Interesting Cutaneous Manifestation in HIV Positive Patients

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Interesting Cutaneous Manifestation in HIV
Positive Patients

• Dr. Sachin Dattatraya Kore
• Fellow
• Mentor Dr. Rajshekaran, Dr.Manoharan
• Dr. Karunakaran

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Cutaneous presentation of IRIS

• A 36-year-old HIV positive male with a CD4 cell
  count of only 32/µL was put on D4t/3TC/EFV on
  April 2007. After 6 months of HAART the patient
  consulted for multiple asymptomatic hyper
  pigmented small macular lesions all over the
  body. The CD4 count had increased to 510 /µl.
• Dermatologic examination revealed numerous
  hyperpigmented macular lesions over trunk and
  face, kobenerization was also present.
• A clinical diagnosis of IRIS - plane warts (HPV)
  was made.

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Human Papilloma Virus (HPV) infection

• The prevalence of warts in HIV infected
  individuals is greatly increased.
• The lesions are more frequently diffuse,
  dysplastic and subclinical in HIV infected
  patients.
• An unusual pattern of extensive verruca plana and
  tinea versicolor like warts, similar to the
  pattern seen in epidermodysplasia verruciformis,
  as described in our patient has also been
  reported.
• With moderate or advanced HIV induced
  immunodeficiency, warts may become much more
  numerous and refractory to usual treatment.
• Treatment of warts appears easier when a person's
  underlying HIV infection is better controlled.

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Interestening manifestation of extrapulmonary
tuberculosis

• 30-year-old HIV positive man presented with
  progressive swelling in left inguinal region
  since 15 days and penile swelling with difficulty
  in retracting the prepuce a similar swelling
  right inguinal region since 1 wk.
• There was no history of genital ulcer, no
  urethral discharge and no swellings in other part
  of body. Patient was not revealing his sexual
  history. He was married 5 years back and wife
  also tested positive.
• Physical examination BMI was 14 , pallor was
  present , no icterus, no cyanosis, no pedal
  edema, vitals were stable.

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Interestening manifestation of extrapulmonary
tuberculosis

• Systemic examination no abnormalities.
• Local examination there was an ill-defined
  swelling in left inguinal region measuring 10 x 8
  cm, with single opening discharging pus. On
  palpation swelling was nontender, local
  temperature was not raised. Similar swelling was
  also present in opposite region. There was edema
  of penis with difficulty in retracting the
  prepuce.
• Haemoglobin 7.1 gm.
• Peripheral smear microcytic hypochromic anaemia.
• Renal and liver functions normal.
• CD4 cell count 96 /µl.
• AFB positive in the pus from inguinal swelling.
• Final Diagnosis PLHA with tuberculous inguinal
  lymphadenopathy

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Bubo

• A tender, enlarged, and inflamed lymph node,
  particularly in the axilla or groin, due to such
  infections as
• Bubonic plague (Yersinia pestis malignant
  bubo)
• Primary syphilis (Treponema pallidum subsp.
  pallidum syphilitic bubo)
• Gonorrhea (Neisseria gonorrhoeae )
• Chancriod (Hemophilus ducreyi chancroidal or
  virulent bubo)
• Lymphogranuloma venereum (Chlamydia trachomatis
  climatic or tropical bubo)
• Tuberculosis (Mycobacterium tuberculosis )

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Key Points

• Some cutaneous conditions, such as herpes zoster,
  mucocutaneous herpes, eosinophilic folliculitis
  and warts may worsen because immune restoration
  after HAART therapy.
• In country like India tuberculosis should be
  included in differential diagnosis of bubo in
  immunosuppressed patients.