Transitory acantholytic dermatosis (Grover) in an HIV infected patient

We report on a patient with HIV infection and persistent generalized lymphadenopathy (stage III of HIV infection), who developed transitory acantholytic dermatosis (Grover's disease). Both the clinical picture and the histological features were typical for Grover's disease; the skin eruptions subsided within 6 months.     

AIDS and HIV infections: uncommon presentations

Infection with HIV or AIDS has a great impact on skin diseases, not only by affecting the immune system and thereby host defense against bacterial, viral, or mycotic infection, but also by changing tumor immune response and autoimmune reactivity. In the present review, emphasis will be made on infectious diseases, including sexually transmitted disease, inflammatory skin disease, and neoplasias. Knowledge of changing disease pattern with HIV/AIDS may help the clinical dermatologist and venerologist to identify dermatoses and act in the most appropriate manner to support the patient.     

The cutaneous manifestations of HIV infection

Dermatologic disease is extremely common and varied in HIV-infected patients. While some cutaneous findings are nearly exclusive to HIV-seropositive individuals, many are found in the general population. However, HIV-infected individuals often have an increased prevalence or severity, atypical presentations, or difficulty with treatment of the disease. Immune reconstitution with HAART significantly reduces the prevalence of many dermatologic diseases, but also has associated cutaneous side effects. Correct and early diagnosis of skin disease in HIV-infected individuals allows for early management and improved quality of life. Because dermatologic manifestations may be the first clue of HIV infection, offering HIV testing to affected individuals can lead to early diagnosis and treatment of HIV infection and, ideally, a decrease in disease progression and transmission.     

Palatal necrosis in an AIDS patient: a case of mucormycosis

We report a case of rhinocerebral mucormycosis presenting in a patient with AIDS and review the literature on mucormycosis occurring in the setting of HIV disease. Mucormycosis in HIV is rare. However, it can be the presenting opportunistic infection in AIDS. Predisposing factors for Mucor infection in HIV disease include low CD4 count, neutropenia, and active intravenous drug use. Mucormycosis can present in the basal ganglia, the skin, the gastrointestinal tract, the respiratory tract, or may be disseminated. The disease may develop insidiously or may progress rapidly with a fulminant course. Therapy usually consists of surgical debridement/excision accompanied by intravenous amphotericin B.     

Papulosquamous disorders associated with human immunodeficiency virus infection

Papulosquamous eruptions are the most frequently seen cutaneous manifestations of human immunodeficiency virus (HIV) infection. Especially common and useful in making a diagnosis of HIV infection are seborrheic dermatitis, xerosis or ichthyosis, and a pruritic or papular eruption. There is some evidence from transgenic mice studies that the transactivating gene TAT and the HIV provirus may produce epidermal hyperplasia, either directly or through cytokine production, without associated immunodeficiency. The association of certain papulosquamous diseases, especially psoriasis, with HIV has opened up new avenues of research on pathogenesis of hyperproliferative skin disease.     

HIV-associated pruritus: etiology and management

With the advent of highly active antiretroviral therapy (HAART), life-threatening opportunistic infection has become less common in patients with HIV infection and longevity has increased dramatically. With increased longevity, the problems of living with a chronic disease have become more prominent in this patient population. Disorders such as fat redistribution and metabolic abnormalities can result from antiviral medications and from HIV disease itself. Pruritus is one of the most common symptoms encountered in patients with HIV. The spectrum of skin diseases in such patients encompasses dermatoses of diverse etiologies; a few are peculiar to patients with HIV while others are not. Some of these conditions may cause severe and sometimes intractable pruritus that provokes scratching, picking, disfigurement, sleep loss, and significant psychological stress. Moreover, the expense of ongoing medical treatments can be daunting. Skin rash can sometimes be the initial presentation of HIV infection or serve as a harbinger of disease progression. Causes of pruritus include skin infections, infestations, papulosquamous disorders, photodermatitis, xerosis, drug reactions, and occasionally lymphoproliferative disorders. Drug eruptions are particularly common in patients who are HIV positive, presumably as a result of immune dysregulation, altered drug metabolism, and polypharmacy. Itching can also result from systemic diseases such as chronic renal failure, liver disease, or systemic lymphoma. Workup of pruritus should include a careful examination of the skin, hair, nails, and mucous membranes to establish a primary dermatologic diagnosis. If no dermatologic cause is found, a systemic cause or medication-related etiology should be sought. Idiopathic HIV pruritus is a diagnosis of exclusion and should only be considered when a specific diagnosis cannot be established. The management of HIV-associated pruritus should be directed at the underlying condition. Phototherapy has been found to be useful in the treatment of several HIV-associated dermatoses and idiopathic pruritus as well. Unfortunately, some of the treatments that have been suggested for patients with HIV are anecdotal or based on small uncontrolled studies. The last decade has seen a surge in the utilization of HAART which, to some degree, reconstitutes the immune system and ameliorates some dermatologic diseases. On the other hand, some skin diseases flare temporarily when HAART is started. Unless frank drug allergy is suspected, HAART does not need to be stopped.     

Frequent and rare dermatological diseases in HIV patients

HIV patients develop a variety of infectious and non-infectious diseases of the skin and mucous membranes. Some of these serve as indicator diseases for a weakening immune system. While none of the dermatological complications is pathognomonic, conditions such as oral hairy leukoplakia, herpes zoster, thrush, and eosinophilic folliculitis should make physicians consider the possibility of underlying HIV disease. Moreover, one has to consider HIV if these skin diseases take an atypical or severe course, or if they do not respond properly to appropriate medication. Frequent and rare dermatoses occurring in HIV infection are discussed.     

Häufige und seltene dermatologische Erkrankungen bei HIV-Patienten

HIV patients develop a variety of infectious and non-infectious diseases of the skin and mucous membranes. Some of these serve as indicator diseases for a weakening immune system. While none of the dermatological complications is pathognomonic, conditions such as oral hairy leukoplakia, herpes zoster, thrush, and eosinophilic folliculitis should make physicians consider the possibility of underlying HIV disease. Moreover, one has to consider HIV if these skin diseases take an atypical or severe course, or if they do not respond properly to appropriate medication. Frequent and rare dermatoses occurring in HIV infection are discussed.     

Malignant melanoma associated with human immunodeficiency virus infection in three homosexual men

This report concerns three patients with human immunodeficiency virus (HIV) infection in whom malignant melanoma developed. One patient had metastatic malignant melanoma, one had iris melanoma, and one had a single skin melanoma. All three had lower absolute numbers of CD4+ cells than a control group, and the severity of their disease was inversely proportional to the absolute number of CD4+ cells. This report suggests an association between the immunodeficiency resulting from HIV infection and the development of malignant melanoma.     

Post-kala-azar dermal leishmaniasis in HIV-positive patients: A study of two cases

Cutaneous leishmaniasis and human immunodeficiency virus (HIV) co-infection is emerging as increasingly frequent and serious new disease. Leishmaniasis may be acquired before or after HIV infection. We describe two cases of post-kala-azar dermal leishmaniasis in HIV-positive patients. Both the patients had papulonodular lesions on upper extremities and back with low CD4 count. Slit skin smear with giemsa stain revealed Leishman Donovan (LD) bodies and skin biopsy of both the patients revealed lymphohistiocytic infiltrate with numerous intracytoplasmic LD bodies.     

Prevalence and clinical spectrum of skin disease in patients infected with human immunodeficiency virus

We examined 100 serial patients who were receiving care in a county outpatient immunodeficiency clinic and whose serum was positive by Western blot test for the human immunodeficiency virus (HIV). Skin disorders were found in 92% of these HIV-infected patients, with little difference in prevalence or severity in three clinical categories: patients with the acquired immunodeficiency syndrome, patients with acquired immunodeficiency syndrome-related complex, and those who were asymptomatic. Patients positive for HIV antibodies had significantly more skin disease, with the exception of dermatophytosis, than did a historical control population. A strong association was observed between the use of zidovudine and the absence of infection with Candida albicans. We conclude that there is a high prevalence of skin disease in HIV-positive patients who seek medical care, and that specialists in skin disease should be included in these patients' initial evaluation and continuing care.     

Bacillary angiomatosis

An infection with Bartonella henselae transmitted from domestic cats to humans by scratching normally leads to cat‐scratch disease. When the human host has severe immunosuppression or HIV infection, the potentially life‐threatening disease bacillary angiomatosis can develop. A 79‐year‐old man presented with livid‐erythematous, angioma‐like skin lesions. We considered a cutaneous infiltrate from his known chronic lymphocytic leukemia, Merkel cell carcinoma, cutaneous metastases of internal tumors, cutaneous sarcoidosis, mycobacterial infection and even atypical herpes simplex infection. The correct diagnosis was proven histologically and by PCR. Because of increasing numbers of immunosuppressed and HIV‐positive patients, as well as an infection rate of 13 % for B. henselae in domestic cats in Germany, one must be alert to the presence of bacillary angiomatosis.     

Skin manifestations in patients with HIV infection

Cutaneous manifestations are common in patients with HIV infection and mainly due to the immunodeficiency. In the initial stage of HIV infection, we frequently observe a rash of macular lesions. During the asymptomatic phase, the patients may typically show the following skin diseases: seborrhoic dermatitis, acneiform folliculitis, persistent herpes simplex, and infections with the human papilloma virus. In ARC and AIDS patients, 3 groups of skin disorders are found: cutaneous infections, skin tumors, and other mixed skin diseases. Herpes simplex and herpes zoster may develop into ulcerating and necrotising forms especially in patients with advanced immunodeficiency. The most frequent skin tumors in AIDS patients are the disseminated Kaposi's sarcoma and non-Hodgkin's lymphoma. More than 50% of the AIDS patients treated with trimethoprim/sulfamethoxazole developed a severe drug eruption. African and Caribbean patients with AIDS frequently suffer from pruritic skin lesions, the pathogenesis of which is not known. Aside from these cutaneous manifestations, a variety of other skin disorders have been reported in patients with HIV infection, ARC, or AIDS; future research will furnish definite proof whether they are correlated with HIV infection.     

Skin diseases and sexually transmitted diseases in HIV‐infected patients on HAART compared to a non‐infected population – results of a retrospective study

Background: The prevalence of skin diseases and sexually transmitted diseases has always played a special role in studying HIV infections, both because of immunosuppression and simultaneous transmission. In the early years of the HIV epidemic, skin diseases were often a pathognomonic sign in heavily immunosuppressed patients. With highly active antiretroviral therapy (HAART), HIV infection has become a treatable chronic disease. For this reason the spectrum as well as the prevalence of skin diseases has changed. Pathognomonic skin diseases have become rare and the wide spectrum today ranges from infectious to iatrogenic skin diseases. Patients and methods: From April to October 2007 166 HIV‐infected patients and 173 patients of a comparison group were surveyed in retrospect by means of a questionnaire about skin diseases and sexually transmitted diseases that appeared over the entire year 2006. Results and conclusions: The study confirmed the shift to a wide variety of mostly trivial skin diseases and away from severe opportunistic skin diseases. HIV‐infected patients today have more numerous skin problems than the non‐infected population and thus need regular dermatologic control examinations.     

Skin as an indicator for sexually transmitted infections

Cutaneous signs and skin conditions associated with sexually transmitted infections (STIs) are discussed. Syphilis, condyloma acuminata, and scabies are well-known STIs with cutaneous manifestations. Chlamydia and gonorrhea can also cause specific muco-cutaneous signs and symptoms. HIV often manifests itself through skin conditions. Dermatologists are pivotal in the timely diagnosis of HIV infection and play an important role in the disease prognosis and ongoing transmission. Anal intra-epithelial neoplasia (AIN), an HPV related precursor of anal carcinoma affecting HIV positive men, is a relatively new condition that many dermatologists will face in the future. STIs should be involved in the differential diagnosis when dermatologists are confronted with anogenital dermatoses, especially in patients with an increased risk for STIs.     

Cutaneous markers of HIV infection

Despite the development of laboratory methods, dermatological symptoms are a basic index of the presence and physical course of HIV infection. HIV infection usually undergoes a long latent period, proceeds to a period of immunodeficiency-related symptoms, and ends in an advanced immunodeficiency state characterized by opportunistic infections and neoplasms. Occasionally, dermatological manifestations can be the first signs of asymptomatic disease, indices of advanced immunodeficiency, or symptoms of opportunistic infections or neoplasms. The variety of symptoms and signs for the skin during the course of HIV infection is a consequence of the progressing immunodeficiency and therefore indicates the underlying disorder. The use of these manifestations is a challenge for clinical praxis.     

Search for evidence of a Th2 profile in HIV+ patients

BACKGROUND: Hypersensitivity dermatoses are common in human immunodeficiency virus-positive (HIV+) patients, particularly as the disease progresses. Studies have shown that a switch to T-helper 2 (Th2) might represent a turning point in HIV. This study investigated whether increases in the number of skin mast cells, immunoglobulin E (IgE) serum levels, and eosinophilia, involved in the Th2 response in allergic disease, might also be present in HIV+ patients. If so, these alterations might explain one of the mechanisms of skin hypersensitivity in these patients. METHODS: Forty-five skin biopsies from the normal skin of the upper arm of HIV+ patients and 15 controls were included in the study. HIV+ individuals were classified into three equal categories according to their immunologic status: Category I (< 200/microL), Category II (200-499/microL), and Category III (> 500/microL). Anti-tryptase antibody was employed in tissue sections to show mast cells; IgE serum levels and eosinophils in peripheral blood count were investigated; delayed-type hypersensitivity (DTH) skin tests (candidin, trichophytin, and PPD 2U) were evaluated. RESULTS: Normal cutaneous mast cell and eosinophil counts were the same in all categories and in the control group, but increased IgE levels (P < 0. 01) and DTH skin test anergy (P < 0.006) were observed among acquired immunodeficiency syndrome (AIDS) patients. CONCLUSIONS: The density of skin mast cells in HIV infection was not modified in the course of the disease. Mast cells do not seem to be primarily responsible for triggering hypersensitivity dermatoses among AIDS patients, although data in support of the Th2 response, as seen in increased IgE serum levels and DTH anergy, are present.     

Chronic actinic dermatitis as the presenting feature of HIV infection in three Chinese males

There have been a few reports in the literature of chronic actinic dermatitis (CAD) associated with HIV infection, mostly in African--Americans of skin type VI, where photosensitivity predated the diagnosis of HIV infection. We report three cases, all Chinese males with skin type III or IV, who presented to our centre with CAD, and in whom advanced asymptomatic HIV infection was subsequently diagnosed. All had CD4 cell counts less than 100 cells/ micro L, with no evidence of AIDS-related complex. They were treated conservatively with photoprotection and topical steroids with mild to moderate improvement. A comparison with nine previously reported cases is made. The pathogenesis of CAD is unclear, but predominance of CD8 cells in severe cases and reversal of the CD4 : CD8 ratio in lesional skin and peripheral blood of HIV-negative CAD patients has been observed. CAD may be consequent to, and a presenting feature of, advanced HIV infection.     

Photolichenoid plaques with associated vitiliginous pigmentary changes

A 49-year-old man with advanced HIV/AIDS on anti-retroviral therapy (HAART) and trimethoprim-sulfamethoxazole (TMP-SMX) presented with a several-month history of pruritic, erythematous, lichenified papules that coalesced into hyperkeratotic plaques on the trunk and extremities in a sun-exposed distribution. He shortly thereafter developed a progressive depigmentation over more than 80 percent of his body surface area. A biopsy specimen of an erythematous plaque on the trunk showed a superficial and mid-dermal infiltrate of lymphocytes with eosinophils, most consistent with either chronic lichenoid drug eruption or atypical lymphoproliferative disorder (ACLD) of HIV. The patient's lichenoid skin disease has persisted despite discontinuation of TMP-SMX, although it has improved partially with administration of topical glucocorticoids and acitretin. His depigmentation has continued to progress. We discuss the overlapping diagnostic entities which may be comprised by this patient's clinical disease, and highlight a unique presentation of the complex interaction between HIV infection and the skin.