Disseminated cutaneous histoplasmosis in acquired immunodeficiency syndrome: report of 23 cases

Disseminated cutaneous histoplasmosis is an opportunistic infection in patients with acquired immunodeficiency syndrome. We report a series of 23 cases (21 men, two women; median age 29 years) with disseminated cutaneous histoplasmosis seen at two hospital centres. Most of the patients (21/23) were classified as stage C3. The most common dermatological findings were papules, crusting plaques, nodules and ulcers, mainly located on the face and chest. Of the 23 cases, 15 (65%) had pulmonary involvement. Amphotericin B and itraconazole were the main drugs used for treatment. Treatment response was variable: four of the patients were cured, six improved and remain stable, nine patients died, and four patients were lost to follow-up.     

Visceral leishmaniasis with cutaneous lesions in a patient infected with human immunodeficiency virus

Patients with subacute cutaneous lupus erythematosus (SCLE) have circulating antibodies to Ro/SSA directed to two antigenically distinct ribonucleoproteins of 60 kDa and 52 kDa. Three laboratory tests may be used to detect anti-Ro/SSA antibodies: counterimmunoelectrophoresis (CIE), enzyme-linked immunosorbent assay (ELISA) and immunoblotting (IB). Their relative efficacy and clinical correlations were ascertained. We determined anti-Ro/SSA antibodies with CIE, with two different ELISA methods (ELISA 1 and 2) and with IB in 29 SCLE patients. Anti-52 kDa and -60 kDa Ro/SSA antibodies were also assayed with IB. In addition, we determined antinuclear antibodies with indirect immunofluorescence, anti-Sm, anti-RNP, anti-La/SSB and anti-Ro/SSA antibodies with CIE and ELISA, and anti-nDNA and cardiolipin antibodies using an ELISA method. CIE detected anti-Ro/SSA antibodies in 22 patients while ELISA 1 and 2 did so in 17 and 18 patients, respectively. In five patients, IB revealed a reactivity to 60 kDa polypeptides and in two, a reactivity to 52 kDa polypeptides. Of these seven patients, four had a myocardial infarction. Of these, two reacted to the 52 kDa antigen and two to the 60 kDa antigen. A combination of techniques was often needed to detect all specificities. ELISA proved to be very specific and sensitive. The IB technique detected a group of patients with myocardial infarction. A case–control study is needed to confirm the data of cardiac involvement.     

Varicella in patients infected with the human immunodeficiency virus

In a retrospective study of 421 patients infected with human immunodeficiency virus, 15 (3.5%) had varicella. Twelve patients had a typical varicella. Complications were as follows: profuse eruption, 6; hemorrhagic eruption, 1; hepatitis, 5; and pulmonary involvement, 1; 1 patient developed an intravascular disseminated coagulation and died of varicella. Three patients with acquired immunodeficiency syndrome, having a history of varicella, presented with an atypical form of varicella with a small number of disseminated cutaneous poxlike lesions; 1 of these patients experienced three relapses of atypical varicella. Assay of serum antibodies to varicella zoster virus showed that, while typical varicella was the primary varicella zoster virus infection, atypical varicella was a reactivation of varicella zoster virus infection. Acyclovir was given to 11 patients and vidarabine to 1 patient. The one patient who died and the one who suffered a relapse had received acyclovir. Thus, varicella in patients infected with human immunodeficiency virus may be complicated and even lethal. Atypical forms of varicella could be, as is the case with herpes zoster, a reactivation of endogenous varicella zoster virus.     

Detection and typing of human papillomavirus in cutaneous warts of patients infected with human immunodeficiency virus type 1

BACKGROUND: Cutaneous warts are caused by human papillomavirus (HPV). To date, more than 120 different types of HPV are known, of which 80 have been completely characterized. Prevalence studies on types of HPV present in cutaneous warts have been carried out in immunocompetent individuals and immunosuppressed organ allograft recipients, but not in human immunodeficiency virus (HIV)-positive patients. OBJECTIVES: To determine the HPV types present in cutaneous warts of HIV-infected patients. METHODS: Twenty-five biopsies of cutaneous warts from HIV-infected patients and 14 samples from control non-HIV-infected patients were studied. HPV detection was performed by polymerase chain reaction using two sets of primers: MY09/MY11 and RK91. The type of HPV was determined by restriction fragment length polymorphism analysis and direct sequencing of the amplified products. RESULTS: HPV DNA was detected in 64% of cutaneous warts from HIV-infected patients and in 79% of samples from the control group. The HPV types identified in HIV-infected patients were: HPV 2 (38%), 57 (31%), 27 (12%), 6 (12%) and 7 (6%). HPV 2/27/57 predominated in both groups, being present in 81% of lesions from HIV-infected patients and 82% of samples from non-HIV-infected patients. HPV 6, a genital HPV type rarely found in cutaneous lesions, was detected in two warts from HIV-infected patients and in one lesion of the immunocompetent group. HPV 7, characteristically associated with butcher's warts, and recently detected in oral and perioral lesions of HIV-infected patients, was found for the first time in a non-facial lesion of an HIV-infected patient. CONCLUSIONS: This is the first study evaluating the prevalence of HPV types in cutaneous warts of HIV-infected patients and immunocompetent individuals in Brazil.     

Disseminated primary cutaneous histoplasmosis successfully treated with itraconazole

A 60-year-old immunocompetent lady with disseminated primary cutaneous histoplasmosis is reported. Histology showed a granulomatous skin infiltrate with numerous intracellular PAS positive rounded yeast cells within macrophages. Culture on Sabouraud's dextrose agar yielded a typical cottony white colony characteristic of Histoplasma capsulatum. Treatment with itraconazole showed an excellent response.     

Disseminated cutaneous histoplasmosis in an immunocompetent adult

Histoplasmosis, a systemic mycosis caused by the dimorphic fungus Histoplasma capsulatum var capsulatum and Histoplasma capsulatum var duboisii is endemic to many parts of the world. The clinical manifestations range from acute or chronic pulmonary infection to a progressive disseminated disease. After initial exposure to the fungus, the infection is self-limited and restricted to the lungs in 99% of healthy individuals. The remaining 1%, however, progress to either disseminated or chronic disease involving the lungs, liver, spleen, lymph nodes, bone marrow or rarely, the skin and mucous membranes. Mucocutaneous histoplasmosis is frequently reported in patients with acquired immune deficiency syndrome (AIDS), but it is rare in immunocompetent hosts. A 60-year-old male presented with asymptomatic swelling of the hard palate and crusted papules and nodules over the extremities, face and trunk. Clinically, the diagnoses of cutaneous cryptococcosis versus histoplasmosis was considered in this patient. A chest X-ray revealed hilar lymphadenopathy. Enzyme-linked immunosorbent assay (ELISA) for human immunodeficiency virus (HIV) was nonreactive. Skin biopsy revealed multiple tiny intracellular round yeast forms with a halo in the mid-dermis. Culture of the skin biopsy in Sabouraud's dextrose agar showed colonies of Histoplasma capsulatum. Despite an investigation including no evidence of underlying immunosuppression was found, he was started on IV amphotericin-B (0.5 mg/kg/day). However, the patient succumbed to his disease 2 days after presentation. We report a rare case of disseminated cutaneous histoplasmosis in an immunocompetent individual.     

Ramsay Hunt syndrome in patients infected with human immunodeficiency virus

Ramsay Hunt syndrome (RHS) is defined as herpes zoster infection of the head and neck that involves the facial nerve. Immunocompromised people, such as those infected with human immunodeficiency virus (HIV), are predisposed to herpes zoster. However, reports of RHS in patients with HIV are rare. We report two cases of RHS in patients with HIV at our hospital, located in southern Brazil. We hope this report will increase the awareness of this condition among doctors caring for patients with HIV.     

Disseminated cutaneous herpes zoster: A clinical predictor of human immunodeficiency virus infection

A 45-year-old woman presented with thoracic (3,4,5) herpes zoster with cutaneous dissemination. She was found positive for human immunodeficiency virus infection. Mucocutaneous examination revealed presence of oral thrush and oral hairy leukoplakia. The patient possibly acquired the infection through blood transfusion.     

The prevalence of dermatophyte infection in patients infected with human immunodeficiency virus

Background It is not known whether human immunodeficiency virus (HIV) infection is associated with an increased susceptibility to dermatophytes. Methods In this study, we determined the prevalence of cutaneous fungal infection in a cohort of HIV‐infected patients and HIV‐negative controls, and examined the factors associated with an increased risk of infection. Results Using a multiple regression analysis, we found that the strongest independent predictor of cutaneous fungal infection in both groups was a self‐reported history of homosexual sex. There was no relationship between HIV infection or reduced CD4 count and the prevalence of dermatophyte infection. Conclusions HIV infection is not independently associated with an increased risk of cutaneous fungal disease.     

Skin and oral mucosal changes in patients infected with human immunodeficiency virus

During a 6-month-period, 150 patients infected with Human Immunodeficiency Virus (HIV) were repeatedly examined by dermatologists and dentists for lesions of skin and oral mucosa. The most frequently encountered diseases were: oral hairy leukoplakia (21%), dermatophytosis (including tinea unguium/tinea pedis et inguinalis) (20%), seborrheic dermatitis (19%), viral infections (10%), oral candidiasis (7%), acne vulgaris (6%), and folliculitis (5%). A variety of other manifestations were seen, with frequencies less than 5%. Herpes zoster was seen in 3% of the patients, indicating a rate of 60/1,000 per annum. The presence of seborrheic dermatitis was statistically associated with low T-helper lymphocyte count. Patients with low T-helper lymphocyte count had on average twice as many mucocutaneous lesions as patients with a normal or moderately decreased count. Any one of the manifestations seborrheic dermatitis, oral candidiasis or oral hairy leukoplakia was associated with a greater average number of additional mucocutaneous changes than seen in patients exhibiting none of these three conditions. The high proportion of HIV-infected patients with cutaneous and oral lesions underlines the importance of referring the patients to dermatologists and dentists for examination. Prospective examinations of the study population remain to elucidate the prognostic significance of mucocutaneous manifestations of HIV-infected patients.     

Multiple eruptive dermatofibromas in 2 patients infected with the human immunodeficiency virus

Multiple eruptive dermatofibromas are an uncommon clinical entity in which several lesions appear in a short period of time. Baraf and Shapiro defined them in 1970 as the appearance of at least 15 dermatofibromas in a few months. Given that incipient cases might be omitted, appearance of 5 to 8 dermatofibromas in 4 months has been proposed as sufficient to establish diagnosis. Although this entity has been reported in healthy subjects, it usually appears with underlying autoimmune diseases (lupus erythematosus), human immunodeficiency virus (HIV) infection, or treatment with certain drugs. We report 2 cases of multiple eruptive dermatofibromas associated with HIV infection. One of these patients was unaware of being infected with HIV, and so we believe that the appearance of these skin lesions could help early diagnosis of autoimmune diseases or patients with immunodepression.     

Bronchopulmonary infection with Pseudomonas aeruginosa in patients infected with human immunodeficiency virus.

BACKGROUND--Pseudomonas aeruginosa infection is uncommon in HIV infected patients and is usually nosocomially acquired and associated with risk factors such as neutropenia or central lines. We have recently noted an increase in the number of respiratory isolates of Ps aeruginosa in hospitalised HIV positive patients and sought to describe the clinical correlates of this observation. METHODS--A retrospective case notes review of HIV positive patients admitted to a specialist unit for respiratory investigations from January 1989 to December 1993 was undertaken in order to identify those with Ps aeruginosa respiratory infection and to describe associated risk factors, patterns of presentation and radiographic abnormalities. RESULTS--Of 617 patients admitted 38 (6%) had Ps aeruginosa respiratory infection (notes were incomplete in 1 patient). All patients had advanced HIV disease; median CD4 = 0.02 x 10(9)/l. Two distinct presentations were seen; 9 patients had a fulminant course as part of a sepsis syndrome, 28 patients had an indolent presentation (18 had a single episode and 10 relapsed on one or more occasions, despite successful treatment of the initial episode). Infection was community acquired in 24 patients. Many patients had risk factors traditionally associated with Ps aeruginosa including neutropenia or indwelling central venous catheters, but 13 had no obvious risk factor. Most patients were receiving systemic pneumocystis prophylaxis and/or broad spectrum antibiotics; 20 had co-existent symptomatic sinus disease. A wide variety of chest radiographic abnormalities were seen including interstitial shadowing, mimicking pneumocystis pneumonia in 12 patients, lobar pneumonia in 2 and bronchial wall thickening in 13 patients. CONCLUSIONS--Ps aeruginosa respiratory infection occurs with increased frequency in patients with advanced HIV disease; in a significant proportion infection is community acquired. Although recognised risk factors were present in two thirds of patients it appears that advanced HIV immunosuppression, use of systemic pneumocystis prophylaxis and/or broad spectrum antibiotics and sinus disease are important risk factors. The diagnosis should be considered in patients with advanced HIV disease who present with new respiratory symptoms.     

Unusual cutaneous features of syphilis in patients positive for human immunodeficiency virus

Dermatologists commonly find it difficult to diagnose syphilis, because of its protean clinical features. In cases of co‐infection with human immunodeficiency virus (HIV) syphilis may present particularly unusual clinical features, further confounding the diagnosis. We report two cases of syphilis/HIV co‐infection in Japanese patients showing uncommon skin features that made the diagnosis of syphilis difficult. These cases underline the need for dermatologists to be more aware of atypical cutaneous features of syphilis in patients positive for HIV.