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Cutaneous Lesions Associated

with AIDS

Dr Sampurna Roy MD

June 2014

Dr Sampurna Roy  MD

Consultant   Histopathologist (Kolkata - India)


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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.

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. 

Infectious diseases in AIDS

Virus related lesions in AIDS:

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. 

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.    

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.  

Cytomegalovirus: Almost 90% HIV positive patients  develop Cytomegalovirus infection. 

Histological examination reveals Cytomegalovirus inclusions in endothelial cells and fibroblasts together with areas of epidermal necrosis. 

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. 

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 , Cryptococcosissporotrichosis 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.

- 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.

List of bacterial lesions in patients with AIDS:

Mycobacterial infections- (Mycobacteium avium-intracellulare , Mycobacterium Kansasii, Mycobacterium haemophilum, Mycobacterium marinum etc)    

Usual infections- Staphyloccocus aureus,  Staphylococcus pyogenes  ;  Syphilis  ;  Bacillary Angiomatosis

List of fungal lesions in patients with AIDS:

Histoplasmosis ;  Cryptococcosis;    Candidiasis Sporotrichosis Penicillium marneffei;


Protozoal infection AIDS:

Acanthamebiasis ;  Pneumocystis Pneumonia  

Arthropod related lesions:  Scabies ;  Demodicosis ;

The following cutaneous lesions are noted in patients with AIDS: (Dermpath-India)

- Seborrheic dermatitis ;

- Psoriasis vulgaris ;

- Hypertrophic lichen planus ;

- Eosinophilic folliculitis;

- Contact dermatitis ;

- HIV associated  photosensitivity;

- Cutaneous drug eruption ;

Neoplasms related to AIDS are as follows:

- Kaposi's Sarcoma: Epidemic (HIV associated) Kaposi's Sarcoma

- Cutaneous lymphoma : 

- Bowen's disease :

- Squamous cell carcinoma :

- Basal cell carcinoma:

Related post:  AIDS related malignant tumors



Further reading:

Dermatologic Manifestations of HIV Infection. 

Oral Manifestations of HIV Disease.

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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