Statistical modeling in pharmaceutical research and development.
Β
Dermatology in HIV
1. Sanjay M. Chawhan, Dharitri M. Bhat, Seema M.
Solanke
Indian Journal of Sexually Transmitted Diseases and
AIDS 2013; Vol. 34, No. 2
2. ο Diseases of skin and mucous membranes are
common clinical manifestations of acquired
immunodeficiency syndrome (AIDS).
ο More than 90% of patients develop
skin lesions at some time during the disease.
ο In some patients, skin is the first organ
affected.
3. ο Impaired skin immune system occurring
early in HIV disease is believed to be
responsible for the frequent occurrence of
both infectious and non-infectious skin
diseases
4. ο Skin lesions occurrence in HIV
infected patients is often atypical and
more severe, explosive, extensive or
resistant to therapy
5. ο Unusual histology of some of the diseases
in AIDS may contribute to misdiagnosis.
ο Diagnosis of skin manifestations is very
important as it may serve as the earliest
manifestation to suspect a case of HIV
infection
6. ο prospective observational study
ο 2 year duration
ο carried out in the Department of
Pathology of a tertiary referral center.
7. ο Total 110 known HIV positive
patients of all ages with symptomatic
skin lesions attending skin and
venereal disease out-patient
department and Anti Retroviral
Therapy
8. ο Patientβs HIV positivity was confirmed by three
different sets of Ag systems
ο HIV comb-AIDS Rapidtest
ο Rapid spot test-Pareekshak and
ο Tridot
9. ο complete clinical details, in particular skin
lesions were noted along with CD4 counts when
available.
ο Irrespective of any other systemic involvement
or presence of other STDs, only skin lesions were
sampled after taking informed written consent.
10. ο The lesions were sampled using the punch
biopsy or cytology and the diagnosis was made
with the help of special stains
ο total 110 patients, 106 punch biopsies were taken
and cytology was done in 25 cases.
11. ο The type of cytology sample varied
depending upon the nature of the
lesions
ο Nodular lesions β FNAC
ο Ulcerative lesions β scrape smears
ο Vesicullobullous - Tzanck smears
12. ο Scaly pruritic β wet KOH mount
preparation
ο Eruptions or a rash or maculopapular
- punch biopsy
13. ο All universal aseptic precautions
according to National AIDS Control
Organization guidelines were followed.
ο The biopsy obtained was processed by
standard formalin fixing paraffin
embedding method.
ο Serial sections and special stains were
studied
14. ο Out of total 110 known HIV infected patients,
ο 74 were males and 36 were female patients.
ο 31 and 40 years of age group
ο Average age in the study was 34 years.
ο CD4 counts were correlated in 70 cases
15.
16. ο 53 (48%) had infectious pathology
ο 37 (35%) patients had non-infectious
pathology.
ο Three patients had infectious as well
as non-infectious pathology.
17. ο Few pt had more than one infectious
lesion.
ο A total of 11 patients had Miscellaneous
and other skin pathology
18. ο Variety of infectious skin lesions were
observed such as viral, bacterial,
fungal and parasitic (Arthropod)
infections.
ο Total 30 (27.28%) patients showing
viral pathology included
22. ο Total 7 (6.36%) cases of parasitic
infections were seen which included
ο Demodex follicularum (6) and
ο scabies (1).
23. ο Total fungal infections were 6 (5.45%)
ο candidiasis (2),
ο dermatophytoses-tinea (2),
ο cryptococcosis (1) and
ο histoplasmosis (1)
24. ο In non-infectious category, majority of pt
s(25)
ο pruritic papular eruptions (PPE) followed
by
ο seborrheic dermatitis (5),
ο psoriasis (4),
ο eosinophilic
ο folliculitis (3) and prurigo (3).
25. ο Total 8 number had non-specific
pathology,
ο two patients had neutrophilic
dermatitis
26. ο lot of literature regarding the etiology
of cutaneous manifestations in HIV
patients is available in Western world
and some parts of Asia
27. ο very few case studies in Indian
patients are available.
ο No such type of study has been
carried out in Central India.
28. ο In our study of 110 HIV infected patients, CD4
correlation was done in 70 patients.
ο Maximum patients, i.e., 42 (59%) had CD4 count
below 200,
ο followed by 21 (31%) patients with CD4 counts
between 200 and 500,
ο whereas 7 (10%) patients had CD4 counts above
29.
30. ο Maximum number of infective lesions
were seen in patients with CD4
counts below 350
ο whereas patients with CD4 count
above 350 showed minimum
infective, but most of the
non-infectious lesions
31. ο Previous studies showed that CD4
counts <200 cells/cumm were
associated with more number of
infectious lesions
32. ο Munoz-Perez (1998) study stated
ο Genital herpes, tinea,
ο Kaposiβs sarcoma, xerosis, HSV,
ο Drug eruptions, candidial folliculitis, M.
contagiosum,
ο psoriasis,abscess,verruca vulgaris, PPE,
oral hairy
ο Leukoplakia.
33. οSeborrheic dermatitis could be
used as clinical markers of
disease progression due to
their strong association with
CD4 counts
34. ο We found that 57 out of 110 (52%) patients
had infectious lesions with Unusual
clinical presentations
ο In these patients, infectious agents can
produce skin lesions even though the
classic organs of involvement for that
agent do not include the skin,
ο e.g., cryptococcosis, Cytomegalovirus and
35.
36. β’ We found 30 (27.28%)
patients with viral lesions.
β’ Out of 15 cases of M.
contagiosum,
β’ 2 cases had giant
Molluscum all over the body
diagnosed first on FNAC.
β’ Maximum patients
showed CD4 counts <200
37. ο HPV :
ο verruca vulgaris, verruca plana
ο Bowenoid papulosis, condylomata
accuminata
ο Munoz-Perez et al. found no significant
difference between the incidence of
condyloma acuminata or verruca vulgaris
in stage III and stage IV disease or with
CD4 counts.
38. ο Present study showed no significant
difference in the occurrence of HPV related
lesions in patients with <200 or >200/cumm
CD4 counts.
ο Munoz-Perez et al. in their study mentioned
that HIV infection itself predisposes to an
increased risk of HPV infection that is not
directly related to the degree of
immunosuppression.
39. ο Friedman- Kien et al. had mentioned
a strong association between the
occurrence of herpes zoster and
incidence of AIDS.
ο Nichols et al. stated that bacteria
infections in AIDS were often under
represented.
40. ο In our study we found 14 (12.72%)
cases of bacterial infection including
Mycobacterium infections.
ο Dermatological lesions of tuberculosis
(TB) infection are rarely found in
Western countries.
41. ο Various mycobacterium lesions in our
study were
ο leprosy (three cases of borderline
tuberculoid and one case of tuberculoid
leprosy),
ο Papulonecrotic tuberculid (2),
ο scrofuloderma and
ο TB cutis orificialis one each.
42. ο Frommel et al. Found no association
between leprosy and HIV-1 infection;
he had mentioned that it does not
seem to alter its course.
43. ο We found six cases of fungal lesions which included
ο two cases of dermatophytoses and candidiasis
ο one case each of histoplasmosis and cryptococcosis.
Nodule over lower lid in a patient
with cutaneous
cryptococcosis
May-Grunwald-Giemsa stained
cytology smears showing
budding forms of Cryptococcus
44. ο All fungal infections were seen in CD4 counts below
350 cells/cumm
Nodulo-ulcerative lesion over
nose with cutaneous
histoplasmosis
Cytology smears showing
macrophage
containing intracytoplasmic
tiny capsulated histoplasma
organisms
45. ο We found 7 (6.36%) cases of parasitic infection,
which included six cases of demodicidosis and
one case of scabies.
ο Kaplan et al. reported four cases of scabies who
presented with pruritic dermatitis
ο Clinically, the lesions of
psoriasis vulgaris or
Darierβs disease
scabies may resemble
46. ο The most common non-infectious skin
manifestation found in our study was
PPE.
ο They were intensely pruritic, papular
lesions more on the trunk and
extremities with a predominance of
eosinophils as described by Francis.
ο African and Haitian patients.
47. ο Hevia et al. (1991) mentioned histological
and clinical criteria for the diagnosis of
these lesions.
ο Most of the cases of PPE in our study were
seen with CD4 counts more than 350
cells/cumm.
48. ο We found three cases of eosinophilic
folliculitis.
ο Rosenthal et al. found its association in
patients with CD4 counts between 200 and
500 cells/ cumm.
ο It could be an important clinical marker of
HIV infection, particularly in patients at
increased risk of developing opportunistic
49. ο The clinical and histological
differential diagnoses of eosinophilic
folliculitis include demodicidosis and
PPE
50. ο We found three cases of psoriasis and
ο One case of Reiterβs syndrome.
ο Incidence of psoriasis as high as 70%
had been reported by Duvic et al.
51. ο We found 4 cases of seborrheic
dermatitis.
ο it is mentioned that the incidence of
seborrheic dermatitis is very high
from 40% to 83% in Western literature
52. ο We found one case each of
ο drug eruption, keratosis pilaris,
ο porokeratosis, seborrheic keratosis,
ο lichen planus and papular urticaria
53. ο Miscellaneous group included
ο 8 cases of non-specific dermatitis,
ο two cases of neutrophilic dermatitis and
ο one case each of chronic dermatitis,
ο Interface dermatitis,
ο pityriasis rosea,
ο Panniculitis,
ο Vasculitis and abscess.
54. ο We did not get any case of neoplastic
lesion, i.e.,
ο Kaposiβs sarcoma, lymphoma or
ο Any other cutaneous malignancies.
55. ο Wiwanitkit (2004) and D. N.
Lanjewar (2011) also found striking
low prevalence of cutaneous and
other malignancies in these patients.
56. ο infectious skin lesions were seen more commonly
with CD4 counts below 350 and
ο non-infectious skin lesions were seen more
commonly with CD4 counts more than 350.
ο The most common infectious lesion was M.
Contagiosum and
ο most common non-infectious lesion was PPE
ο Strikingly low occurrence or absence of cutaneous
malignancies
57. ο Dermatology of the Patient with HIV
ο Mariam M. Khambaty
ο This review focuses on rashes almost
exclusively related to HIV and
ο rashes that have unusual presentations
because of HIV infection.
58. ο Pruritic papular eruption and
eosinophilic folliculitis
associated with human
immunodeficiency virus (HIV)
infection: A histopathological and
immunohistochemical comparative
study
59. ο Among the HIV-EF patients, we found an
intense perivascular and diffuse
inflammatory infiltration compared with
those patients with HIV-PPE.
ο The tissue mast cell count by toluidine
staining was higher in the HIV-EF patients,
who also presented higher expression levels
of CD15 (for eosinophils), CD4 (T helper),
and CD7 (pan-T lymphocytes) than the HIVPPE patients.
60. ο Psoriasis in patients with HIV
infection: From the Medical Board of
the National Psoriasis Foundation
61. ο Based on a review of the literature, 29 reports
ο Topical therapy is the first-line
recommended treatment for mild to moderate
disease.
ο For moderate to severe disease, phototherapy
and antiretrovirals are the recommended
first-line therapeutic agents.
ο Oral retinoids may be used as second-line
treatment
ο refractory, severe disease, cautious use of
cyclosporine, methotrexate, hydroxyurea, and
tumor necrosis factor-a inhibitors may also be
considered
62. ο The Relationship between Skin
manifestations and CD4 counts
among HIV positive patients
63. ο In this study 66 (94.3%) patients had at
least one skin problem.
ο Fungal infections were the most common
ο 8 MC types of mucocutaneous problems
were
gingivitis,
pallor,
itching,
photosensitivity, seborrheic dermatitis,
candidiasis,
folliculitis
and
versicolor.
ο MC manifestation was gingivitis.
tinea