Mucocutaneous manifestation of pediatric human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) in relation to degree of immunosuppression: a study of a West African population

Background Mucocutaneous lesions occur at one point or the other during the course of human immunodeficiency virus (HIV) disease. These lesions can be the initial presenting features but could also be a pointer to the presence of immunosuppression. Aim and objectives This study was carried out to determine the pattern of mucocutaneous manifestation in children who have human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) in relation to their level of immunosuppression. Methods One hundred children who were HIV seropositive aged 18 months to 16 years were evaluated for mucocutaneous lesions, and their degree of immunosuppression was also determined using total CD₄₊ count or CD₄₊ percentage. Another group of age and gender matched 100 HIV‐negative children were also examined for mucocutaneous lesions. Results The mucocutaneous manifestations were more common among the subjects compared to controls (P = 0.000). The overall prevalence among the seropositive and seronegative subjects was 64% and 12% respectively. The prevalence of mucocutaneous findings in children with severe, moderate, and no immunosuppression were 93.8%, 55.2%, and 46.2%, respectively. The lesions were significantly more common among those with moderate and severe immunosuppression compared to those with no immunosuppression (P = 0.000). Multiple lesions were more frequent among those with severe immunosuppression. Oral thrush was the most frequent lesion (25.6%) among the subjects followed by pruritic papular eruption (20.7%) and dermatophytosis (14.1%). Severe and atypical forms of dermatophytosis and herpes ulcer were also observed among the subjects. Conclusion This study shows that mucocutaneous lesions are common in children with HIV/AIDS and could be an early indicator of immune suppression. It is important to recognize them early in order to enhance early case detection and treatment.     

Acquired immunodeficiency syndrome-related oral and/or cutaneous histoplasmosis: a descriptive and comparative study of 21 cases in French Guiana

BACKGROUND: Oral or cutaneous acquired immunodeficiency syndrome (AIDS)-related histoplasmosis is a rare presentation of disseminated histoplasmosis. OBJECTIVE: To describe this clinical presentation and to compare it with other forms of AIDS-related disseminated histoplasmosis. METHODS: A cross-sectional study of patients with AIDS-related disseminated histoplasmosis was performed. CD4 counts and survival were compared between patients with oral or cutaneous histoplasmosis and patients with nonmucocutaneous disseminated histoplasmosis. RESULTS: The mean CD4 lymphocyte count was lower in patients with mucocutaneous lesions than in patients with nonmucocutaneous disseminated histoplasmosis (29 vs. 72/mm3, P = 0.002). The proportion of survivors 1 month after diagnosis did not differ significantly between the two groups (13/21 vs. 32/45, P = 0.4). At 6 months, the proportion of survivors was significantly lower for patients with mucocutaneous lesions (6/21 vs. 22/39, P = 0.03). CONCLUSIONS: These results suggest that mucocutaneous lesions occur at a later stage of human immunodeficiency virus infection, but are not, in themselves, associated with a higher level of mortality. The excess mortality at 6 months reflects deaths from other complications of severe immunodepression. This study confirms the polymorphism of mucocutaneous lesions, emphasizing the need for systematic testing for Histoplasma in all cases of mucocutaneous lesions in AIDS patients.     

Mucocutaneous manifestations of HIV infection: a retrospective analysis of 145 cases in a Chinese population in Malaysia

BACKGROUND: Mucocutaneous lesions directly related to human immunodeficiency virus (HIV) infection usually present as initial manifestations of immune deficiency. The most common mucocutaneous lesions are Kaposi's sarcoma, histoplasmosis, oro-esophageal candidiasis, oral hairy leukoplakia, and, in Asia, Penicillium marneffei infection. Non-HIV-related skin lesions, such as psoriasis, seborrheic dermatitis, and nodular prurigo, may be the initial presentation among HIV infected patients attending outpatient clinics. METHODS: A retrospective analysis was performed on 145 HIV-positive Malaysians of Chinese descent from two centers at the University Hospital Kuala Lumpur (UHKL) and the General Hospital Kuala Lumpur (GHKL) from March 1997 to February 1998. Demographic data and clinical data were analyzed. RESULTS: The analysis showed that 104 out of 145 patients had mucocutaneous disorders (71.7%). In the study, there were 100 men (96.2%) and four women (3.8%). The majority of patients were in the age group 20-50 years. The patients who presented with mucocutaneous disease also had low CD4+ T-lymphocyte counts and most had acquired immunodeficiency syndrome (AIDS) defining illness. The number of cases with generalized hyperpigmentation was very high in the group (35.9%), followed by nodular prurigo (29.7%) and xerosis (27.6%). Seborrheic dermatitis was seen in 20.7% of cases, with psoriasis in 8.3%. The most common infections were oral candidiasis (35.9%), tinea corporis and onychomycosis (9.7%), and herpes infection (5.5%); however, mucocutaneous manifestations of Kaposi's sarcoma were rare. CONCLUSIONS: The results suggest that mucocutaneous findings are useful clinical predictors of HIV infection or signs of the presence of advanced HIV infection.     

Mucocutaneous manifestations of HIV‐infected patients in the era of HAART in Guangxi Zhuang Autonomous Region,China

Background Human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) are frequently associated with diverse mucocutaneous manifestations. However, few studies of HIV/AIDS‐related mucocutaneous manifestations have been reported in China. Objective To investigate the occurrence of mucocutaneous disorders and their relationship with the degree of immunosuppression in 348 HIV‐infected Chinese patients. The influence of highly active antiretroviral therapy (HAART) on the spectrum of mucocutaneous manifestations was also evaluated. Methods A cross‐sectional study was performed on 348 HIV‐infected Chinese patients seen at the Guangxi Longtan Hospital from August 2010 to November 2010. Collected information included demographic data, HIV‐associated mucocutaneous disorders, CD4 cell count, AIDS‐defining illness and antiretroviral therapy. Results In this study, 62.9% of all patients had mucocutaneous disorders. The prevalence of mucocutaneous disorders in the patients who had received HAART was lower than in those without HAART (54.05% vs. 88.76%, P < 0.001). The prevalence of mucocutaneous disorders was higher in the patients with CD4 < 200 cells/mm³ in comparison to those with CD4 ≥ 200 cells/mm³ (P < 0.05). The most common mucocutaneous disorders were oral candidiasis (28.47%), Penicillium marneffei infection (11.49%), drug eruptions (10.06%) and pruritic papular eruption (PPE 5.75%). Oral candidiasis, P. marneffei infection and PPE were significantly more prevalent in patients with a CD4 cell count below 200 cells/mm³, but frequency of drug eruptions was not related to the level of CD4 cell counts. Patients treated with HAART had decreased rates of herpes simplex, oral candidiasis and P. marneffei infection, but increased rates of drug eruptions. Conclusions A wide range of mucocutaneous disorders were observed in HIV‐infected Chinese patients. Oral candidiasis, P. marneffei infection and PPE may be the signs of advanced HIV infection. HAART had an impact on the spectrum of HIV‐associated mucocutaneous disorders.     

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.     

Disseminated ecthymatous herpes varicella-zoster virus infection in patients with acquired immunodeficiency syndrome

Herpesvirus infections are among the most common and debilitating opportunistic infections in patients with acquired immunodeficiency syndrome (AIDS), and they may have atypical clinical features. We describe the cases of three patients with AIDS in whom atypical persistent ulcerative skin lesions developed as a result of varicella-zoster virus infection. Two patients had disseminated infection without a vesicular stage; one patient had underlying asteatotic eczema. All responded well to acyclovir. One patient was treated with azidothymidine, and typical dermatomal herpes zoster subsequently developed. The profound loss of helper T cell function in AIDS may lead to multiple abnormalities in local immune response to cutaneous herpesvirus infections and may be responsible for the atypical morphology and a prolonged course.     

Unusual manifestations of tegumentary leishmaniasis in AIDS patients from the New World

Background  Comorbidity from tegumentary leishmaniasis and AIDS is poorly characterized.
Objectives  To describe a series of patients coinfected with Leishmania and human immunodeficiency virus (HIV).
Methods  Clinical records from patients were analysed by demographic data, clinical manifestations, diagnoses, treatments and outcomes.
Results  Fifteen cases of AIDS/tegumentary leishmaniasis were found. The diagnosis of leishmaniasis was confirmed by the detection of Leishmania amastigotes or antigens from the cutaneous or mucosal lesions. The mean CD4+ T-cell count was 84 cells mm⁻³ (range 8–258) and all patients were classified as having AIDS according to the Centers for Disease Control and Prevention. A wide range of manifestations was found, varying from a single ulcer to multiple and polymorphic lesions. Mucosal lesions were present in 80% and cutaneous lesions in 73% of patients (53% with mucocutaneous form), disseminated lesions in 60% and genital lesions in 27% of patients. All patients received anti- Leishmania therapy and 53% showed relapses. Sixty-seven per cent received highly active antiretroviral therapy but showed no difference in outcomes and relapses compared with those not using medication. Forty per cent died during the study period. In these patients, the anti- Leishmania antibody and Montenegro skin test were useful in the diagnosis of leishmaniasis, probably because leishmaniasis preceded immunosuppression due to HIV infection.
Conclusions  Clinical manifestations of tegumentary leishmaniasis in HIV-infected patients are diverse. Our data emphasize possible unusual manifestations of this disease in HIV-infected patients, particularly in severely immunosuppressed cases (< 200 CD4+ cells mm⁻³).     

Disseminated histoplasmosis in a patient with AIDS: case report and review of the literature

Disseminated histoplasmosis was uncommon prior to the AIDS epidemic, and cutaneous eruption rarely was seen. Since the onset of the worldwide AIDS epidemic, histoplasmosis has become a more common opportunistic fungal infection and should be considered in the differential diagnosis of mucocutaneous lesions in patients with AIDS in endemic areas. We report a case of classic disseminated histoplasmosis in a patient with AIDS and discuss the epidemiology, clinical presentation, pathogenesis, laboratory and histopathologic findings, and treatment options for disseminated histoplasmosis.     

Melasma and acquired immunodeficiency syndrome (AIDS)

Background Hyperpigmentation of skin, mucous membranes and nails has been described in patients with acquired immune deficiency syndrome (AIDS). Patients and methods 7 AIDS patients affected with melasma-like facial hyperpigmentation were studied. The patients had human immunodeficiency virus infection associated with recurrent mucocutaneous and systemic opportunistic infections. All had a low T4-CD4 helper cell count and four of them died of severe infections, caused by cytomegalovirus (CMV), mycobacteria (Mycobacterium tuberculosis or Avium) and Pneumocystis carinii pneumonia. In these patients the autopsy showed intense infiltration of the adrenal glands. One of them died of Waterhouse-Friderichsen syndrome; her autopsy showed a massive presence of cytomegalovirus in the adrenal glands. Results In 4 patients dosages of testosterone, cortisol, T3, T4, TSH gave normal results. The level of DHEA-S was below normal revealing an adrenal insufficiency. The α-MSH test in 12 patients (4 patients with AIDS and facial hyperpigmentation and 8 volunteers with AIDS, but without pigmented facial lesions) revealed blood levels of α-MSH above the norm (60.33 pg/ml standard deviation 13.21). The α-MSH test in 20 healthy subjects revealed a mean value of 44.40 pg/ml (standard deviation 10.47). The biopsy of melasma revealed that melanocytes were present in normal numbers and size with a localized increase of melanin pigment in the basal cell layer. Conclusion An increased production of ACTH and its derivatives such as α-MSH pituitary may be the cause of hyperpigmentation in AIDS patients.     

Disseminated Histoplasmosis Presenting as an Ulcerated Verrucous Plaque in a Human Immunodeficiency Virus-Infected Man

A 46-year-old homosexual man with disseminated histoplasmosis and human immunodeficiency virus (HIV) infection had a histoplasmosis-related ulcerated verrucous plaque above his left upper lip; systemic and cutaneous disease manifestations of histoplasmosis resolved with daily ketoconazole therapy. Disseminated histoplasmosis, with similar cutaneous features, also was present in his HIV-seropositive male sexual partner. The possibility of human-to-human transmission of histoplasmosis between these patients is considered and the skin lesions of systemic fungal infections in HIV-infected patients are reviewed.     

Unresponsive cutaneous leishmaniasis and HIV co-infection: report of three cases

Cutaneous leishmaniasis (CL) is a vector borne disease caused by various species of Leishmania parasite. CL is endemic in the Thar desert of Rajasthan state and Himachal Pradesh in India. Immune suppression caused by human immunodeficiency virus (HIV) infection is associated with atypical clinical presentation of CL which responds poorly to the standard treatment and causes frequent relapses. We are reporting three cases of localized and disseminated CL due to Leishmania tropica which failed to respond to conventional intralesional/intramuscular sodium stibogluconate (SSG) injections. Initially, we did not think of HIV infection because CL is endemic in this region. When patients did not respond to SSG injections, we performed enzyme-linked immunosorbent assay (ELISA) tests for HIV and they turned out to be HIV positive. Our report showed that CL is emerging as an opportunistic infection associated with HIV/AIDS and may be the first manifestation in HIV positive patients in an endemic area.     

Mucocutaneous manifestations of disseminated histoplasmosis in patients with acquired immunodeficiency syndrome: particular aspects in a Latin-American population

BACKGROUND: Mucocutaneous lesions in human immunodeficiency virus (HIV)-infected patients with disseminated histoplasmosis have a wide spectrum of clinical manifestations, making its diagnosis difficult. Studies have been restricted to case reports and series with small numbers of patients not specifically focusing on the dermatological aspects of histoplasmosis. AIMS: To describe the characteristics of mucocutaneous lesions of disseminated histoplasmosis in HIV-infected patients. METHODS: A retrospective and prospective study was conducted on 36 HIV-infected patients with mucocutaneous histoplasmosis in a tertiary-care hospital in Brazil. RESULTS: Mucocutaneous histoplasmosis was diagnosed by histopathology in 33 of the 36 patients (91%) and/or culture in 23 (64%). Their CD4+ cell counts ranged from 2 to 103 cells/mm(3). The average number of different morphological types of lesions was three per patient. Despite the variability of the lesions, papules (50%), crusted papules (64%) and oral mucosal erosions and/or ulcers (58%) were the most frequent dermatological lesions. A diffuse pattern of distribution of the skin lesions was found in 58% of the cases. There was significant association between the CD4+ cell counts and the morphological variability of lesions per patient. Variation in the lesions seemed to be associated with higher CD4+ cell counts. CONCLUSION: Doctors caring for HIV-infected patients should be aware of the wide spectrum of dermatological lesions observed in disseminated histoplasmosis and the importance of detecting and isolating the fungus in mucocutaneous tissues.     

Human immunodeficiency virus infection

Knowledge of the ever increasing spectrum in cutaneous pathology caused by infection with the human immunodeficiency virus (HIV) is essential for the clinician examining high-risk individuals as well as patients presenting with recent suspicious cutaneous/mucocutaneous lesions. Timely diagnosis of the unique lesions associated with developing immunodeficiency (such as Kaposi's sarcoma and oral hairy leukoplakia)--as well as the often atypical and overlapping infections and neoplastic and allergic manifestations--is critical in order to initiate the appropriate treatment that may prove life saving and help extend the lives of individuals struck by infection with HIV.     

Disseminated varioliform pustular eruption due to Mycobacterium avium intracllulare in an HIV-infected patient

Summary Severe disseminated infection due to Mycobacterium avlum intracellulare , with unusual cutaneous features, is reported in a patient with acquired immunodeficiency syndrome (AIDS). The eruption appeared as disseminated pustule lesions which showed necrotic features and which led to varioliform scarring. Bacterial culture from the skin, blood, and bone marrow, and ultimately from the hronchoalveolar fluid and sputum, was positive for M. avium intracellulare. The patient was successfully treated using a multiple agent anti-mycohacterial regimen including clarithromycin, which appeared to be the most effective drug. This resulted in resolution of the cutaneous and general symptoms. Our patient illustrates the wide spectrum of skin presentations that may he seen with mycohacterial infections in subjects infected with the human immunodeficiency virus (HIV). Clarithromycin is an important agent for the treatment of these severe infections.     

The spectrum of mucocutaneous manifestations during the evolutionary phases of HIV disease: an emerging Indian scenario.

Third world countries, including India, lack sophisticated investigations to assess the progression of HIV disease. Hence, this study was undertaken to determine the clinical mucocutaneous markers of HIV disease and to establish its relationship with the stage of the disease. This was an observational institutional study of 75 patients with mucocutaneous disorders and HIV infection recruited over a period extending from September of 1996 to June of 1998. The patients with mucocutaneous lesions were staged according to the Centers for Disease Control classification system for HIV infection (1986). The most frequent mode of acquisition of HIV infection was heterosexual contact (96%). The patients were broadly categorized into two groups. The AIDS group was comprised of patients who were in group IV and the early HIV infection group included patients in group II and III; none were detected in group I. Forty-eight cases belonged to the AIDS group, and 27 belonged to the early HIV infection group. A total of 207 dermatoses were diagnosed and grouped as fungal, viral, bacterial, or miscellaneous. The common mucocutaneous disorders in order of frequency observed in this study were: candidiasis, dermatophytosis, herpes simplex, oral aphthae, xerosis/ichthyosis, scabies, HPV infection, molluscum contagiosum, and psoriasis. Xerosis/acquired ichthyosis and giant molluscum contagiosum were characteristically seen in group IV of HIV disease, whereas oral candidiasis, oral aphthae, papular dermatitis of HIV, and psoriasis were early warning signs. The mean number of dermatoses per patient in group IV was 3.15; in group III, it was 2.41; and in group II, it was 1.5. There was a statistically significant difference between the early HIV infection group and AIDS group with regard to number of dermatoses. Apart from syphilis and human papilloma virus infection, the treatment outcomes were satisfactory.     

Micosis sistémicas en pacientes con virus de la inmunodeficiencia humana/sida

Histoplasmosis is a systemic infection caused by the dimorphic fungus Histoplasma capsulatum. In immunocompromised patients, primary pulmonary infection can spread to the skin and meninges. Clinical manifestations appear in patients with a CD4⁺ lymphocyte count of less than 150 cells/μL.Coccidioidomycosis is a systemic mycosis caused by Coccidioides immitis and Coccidioides posadasii. It can present as diffuse pulmonary disease or as a disseminated form primarily affecting the central nervous system, the bones, and the skin.Cryptococcosis is caused by Cryptococcus neoformans (var. neoformans and var. grubii) and Cryptococcus gattii, which are members of the Cryptococcus species complex and have 5 serotypes: A, B, C, D, and AD. It is a common opportunistic infection in patients with human immunodeficiency virus (HIV)/AIDS, even those receiving antiretroviral therapy.Histopathologic examination and culture of samples from any suspicious lesions are essential for the correct diagnosis of systemic fungal infections in patients with HIV/AIDS.     

Concurrent Cytomegalovirus,M. Tuberculosis and M. Avium-Intracellulare Cutaneous Infection in an HIV Patient

We report a 25-year-old HIV-positive man with a past medical history of disseminated cytomegalovirus (CMV) infection, who developed cutaneous lesions during a disseminated mycobacterium infection. The histological changes of CMV and acid-fast bacilli were seen on histopathology of the lesions. Cultures were positive for M. tuberculosis and M. avium-intracellulare (MAI). CMV is frequently isolated from HIV patients, but skin involvement is rare. The association of CMV and mycobacteria can occur in cutaneous lesions of AIDS patients, but concurrent cutaneous involvement of CMV, M. tuberculosis, and MAI is unusual. These findings emphasize the polymorphous presentation of infectious disorders in AIDS patients and the need for multiple biopsies and for special stains in such patients.     

Mucocutaneous findings in pediatric AIDS related to degree of immunosuppression

The normal value of the absolute CD4-positive T-lymphocyte count is relatively high in normal infants and declines steadily until 6 years of age, whereas the CD4 percentage of the total lymphocyte count is constant. The immunologic categories according to the 1994 revised pediatric human immunodeficiency virus (HIV) classification, based on CD4-positive percentage of the total lymphocyte count, is classified into three categories: no evidence of suppression (> or =25%), moderate suppression (15-24%), and severe suppression (1-14%). Our objective was to determine the prevalence of mucocutaneous findings in pediatric acquired immunodeficiency syndrome (AIDS) related to the degree of immunosuppression. We prospectively examined 120 children less than 13 years of age who were born to HIV-seropositive women and developed definite HIV infection. The prevalence of mucocutaneous findings in those children who had severe, moderate, and no evidence of immunosuppression were 62%, 43%, and 20%, respectively. The mucocutaneous findings in patients in the moderate and severe suppression groups were significantly more common than in patients without evidence of immunosuppression (p < 0.001). In the moderate immunosuppression group, 11% had two mucocutaneous findings while 21% in the severe immunosuppression group had two or more mucocutaneous findings. The most common mucocutaneous finding was oral candidiasis (33%), which had a mean corresponding CD4 percentage of the total lymphocyte count of 11.3%. Herpes zoster was found in 6% of the patients (mean CD4 percentage of the total lymphocyte count = 13.5%). Chronic herpes simplex virus (HSV) stomatitis was found in 3% of the patients (mean CD4 percentage of the total lymphocyte count = 3%). Mucocutaneous manifestations are common in pediatric AIDS. The majority of these findings have an infectious etiology. The prevalence increases as the CD4-positive percentage of the total lymphocyte count decreases. More than one mucocutaneous finding can be found at the same time in patients with moderate or severe immunosuppression.     

A retrospective survey of mucocutaneous manifestations of HIV infection in Malaysia: analysis of 182 cases

A retrospective analysis of 182 HIV positive Malaysians was done in two centers, the University Hospital Kuala Lumpur (UHKL) and the General Hospital Kuala Lumpur (GHKL) from March 1997 to February 1998. Demographic and clinical data were analyzed. The analysis showed that 130 out of 182 patients had mucocutaneous disorders (71.4%). In the study there were 125 males (96.2%) and 5 females (3.8%). The majority of the patients were in the age group from 20 to 50 years. The patients who presented with mucocutaneous disease also had low CD4+ T lymphocyte counts, and most of them had AIDS defining illnesses. The number of cases with generalized hyperpigmentation was very high (35.7%), followed by papular eruptions (29.1%) and xerosis (27.5%). Seborrheic dermatitis was seen in 19.2% of the cases and psoriasis in 7.7%. The most common infections were oral candida 35.7%, tinea corporis and onychomycosis 9.9%, and herpes infection 4.3%. However, mucocutaneous manifestations of Kaposi's sarcoma were rare. The results suggested that mucocutaneous findings are useful clinical predictors of HIV infection or a sign of the presence of advanced HIV infection.     

Kaposi's sarcoma-like lesions and other nodules as cutaneous involvement in AIDS-related visceral leishmaniasis

A 40-year-old human immunodeficiency virus (HIV)-positive man had three relapses of visceral leishmaniasis (VL). In the third he developed nodular skin lesions of three types, some reminiscent of Kaposi's sarcoma. Biopsy of each type disclosed abundant dermal macrophages with a huge number of intracellular and extracellular Leishman-Donovan bodies. Rapid improvement of lesions was achieved after antiparasitic treatment. AIDS leads to atypical forms of leishmaniasis. Leishmania has been detected both in normal and pathological skin of these patients due to dissemination during VL. It is suspected that a considerable proportion of the population may be infected in endemic areas, Leishmania being opportunistic in immunosuppressed individuals. It is important to recognize the range of lesions that may occur in patients with HIV and VL, many of which are non-specific and may cause diagnostic difficulty.