Cutaneous manifestations of hiv infection

Dermatological problems occur in more than 90% of patients with human immunodeficiency virus (HIV) infection. In some patients, skin is the first organ affected. Skin diseases have proved to be sensitive and useful measures by which HIV progression can be monitored.

1. 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

2. A panorama of cutaneous lesions in HIV

3. CLASSIFICATION OF CUTANEOUS LESIONS IN HIV

4. Kaposi’s sarcoma HIV-associated Kaposi’s sarcoma 95% in homosexual or bisexual men Etiology: 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.

5. Lymphoma *Cutaneous T-Cell Lymphoma(Mycosis fungoides ) *Non-Hodgkin Lymphoma *Hodgkin’s lymphoma Causes : Polyclonal proliferation & lymphoid follicular hyperplasia, Chromosomal abnormalities, Epstein-Barr Virus (EBV) infection 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. T-cell immunohistochemistry of angiocentric pattern. Abnormal epidermotropism Scaling patches and plaques.

6. Molluscum Contagiosum Incidence 10-20% Common at genitalia, face( periorbital area), axilla , groin & buttock CD4+ count <200 cells/cu.mm. Clinical Features: Molluscum contagiosum lesions are pearly or flesh- colored , dome-shaped, umbilicated papules, ranging from 2 to 5 mm, with a central core. In AIDS, hundreds of lesions of molluscum contagiosum may be observed, showing little tendency toward involution. M/E: Many epidermal cells contain large, intracytoplasmic inclusion bodies, Molluscum bodies. (H&E 40X)

7. Herpes Simplex Clinical features : Deep seated (hemorrhagic) vesicles Chronic ulcerative mucocutaneous lesion Exophytic lesion Ulcerated tumor like lesion 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.

8. Leishmaniasis Clinical 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 paranuclear kinetoplast . They represent amastigotes , known as Leishman -Donovan bodies . When numerous, they can also be seen extracellularly .

9. 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

10. Histoplasmosis Macrophages containing intracytoplasmic tiny capsulated histoplasma organisms. ( H&E 40X, 100X) Disseminated histoplasmosis can be the most frequent opportunistic infection in AIDS patients living in highly endemic areas. Clinical features : skin lesions ~ 10-20% exanthema-like maculopapular eruption molluscum -like papulonecrotic lesion oral ulcer or oral mass vegetative plaque diffuse purpura panniculitis

11. Dermatophytosis ( tinea ) Dermatophytosis occurs as tinea corporis , tinea capitis , or onychomycosis . Tinea corporis is characterized by erythematous , sometimes annular (circular), scaling lesions with raised borders. H&E stain shows arthrospores in endothrix infection. (H&E x 40) Tinea capitis often presents as diffuse, round, scaly patches of hair loss and may be associated with tinea on other parts of the body

12. Bacterial skin disease Bacterial skin diseases include : Pyogenic diseases, Mycobacterial diseases, Nocardiosis , Bacillary angiomatosis . Staphylococcus aureus is the cause in most bacterial skin infections. HIV-infected patients are at risk for disseminated mycobacterial infections ( Miliary tuberculosis ). Disseminated nontuberculous mycobacterial 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)

13. 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 hyperpigmented papules 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)

14. 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 folliculitis presents with sudden onset of disseminated follicle- centered pustules, typically on the trunk and less commonly the face.

15. REFERENCES Lever's Histopathology of the Skin, 9th Edition. Rosai and Ackerman's Surgical Pathology, 10th edition. Sternberg's Diagnostic Surgical Pathology, 5th 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