CUTANEOUS MANIFESTATIONS OF HIV INFECTION Dr Tashi Agarwal (PG, 2nd year resident), Dr Shweta Sharma (PG, 3 rd year resident), Dr Narayani Joshi (HOD), Dr B.P. Nag (Professor), Dr Abha Mathur (Professor) Dr Anuj Sharma( Asst. Prof) Department of Pathology, Mahatma Gandhi Medical College and Hospital, Jaipur
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CUTANEOUS MANIFESTATIONS OF HIV INFECTION
Dr Tashi Agarwal (PG, 2nd year resident), Dr Shweta Sharma (PG, 3rd year resident), Dr Narayani Joshi (HOD), Dr B.P. Nag (Professor), Dr Abha Mathur
(Professor) Dr Anuj Sharma( Asst. Prof)
Department of Pathology, Mahatma Gandhi Medical College and Hospital, Jaipur
A panorama of cutaneous lesions in HIV
CLASSIFICATION OF CUTANEOUS LESIONS IN HIV
INFECTIOUS
• Herpes zoster
• Herpes simplex
• Cryptococcus
• Histoplasmosis
• Human papillomavirus
• Impetigo
• Lymphogranuloma venereum
• Molluscum contagiosum
• Syphilis
• Furunculosis
• Folliculitis
• Pyomyositis
• Superficial fungal infections
NEOPLASTIC
• Kaposi’s sarcoma
• Lymphoma
• Squamous cell carcinoma
OTHERS
• Pruritic papular eruption
• Eosinophillic folliculitis
• Seborrheic dermatitis
• Drug eruption
• Vasculitis
• Psoriasis
• Hyperpigmentation
• Photodermatitis
• Atopic Dermatitis
• Hair changes
Kaposi’s sarcoma HIV-associated Kaposi’s sarcoma•95% in homosexual or bisexual menEtiology: genetic marker, immune
dysregulation, retrovirus, HHV-8 (Human Herpes Virus-8)Clinical Features:•symptom & sign of respiratory & GIT involvement.•In the classic form, they develop on the distal lower extremities.•Cutaneous lesions may progress through three stages.
• Lesions of mycosis fungoides usually involve truncal areas and include scaly, red-brown patches; raised, scaling plaques that may be confused with psoriasis and fungating nodules.
• In some individuals, seeding of blood by malignant T cells is accompanied by diffuse erythema and scaling of the entire body surface (erythroderma), a condition known as Sézary syndrome.
•Common at genitalia, face(periorbitalarea),axilla, groin & buttock
•CD4+ count <200 cells/cu.mm.Clinical Features:Molluscum contagiosum lesions are pearly or flesh-colored, dome-shaped, umbilicatedpapules, ranging from 2 to 5 mm, with a central core. In AIDS, hundreds of lesions of molluscumcontagiosum may be observed, showing little tendency toward involution.M/E:Many epidermal cells contain large, intracytoplasmic inclusion bodies, Molluscumbodies. (H&E 40X)
M/E•Earliest change: nuclear swelling of keratinocytes.
•Degeneration of keratinocytes: balooning degeneration.
•Inclusion bodies : eosinolhillic, surrounded by clear space/ halo.
(H&E 100X)
Co-infection with HSV and HIV frequently occurs. About 70% of HIV-positive patients are seropositive for HSV-2.
LeishmaniasisClinical features: Affects primarily the exposed parts of the body, such as face, scalp, and arms.• It appears initially as a painless, erythematous papule which enlarges to a nodule/ plaque upto 2 cm in diameter.• The end stage is represented by a scar accompanied by hypo- or hyper pigmentation.
M/E :The cytoplasm of the histiocytes is filled with numerous round to oval bodies with a round basophilic nucleus, and a rod-shaped paranuclearkinetoplast. •They represent amastigotes, known as Leishman-Donovan bodies. When numerous, they can also be seen extracellularly.
Crusted (Norwegian) scabies
• HIV-infected patients with advanced disease can experience a variant of scabies known as crusted norwegian scabies, which is characterized by generalized scaling and enlarged, hyperkeratotic crusted plaques.
Adult female mite found in skin scrapings
In Norwegian scabies, the thickened horny layer is riddled with innumerable mites, so that nearly every section shows several parasites.
The female mite is located within the stratum corneum
• Disseminated histoplasmosis can be the most frequent opportunistic infection in AIDS patients living in highly endemic areas.Clinical features: skin lesions ~10-20%
• Staphylococcus aureus is the cause in most bacterial skin infections.
• HIV-infected patients are at risk for disseminated mycobacterialinfections (Miliary tuberculosis).
• Disseminated nontuberculousmycobacterial infections, caused by Mycobacterium avium complex, M. kansasii, M. chelonae, M. abscessus, or M. genavense, may occur in HIV-infected patients as skin lesions.
(ZN stain 100X)
Pruritic papular eruption Pruritic papular eruption (PPE) is a chronic eruption
of papular lesions on the skin whose etiology is unclear.
• chronic recall reaction to mosquito bite.
• excoriated hyperkeratotic hyperpigmentedpapules at extremities & lower back.
• severe itch.
• refractory to treatment.
Between 11% and 45% of HIV-infected patients present with PPE. PPE is believed to be a marker of worsening immunosuppression and is more commonly associated with a CD4+ lymphocyte count of less than 50 cells/μL.
Dermis containing degranulated eosinophils and lymphocytes. (H&E x 40)
Eosinophillic folliculitis
Perivascular and periadnexal inflammatory infiltrate of lymphocytes and eosinophils. Eosinophils seen in aggregates within the sebaceous lobules and hair follicles. (H&E x 10)
•It frequently occurs in association with HIV disease. •Eosinophilic pustular folliculitispresents with sudden onset of disseminated follicle-centeredpustules, typically on the trunk and less commonly the face.
REFERENCES
• Lever's Histopathology of the Skin, 9th Edition.
• Rosai and Ackerman's Surgical Pathology, 10th edition.
• World Health Organization. WHO Case Definitions of HIV for Surveillance and Revised Clinical Staging and Immunological Classification of HIV-Related Disease in Adults and Children. Geneva, Switzerland: World Health Organization, 2006.
• El Hachem M, Bernardi S, Pianosi G, et al. Mucocutaneous manifestations in children with HIV infection and AIDS. Pediatr. Dermatol. 1998
• Garmen ME, Tying SK. The cutaneous manifestations of HIV infection. Dermatol. Clin. 2002