Cutaneous Lesions Associated with AIDS

                       Dr Sampurna Roy MD

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The acquired immune deficiency syndrome  (AIDS) is caused by human immune deficiency virus (HIV) infection, damaging  the cell mediated immune system.

        Visit: AIDS related malignant tumors

Skin is the most commonly affected organ in HIV infection. Cutaneous lesions in HIV positive patients serve as a marker of HIV infection and also indicates the stage of the disease.

Opportunistic  infection  patterns are different in different parts of the world and  change as people  migrate.

'Highly active antiretroviral therapy'  (HAART) was introduced in 1997. Opportunistic infections in HIV positive patients have decreased since introduction of the therapy.  Following therapy there is fall in viral titre and increase in CD4 cells. The cutaneous conditions improve or decline in  incidence after the  therapy.  In many developing countries HAART is still not widely  available.

INFECTIONS

Viral:

Molluscum contagiosum: In HIV- positive patients this lesion presents as persistent umbilicated  or verrucous papules, commonly on the head and neck region. Histopathology reveals cup-shaped lesion containing molluscum bodies. Giant and warty verrucous mollusca contagiosa are markers of advanced HIV infection. 

Herpes Simplex Usually occurs in  perianal, genital and orofacial skin. In HIV and HSV coinfection the lesions last for more than one month. Histopathology reveals numerous intranuclear and intracytoplasmic nuclear inclusions. Extensive ulceration and intraepidermal acantholytic vesicles  are noted . Image  

Varicela zoster virus infection  Clues  to HIV and VZV coinfection - The lesions usually occur in younger patients. These are more severe lesions and of longer duration. Image    

Human papillomavirus infection There is a high incidence of common and anogenital wart in HIV positive patients.  Condylomata acuminata may occur in HIV infected homosexual men. There is risk of dysplasia in perianal condyloma.  Grossly, these lesions may present as smooth sessile plaques to exophytic cauliflower  plaques. Verrucae vulgaris, multiple plantar warts, flat and filiform warts may be noted in HIV infected patients. Common warts are frequently  present  on the bearded area of the face in HIV positive patients.  Image1  ;  Image2 .

Cytomegalovirus: Almost 90% HIV positive patients  develop CMV infection.  Histological examination reveals CMV inclusions in endothelial cells and fibroblasts together with areas of epidermal necrosis . Image Link1 (Univ. of Washington) ; Image Link2 (pathguy.com)

Oral hairy leukoplakia:  Poorly defined projections are noted on the lateral borders of the tongue.This lesion indicates advanced immunosuppression. Causative organisms include Epstein-Barr virus, human papillomavirus or candida. Histological examination reveals some acanthosis and parakeratosis. Large pale staining cells resembling keratinocytes are present.  Image   

NOTE:
Viral, bacterial, fungal and parasitic  infections may occur alone or in combination with each other.  In HIV infected patients,  fungal disorders may present as disseminated or localised disorders.  Histoplasmosis , Cryptococcosis ,  sporotrichosis and candidiasis are common in AIDS patients. Staphylococcus aureus is the most common bacterial pathogen identified in HIV- infected patients.  Numerous  non-tuberculous mycobacteria may cause cutaneous lesions in HIV positive patients. These lesions  display a range of histological features ranging from suppurative to granulomatous inflammmation.

HISTOLOGICAL FEATURES IN INFLAMMATORY DERMATOSIS IN HIV-POSITIVE PATIENTS:

1. Neutrophils and eosinophils in the inflammatory infiltrate are increased in number.
2. Plasma cells are present.
3. Apoptotic keratinocyte may be present
4. T-cells  negative for CD7 are increased in the inflammatory infiltrate.
5. Increased number of CD30 positive  cells appear in the inflammatory infiltrate.
6. Histological examination of  papular eruptions in HIV positive patients reveal superficial perivascular infiltrate of lymphocytes and some eosinophils. Dermal fibrosis and features of early necrobiosis are often  present.

NOTE:
- In HIV positive patients, lichen planus (hypertrophic) is widely distributed involving face and extremities. There is extensive epidermal hyperkeratosis, acanthosis, hypergranulosis and a dense lichenoid inflammatory infiltrate.
- Seborrheic dermatitis is characterized by dermal perivascular acute inflammatory infiltrate and keratinocyte necrosis.
- HIV associated eosinophilic folliculitis is usually noted in the last stage of HIV disease.  There is follicular spongiosis together with infiltration of eosinophils and lymphocytes. Flame figures and eosinophil  degranulation may be noted in the dermis.
- Chronic actinic dermatitis is characterized by psoriasiform epidermal  hyperplasia and  interphase dermatitis.  Necrotic keratinocytes and eosinophils are present. This lesion may  indicate advanced HIV infection.
- Cutaneous drug eruptions may be noted in HIV positive patients taking trimethoprim-sulphamethozole. These lesions are characterized by vacuolar degeneration of basal layer,  dermal inflammation , pigment incontinence and  necrotic keratinocytes.

Bacterial:

Mycobacterial infections- (Mycobacteium avium-intracellulare , M. Kansasii, M. haemophilum, M. marinum etc)   Image1 ;  Image2
Usual infections- (staphyloccocus aureus, staphylococcus pyogenes) Image1   Image2 ;   Syphilis ; Image1 ;  Image2  ; Image3 .
Bacillary angiomatosis:.

Fungal:

Histoplasmosis ; Cryptococcosis     Image1;  Image2 .
Candidiasis;
Sporotrichosis:;
Penicillium marneffei;
Mucormycosis;

Protozoa:

Acanthamebiasis :  Image1 ;  Image2.
Pneumocystis Pneumonia :    Image

Arthropod:

Scabies :  Image Link (dermpedia)
Demodicosis:

DERMATOSIS

Seborrheic dermatitis ; Psoriasis vulgaris ; Hypertrophic lichen planus DermAtlas  ; Eosinophilic folliculitis; Contact dermatitis ;
HIV associated  photosensitivity
Cutaneous drug eruption ;

NEOPLASMS

Kaposi's Sarcoma: Epidemic (HIV associated) Kaposi's Sarcoma
Cutaneous lymphoma : 
Bowen's disease :
Squamous cell carcinoma :
Basal cell carcinoma:

Further reading:

Dermatologic Manifestations of HIV Infection. Top HIV Med. 2005 Dec-2006 Jan;13(5):149-54.

Oral Manifestations of HIV Disease.Top HIV Med. 2005 Dec-2006 Jan;13(5):143-8

Disseminated molluscum contagiosum in a HIV-positive child. Improvement after therapy with 5% imiquimod. Vertebral Lesions from AIDS-Related Kaposi's Sarcoma. AIDS-Kaposi Sarcoma and Classic Kaposi Sarcoma: are different ultrasound patterns related to different variants? Cutaneous colesional acquired immunodeficiency syndrome associated Kaposi sarcoma and cryptococcosis. [Syphilis in the context of HIV-infection--a complex disease]. Coexistent Kaposi sarcoma, cryptococcosis, and Mycobacterium avium intracellulare in a solitary cutaneous nodule in a patient with AIDS: report of a case and literature review. L. (L.) chagasi in AIDS and visceral leishmaniasis (kala-azar) co-infection. Co-infection of molluscum contagiosum virus and cryptococcosis in the same skin lesion in a HIV-infected patient. Penicillium marneffei infection presenting as an immune reconstitution inflammatory syndrome in an HIV patient. Post-ART epidermodysplasia verruciformis in a patient with AIDS.

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