, multiple triggers may be present simultaneously in HIV-infected individuals. This article highlights the potential direct and indirect role that HIV infection may play in the development of EM and the clinical dilemma that arises in the management of HIV-infected patients with this condition. These patients may require additional medications to manage opportunistic infections, many of which can also trigger hypersensitivity reactions leading to EM.

Therapeutic challenges of psoriasis in the HIV‑infected patient: A case report

Psoriasis can be paradoxically associated with human immunodeficiency virus (HIV) infection, having a prevalence similar to the general population but with a more severe evolution. In the genetically predisposed patients with the CW^*0602 haplotype, HIV infection can be a triggering factor and a first sign of infection, and lesions can spontaneously remit with immune reconstruction after antiretroviral therapy. Our patient is a 34 year-old male with recent HIV infection, in spite of being for over 10 years the partner of an HIV-positive patient with whom the patient has two HIV-positive children. The patient was diagnosed with psoriasis 7 years ago and was treated topically. The physical examination at HIV diagnosis was overall favorable, with skin findings compatible with disseminated vulgar psoriasis. Following antiretroviral treatment with Triumeq the patient had a favorable viral response, with complete viral suppression after 12 weeks, but the pre-existent psoriasis lesions worsened. Methotrexate (MTX) treatment followed for 12 weeks, with partial improvement of psoriatic dermatitis. This medication was continued for 1 year, but the lesions reappeared, possibly due to treatment resistance. MTX treatment for psoriasis in the HIV-infected patient was beneficial, but limited to one year, leaving biologics as possible treatment following therapy under strict monitoring for adverse effects, T-lymphocyte CD4⁺ and viral levels.

Dermatological Opportunistic Infections in HIV Seropositive Patients: An Observational Study

Background and objective

In developing countries, the dermatological manifestation of the human immunodeficiency virus (HIV) has a high prevalence. Apart from the systemic infection that ensues HIV, skin manifestations form a major part of the disease burden. They can present with atypical forms, and necessary tools for diagnosis may not be available in rural and remote parts of the country. Hence, they can stay misdiagnosed or undiagnosed, contributing to the morbidity of the patients. We attempted to enumerate the dermatologic opportunistic infections (OIs) in Rajkot city, Gujarat, India, in order to disseminate knowledge regarding the same. 

Material and methods

It is a retrospective observational study. A total of 253 patients under treatment for HIV/acquired immunodeficiency syndrome (AIDS) at the ART Center (anti-retroviral therapy center) from 2011 to 2019 were included. The data recorded in the registry during the above-mentioned period were utilized in the study. The diagnoses of OIs were made clinically by multiple health care providers experienced in the field.

Result

Two hundred twenty-seven (227) of 253 (89.72%) of the patients had some form of dermatologic OI during the course of their treatment. Overall, fungal infections (33.03%) were most common, followed by bacterial infections (28.18%) and viral (14.55%) infections. Among the non-infectious causes, cheilitis/angular stomatitis topped the list. Among the STDs, herpes was the most common skin manifestation seen with a 10.57% prevalence. The CD4+ cell count for fungal infection ranged from 353-467 and was seen in stage 2 of the disease course. Bacterial infections were seen mainly during the early and middle stages of the disease while viral infections were most prevalent in stage 2 of the disease.

Conclusion

Skin manifestations can be useful clinical predictors of the disease stage, especially in resource-limited settings and in developing countries. They can present with unusual and atypical forms. Hence, knowledge about the prevalence of these OIs in a particular geographical area can be very useful for physicians in treating them and decreasing the disease burden.

The prevalence and spectrum of mucocutaneous disease in South African people living with HIV and accessing care at a district-level hospital

Background

Although the association between human immunodeficiency virus (HIV) and mucocutaneous diseases has been well studied within South African specialist centres, there is limited data from district-level hospitals. Available data may, therefore, fail to reflect the prevalence and full spectrum of dermatoses seen in people living with HIV (PLWH).

Objectives

To determine the prevalence and spectrum of dermatoses seen in PLWH.

Method

We conducted a cross-sectional, descriptive study of 970 PLWH (men and women, ≥ 18 years old) accessing care at Karl Bremer Hospital, a district-level hospital located in the Western Cape province, South Africa, between 01 September 2016 and 28 February 2017.

Results

The prevalence of mucocutaneous disease in this sample was 12.7% (95% confidence interval [CI] 0.11–0.15). Non-infectious dermatoses comprised 71.0% of the disorders. Pruritic papular eruption (20.0%) and seborrheic dermatitis (6.0%) were the most common non-infectious dermatoses. Tinea corporis (8.0%) and oral candidiasis (6.0%) were the most prevalent infectious dermatoses. There was no significant association between skin disease category (infectious or non-infectious dermatoses) and patient demographics (gender and ethnicity) or HIV-disease characteristics (CD4+ cell count, viral load and duration of antiretroviral therapy [ART]).

Conclusion

This study provides valuable scientific data on the prevalence and spectrum of mucocutaneous disease in PLWH attending a South African district-level hospital. Prospective studies conducted in other district-level centres across the country are required to determine the lifetime prevalence and spectrum of dermatoses in PLWH in the ART era.

Mucocutaneous manifestations in human immunodeficiency virus (HIV)-infected patients in Nouakchott, Mauritania

BACKGROUND

Mucocutaneous manifestations are one of the first clinical signs in patients infected with human immunodeficiency virus (HIV). To the best of our knowledge, there has been no previous study describing dermatologic manifestations in Mauritanians infected with HIV. The aim of the present study was to determine the profiles of mucocutaneous manifestations in relation to CD₄ T cell count in HIV-positive Mauritanian patients.

METHODS

A total of 86 adult patients aged > 18 years old attending the Ambulatory Treatment Center of the National Hospital of Nouakchott, Mauritania, with newly diagnosed HIV and who were not under antiretroviral treatment were included in the study in 2015. Dermatologic manifestations were documented before initiating antiretroviral treatment.

RESULTS

Most of the included patients were in clinical stage 3 of the World Health Organization classification at initial diagnosis, with the mean CD₄ T cell count (± SD) of 514 ± 319 cells/mm³ (range, 2-1328 cells/mm³ ), and 19 of 86 (22.1%) patients had CD₄ T cell counts below 200 cells/mm³ . More than half (64%) of newly diagnosed HIV-infected patients had dermatoses, including the following: pruritic papular eruption (44.2%), seborrheic dermatitis (4.7%), Kaposi's sarcoma (3.5%), extensive xerosis cutis (2.3%), drug-induced skin reactions (1.2%), and various infectious dermatoses (dermatophyte infections [16.3%], oral candidiasis [11.6%], herpes zoster [8.1%], and scabies [2.3%]). A low CD₄ T cell count (< 200 cells/mm³ ) was significantly correlated (P < 0.05) with the presence of following dermatoses: dermatophytosis, oral candidiasis, Kaposi's sarcoma, seborrheic dermatitis, and extensive xerosis cutis.

CONCLUSION

Mucocutaneous lesions occur throughout the course of HIV infection, and dermatologic findings in Mauritanian HIV-positive patients are similar to those of patients in other countries. Early detection of skin disorders in some patients may help establish the diagnosis of HIV and management of HIV-associated diseases, limiting the cost of care in low-resource countries.

Mucocutaneous Manifestations of HIV and the Correlation with WHO Clinical Staging in a Tertiary Hospital in Nigeria

Skin diseases are indicators of HIV/AIDS which correlates with WHO clinical stages. In resource limited environment where CD4 count is not readily available, they can be used in assessing HIV patients. The study aims to determine the mucocutaneous manifestations in HIV positive patients and their correlation with WHO clinical stages. A prospective cross-sectional study of mucocutaneous conditions was done among 215 newly diagnosed HIV patients from June 2008 to May 2012 at adult ART clinic, Wesley Guild Hospital Unit, OAU Teaching Hospitals Complex, Ilesha, Osun State, Nigeria. There were 156 dermatoses with oral/oesophageal/vaginal candidiasis (41.1%), PPE (24.4%), dermatophytic infections (8.9%), and herpes zoster (3.8%) as the most common dermatoses. The proportions of dermatoses were 4.5%, 21.8%, 53.2%, and 20.5% in stages 1–4, respectively. A significant relationship (using Pearson's Chi square with P value <0.05) was obtained between dermatoses and WHO clinical stages. Pearson's correlation coefficient showed a positive correlation between the number of dermatoses and the WHO clinical stages. Dermatoses can therefore serve as diagnostic and prognostic markers in resource limited settings to initiate HAART in clinical stages 3 and 4.

Cutaneous cytomegalovirus infection on multi dermatomal herpes zoster scars: an isotopic immune response

As more patients with human immunodeficiency virus (HIV) are surviving, despite severe immune suppression, clinicians are faced with atypical manifestations of both common and uncommon dermatoses. A 30-year-old black South African woman presented with a 10-month history of multiple chronic ulcers appearing on a multidermatomal herpes zoster (HZ) scar. The woman was infected with HIV, and her CD4 count was 45 cells/μL. Histology and PCR revealed cytomegalovirus (CMV) infection. This case highlights an unusual presentation of cutaneous CMV occurring as an isotopic immune response on a pre-existing multidermatomal HZ scar.