Idiopathic Pyoderma Gangrenosum as a Novel Manifestation of the HIV Immune Reconstitution Inflammatory Syndrome: A Report of Three Cases.

The initiation of antiretroviral treatment for individuals with HIV may be accompanied by a paradoxical flare of underlying inflammatory diseases, the recurrence of dormant infections, or worsening of prior treated opportunistic infections, termed the immune reconstitution inflammatory syndrome (IRIS). Cutaneous manifestations of IRIS are common. Pyoderma gangrenosum is a neutrophilic dermatosis postulated to reflect disrupted innate immune regulation causing altered neutrophil chemotaxis. It is uncommonly reported in association with HIV. In this case series, we present three cases of IRIS manifesting with pyoderma gangrenosum in individuals with HIV from India and the United States to raise awareness of this previously undescribed presentation and discuss the treatment challenges in the management of these patients.

Prevalence, Clinical Features and Antibiotic Susceptibility of Group A Streptococcal Skin Infections in School Children in Urban Western and Northern Uganda.

BACKGROUND: Group A Streptococcus (GAS) skin infections can lead to invasive sepsis, poststreptococcal glomerulonephritis, and potentially rheumatic heart disease (RHD). Within a study to identify predisposing factors of RHD in Ugandan schoolchildren, we determined the prevalence of skin infections and assessed the clinical features and antibiotic susceptibility of GAS skin infection. METHODS: Cross-sectional study conducted at 3 urban primary schools in Western and Northern Uganda in March 2017. A dermatologist rendered clinical diagnoses and obtained a skin swab specimen from lesions with signs of bacterial infection. Beta-hemolytic colonies underwent Lancefield grouping, species identification by polymerase chain reaction and antimicrobial susceptibility testing. RESULTS: From 3265 schoolchildren, we observed 32% with ≥1 fungal, 1.8% with ≥1 bacterial, 0.9% with ≥1 viral, and 0.2% with ≥1 ectoparasitic infection. Of 79, 25 (32%) specimens were GAS-positive, of which one-third demonstrated tetracycline resistance. Of 17 impetigo cases, 13 (76%) were located on the leg/foot and 3 (18%) on the head/neck. Prevalence of GAS skin infection was 0.8% (25 of 3265). In Northern Uganda, where subclinical definite RHD prevalence is 1.1%, GAS skin infection prevalence was 1.2% (4 of 343) and 0.9% (3 of 352). CONCLUSION: This study identifies tetracycline-resistant GAS in Ugandan communities, suggests modified skin examination of exposed anatomic locations may be appropriate for population-based GAS skin infection studies, and underscores need for clear case definitions of GAS skin infection. Future studies are needed to evaluate the role of GAS skin infection in development of RHD in Ugandan communities.

Development of Low-Cost Locally Sourced Two-Component Compression Bandages in Western Kenya.

INTRODUCTION: Compression therapy is well-established standard of care for chronic leg ulcers from venous disease and lymphedema. Chronic leg ulcers and lymphedema have a significant impact on quality of life, driven by pain, foul odor, and restricted mobility. Provision of layered compression therapy in resource-limited settings, as in Western Kenya and other regions of sub-Saharan Africa, is a major challenge due to several barriers: availability, affordability, and access to healthcare facilities. When wound care providers from an Academic Model Providing Access to Healthcare (AMPATH) health center in Western Kenya noted that a donated, finite supply of two-component compression bandages was helping to heal chronic leg ulcers, they began to explore the potential of finding a local, sustainable solution. Dermatology and pharmacy teams from AMPATH collaborated with health center providers to address this need. METHODS: Following a literature review and examination of ingredients in prepackaged brand-name kits, essential components were identified: elastic crepe, gauze, and zinc oxide paste. All of these materials are locally available and routinely used for wound care. Two-component compression bandages were made by applying zinc oxide to dry gauze for the inner layer and using elastic crepe as the outer layer. Feedback from wound clinic providers was utilized to optimize the compression bandages for ease of use. RESULTS: Adjustments to assembly of the paste bandage included use of zinc oxide paste instead of zinc oxide ointment for easier gauze impregnation and cutting the inner layer gauze in half lengthwise to facilitate easier bandaging of the leg, such that there were two rolls of zinc-impregnated gauze each measuring 5 inches × 2 m. Adjustments to use of the compression bandage have included increasing the frequency of bandage changes from 7 to 3 days during the rainy seasons, when it is difficult to keep the bandage dry. Continuous local acquisition of all components led to lower price quotes for bulk materials, driving down the production cost and enabling a cost to the patient of 200 KSh (2 USD) per two-component compression bandage kit. Wound care providers have provided anecdotal reports of healed chronic leg ulcers (from venous stasis, trauma), improved lymphedema, and patient tolerance of compression. CONCLUSIONS: Low-cost locally sourced two-component compression bandages have been developed for use in Western Kenya. Their use has been initiated at an AMPATH health center and is poised to meet the need for affordable compression therapy options in Western Kenya. Studies evaluating their efficacy in chronic leg ulcers and Kaposi sarcoma lymphedema are ongoing. Future work should address adaptation of compression bandages for optimal use in Western Kenya and evaluate reproducibility of these bandages in similar settings, as well as consider home- or community-based care delivery models to mitigate transportation costs associated with accessing healthcare facilities.

Cutaneous malignancy and human immunodeficiency virus disease.

UNLABELLED: Certain skin cancers occur with increased frequency or altered course in patients infected with HIV. Malignant melanoma and squamous cell carcinoma are examples of cutaneous malignancies that have a more aggressive course in patients with HIV. Others, such as basal cell carcinoma, appear more frequently in this population but do not appear to be more aggressive. The incidence of HIV-associated Kapsosi's sarcoma has markedly decreased since the advent of HIV antiretroviral therapy. Our understanding of the pathogenesis of this malignancy and its unique management issues are fully reviewed. Cutaneous T-cell lymphoma (CTCL) is rare in this population. Other types of cutaneous lymphoma and HIV-associated pseudo-CTCL are discussed. This article addresses prevention, treatment, and follow-up strategies for this at-risk population. LEARNING OBJECTIVE: At the completion of this learning activity, participants should be familiar with the unique epidemiology, clinical course, and management of cutaneous malignancy in patients infected with HIV.

Diffuse HIV-associated seborrheic dermatitis - a case series.

Seborrheic dermatitis (SD) is reported to have distinct clinical and histologic presentations in patients with HIV infection. Here we present 20 cases to further define some of these unique characteristics. Common features include erythematous, scaly papules, and plaques involving areas beyond the typical seborrheic distribution; thick, greasy scale on the scalp; and an increased frequency of erythroderma. Histologically, there is widespread parakeratosis, spongiosis, and necrotic keratinocytes. Treatment is often difficult, requiring prolonged use of oral and topical antifungals and corticosteroids as well as antibiotics for bacterial superinfection. SD with these features represents a marker for HIV infection and can aid in early diagnosis.

Dermatologic manifestations of HIV infection.

Although some dermatologic diseases have decreased markedly in frequency in the potent antiretroviral therapy era, other conditions remain common. Among patients with low CD4(+) cell counts who are not on or not adherent to antiretroviral therapy, notable conditions include psoriasis, photodermatitis, prurigo nodularis, molluscum, and adverse drug reactions. Conditions that remain relatively common despite adequate antiretroviral therapy include eczema, xerosis, warts, and Kaposi's sarcoma. Disorders that are associated with immune reconstitution under potent antiretroviral therapy include acne, staphylococcal infections, and erythema nodosum. In addition, HIV and hepatitis C virus (HCV) coinfection is associated with a number of skin disorders.

Relapsing polychondritis in HIV-infected patients: a report of two cases.

Relapsing polychondritis is a rare autoimmune disease characterized by inflammation and degeneration of cartilaginous tissue. We describe the first reported cases of relapsing polychondritis in patients with human immunodeficiency virus (HIV) and no associated connective tissue diseases. The relationship between autoimmune and HIV diseases is complex and unclear. Treatment of HIV disease with antiretroviral therapy and subsequent immune restoration may lead to the development of autoimmune diseases in genetically susceptible individuals.

Immunosenescence is associated with presence of Kaposi's sarcoma in antiretroviral treated HIV infection.

OBJECTIVE: Some antiretroviral treated HIV-infected patients develop Kaposi's sarcoma despite long-term suppression of HIV replication. These Kaposi's sarcoma lesions are consistent with Kaposi's sarcoma observed in the elderly uninfected population ('classical Kaposi's sarcoma'). We investigated potential mechanisms for this phenomenon, focusing on measures of immune activation and T-cell senescence. DESIGN: We compared markers of immunosenescence, naive T cells, activation, and inflammation in CD4+ and CD8+ T cells from antiretroviral-treated participants with new-onset Kaposi's sarcoma (cases, n =  19) and from treated individuals without Kaposi's sarcoma (controls, n  = 47). RESULTS: There was increased frequency of CD4+ and CD8+ T cells with an immunosenescence phenotype (CD57+ and CD28-) in cases vs. controls (CD4+ T cells: CD57+ 7.4 vs. 3.7%, P = 0.025; CD28- 9.1 vs. 4.8%, P  = 0.025; CD8+ T cells: CD57+ 41.5 vs. 27.7%, P  =  0.003; CD28- 60.5 vs. 51.3%, P  = 0.041). Cases had lower proportions of naïve T cells (CD27+ CD28+ CD45RA+) in CD4+ (23.0 vs. 32.2%, P = 0.023) and CD8+ (11.3 vs. 20.7%, P  <  0.001) T-cell compartments. CCR5 was more highly expressed in CD4+ (16.3 vs. 11.0%, P  = 0.025), and CD8+ (43.1 vs. 28.3%, P < 0.001) T-cell compartments in cases vs. controls. There was no difference in telomere length or telomerase activity in peripheral blood mononuclear cells, or in T-cell expression of activation markers (HLADRCD38). CONCLUSION: Among antiretroviral-treated patients, increased frequencies of T cells with an immunosenescence phenotype and lower frequencies of naive T cells were associated with presence of Kaposi's sarcoma among effectively treated patients. These data suggest that certain immunologic perturbations--including those associated with aging--might be causally associated with development of Kaposi's sarcoma.

Etiology and risk factors associated with a pruritic papular eruption in people living with HIV in India.

INTRODUCTION: Papulopruritic eruption (PPE) occurs in people living with HIV in India. Understanding the risk factors associated with this disease may help decrease the prevalence of PPE. METHODS: This study was a case-control study performed at the Government Hospital of Thoracic Medicine, a tertiary care hospital in Chennai, India. Cases included HIV-positive, antiretroviral (ARV) therapy-naïve adults experiencing a pruritic skin eruption for longer than one month, with evidence of multiple papular or nodular lesions and biopsy consistent with arthropod bite. Controls included HIV-positive, ARV-naïve patients without active skin rash. Main outcome measures were CD4 cell count, histology, and environmental exposures. We performed statistical analysis using Epi Info version 3.5.1 and SPSS version 11.0 (SPSS Inc., Chicago, IL). Categorical variables such as gender, urban versus rural residence, occupation, treatment history, CD4 count, use of insect repellents, and environmental exposures were evaluated using the χ(2) test (or the Fisher exact test when an expected value for a category was less than 5). The t-test was used to evaluate differences in age and the duration since HIV diagnosis. The Mann-Whitney test was used to compare non-normally distributed values such as CD4 cell count. A p-value that was less than 0.05 was considered to be statistically significant. RESULTS: Forty-one cases and 149 control subjects were included. Subjects with PPE had significantly lower CD4 cell counts compared to controls (225.5 cells/µL vs. 425 cells/µL; p=0.0001). Sixty-six percent of cases had a CD4 cell count less than 350 cells/µL. PPE cases were less likely to use mosquito repellent techniques (odds ratio 2.81, CI = 1.45-5.45). DISCUSSION: PPE may be an altered and exaggerated immune response to arthropod bites in HIV-positive patients. CD4 cell count is significantly lower in patients with PPE, and therefore it may be considered a qualifying clinical finding for ARV initiation in resource-poor settings. Protective measures against mosquito bites appeared to be important in preventing PPE in subjects at risk.

Immune reconstitution inflammatory syndrome and tropical dermatoses.

The human immunodeficiency virus (HIV) pandemic has disproportionately affected tropical regions of the world, where dermatoses, such as leprosy and leishmaniasis, rarely encountered in temperate climates, are endemic. Although the introduction of highly active antiretroviral therapy (HAART) has been lifesaving, a few patients undergoing HAART experience clinical deterioration caused by immune reconstitution inflammatory syndrome (IRIS). This article explores the range of tropical dermatoses that are reported to date with associated IRIS events.

Dermatologic manifestations of HIV in Africa.

Dermatologic disease is common in HIV-infected individuals, and clinicians caring for patients with HIV infection or AIDS in Africa are routinely confronted with skin problems in their patients. Scarce access to dermatologic specialty care and limited educational resources describing the unique clinical characteristics of HIV-related skin disease can make diagnosing and treating skin diseases a challenge in Africa. This article describes common HIV-related dermatologic conditions in Africa and their differential diagnoses and includes treatment strategies that are likely to be available locally. It is not meant to be comprehensive but rather to serve as a practical resource to aid practitioners by providing images of common conditions and describing distinctive clinical presentations of common conditions.

Approach to the treatment of cutaneous malignancy in HIV-infected patients.

Patients infected with human immunodeficiency virus (HIV) have an increased risk of developing skin cancers. These at-risk patients may have atypical presentations and/or altered clinical courses. This article will review and discuss management issues for the following malignancies: lymphomas, malignant melanoma, basal cell carcinoma, squamous cell carcinoma, and Kaposi's sarcoma.

Skin-related quality of life in HIV-infected patients on highly active antiretroviral therapy.

BACKGROUND: The overall health status and survival of HIV-infected patients has changed with the advent of highly active antiretroviral therapy (HAART). With this improved survival, there is a greater urgency to study quality-of-life issues. OBJECTIVE: Our objectives were to measure skin-related quality of life in a cohort of HIV-infected patients and to determine whether the use of highly active antiretroviral therapy is associated with improved skin-related quality of life. METHODS: We assembled a retrospective cohort of patients who were seen in our HIV-Dermatology Clinic at San Francisco General Hospital in June, July, or August of 1996. Eligible subjects were contacted by mail and asked (1) to complete a questionnaire (Skindex) and (2) to have a skin exam. Information on medication use and laboratory parameters was also collected. RESULTS: Of 107 eligible patients, 76 (71%) responded to the questionnaire; 60 patients were examined. Many patients had multiple skin conditions. For most diagnoses (except warts and onychomycosis), there were no consistent differences in Skindex scores of HIV-infected patients compared with scores of patients not known to be infected with HIV. Patients on HAART for longer duration had significantly lower Skindex scores (improved skin-related quality of life) compared with those on HAART for a shorter duration. CONCLUSION: HAART is associated with improved quality of life with regard to HIV-associated skin diseases.