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  In this article
    Abstract
    Introduction
    Methods
    Results
    Discussion
    Acknowledgements
    References

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STUDIES
Year : 2004  |  Volume : 70  |  Issue : 2  |  Page : 82-86

Mucocutaneous manifestations of HIV infection


Departments of Tropical Medicine, School of Tropical Medicine, Kolkata

Correspondence Address:
Block-Q, Flat-7, Lakegardens R.H.E., 48/4 Sultan Alam Road, Kolkata - 700033
drskguha@vsnl.net

   Abstract 

BACKGROUND AND AIMS: Human immunodeficiency virus (HIV) is associated with various mucocutaneous features, which may be the first pointer towards the existence of HIV infection. This study was done to note the different mucocutaneous lesions present in the HIV population in eastern India. METHODS: Four hundred and ten HIV seropositive patients attending the outpatient and inpatient departments were included in the study. RESULTS: Out of 410 HIV positives, 40% had mucocutaneous involvement at presentation. The mean age of the study population was 29 years and male to female ratio was 2.5:1. The common mucocutaneous morbidities included oral candidiasis (36%), dermatophytosis and gingivitis (13% each), herpes zoster (6%), herpes simplex and scabies (5% each). A striking feature, noted in 36% males, was straightening of hairs. Genital herpes was the commonest genital ulcer disease. Lesions associated with declining immunity included oral candidiasis, oral hairy leukoplakia and herpes zoster with median CD4 counts of 98, 62 and 198/ L respectively. CONCLUSION: Early recognition of mucocutaneous manifestations and associated STDs help in better management of HIV/AIDS.

How to cite this article:
Shobhana A, Guha SK, Neogi D K. Mucocutaneous manifestations of HIV infection. Indian J Dermatol Venereol Leprol 2004;70:82-6


How to cite this URL:
Shobhana A, Guha SK, Neogi D K. Mucocutaneous manifestations of HIV infection. Indian J Dermatol Venereol Leprol [serial online] 2004 [cited 2019 Sep 17];70:82-6. Available from: http://www.ijdvl.com/text.asp?2004/70/2/82/6897



   Introduction Top


Ever since its recognition in 1981,[1] HIV/AIDS continues to ravage all the continents of the world. Currently, in India, an estimated number of 4.58 million people are living with the virus.[2] HIV infection produces a panorama of mucocutaneous manifestations, which may be the presenting features of the disease.[3],[4] From the macular, roseola-like rash seen with the acute 'seroconversion' syndrome to extensive end-stage Kaposi's sarcoma, dermatological features of HIV disease can be seen throughout the course of HIVinfection.[1] Oral candidiasis, seborrhoeic dermatitis are seen with higher frequencies and increased severity.[5] The skin is not only a target organ for drug reaction but also is responsible for cosmetic changes which are troubling to the patients.[1] The importance of Sexually Transmitted Diseases (STDs) in the transmission and hence the importance of their diagnosis and management is well known in HIV disease.[1]


   Methods Top


The present study dealt with 410 HIV seropositive patients selected from the outpatient department as well as indoor patients of the Carmichael Hospital for Tropical Diseases at the School of Tropical Medicine, Kolkata which is a National Reference Laboratory (Department of Virology) for HIV diagnosis. The duration of the study was from May 2000 to April 2002. After pre-test counseling of the individuals blood samples were tested in the department of Virology for anti-HIV antibodies by ELISA tests (INNOTEST HIV-1 / HIV-2 Ab - Innogenetics, Belgium). Two successive reactive ELISA sera were confirmed by Western Blot test (INNO-LIA HIV - 1 / HIV - 2 Ab - INNOGENETICS, BELGIUM & UBI - HIV - 1 / HIV - 2 EIA - UNITED BIOMEDICAL CO LTD, BEIJING). Only the Western Blot positive cases were included in the study. Post-test counseling of the individuals was also done.

Detailed history was taken from each patient and thorough physical examinations were performed at the first visit with emphasis on mucocutaneous manifestations. AIDS cases were diagnosed according to the National AIDS Control Organization (NACO) guidelines. CD4 count was done by flowcytometry in all HIV positives. The clinical diagnosis was supplemented with laboratory procedures like microscopy (KOH preparations, Tzanck smear) where applicable. Serological test for syphilis was done using the Venereal Disease Research Laboratory test (VDRL) in all the 410 subjects. A titer of 1:8 or above was considered to be reactive. However, specific treponemal antibody testing was not carried out.


   Results Top


A brief account of the demographic profile of the study participants is given in [Table - 1]. Majority of the males (65%) and most of the females (95%) were married. Predominant mode of transmission of HIV was through heterosexual route.

A total of 164 (40%) subjects had mucocutaneous lesions at presentation. Generalized pruritus was observed in 123 (30%) individuals. Common mucocutaneous lesions of HIV/AIDS are given in [Table - 2] [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4].

Straightening of hairs that became thick, coarse and could not be combed properly resulting in a “palm-tree” like appearance, was recorded exclusively in males (106/295, 36%) and diffuse alopecia was noted in 10% (40) of total study participants.

Candidiasis (148, 36%) was the commonest oral lesion followed by gingivitis (53, 13%). The most frequently observed dermal morbidity among the study subjects was dermatophytosis (53, 13%). Combination of tinea at 2 or more sites was noted in 16 out of 53 (30%). Multidermatomandl &/or recurrent herpes zoster was noted only in 25 (6%) individuals.

Genital lesions
Seventy-eight (19%) of the study subjects had past history of either Genital Ulcer Disease (GUD) or Genital Discharge Disease (GDD). Commonly encountered genital lesions are depicted in [Table - 3].

Genital herpes (34, 8%) was the commonest genital lesion observed among the study participants followed by genital warts (22, 5%).

VDRL and its association with STDs
Among the 410 study subjects, 88 (21%) were VDRL positive. While the VDRL reactivity in patients with GUD (22/46, 47%) and GDD (12/27, 44%) were similar, a significant number of patients with past history of either GUD or GDD (36/78, 46%) tested positive for the test.

Association of mucocutaneous manifestations and CD4 count
The relationship between CD4 counts and various mucocutaneous lesions could be seen in [Table - 4].

Oral candidiasis, OHL, herpes zoster and straightening of hair with median CD4 counts of 98, 62, 198 and 134/mL respectively were associated with severe immunosuppression. Median CD4 counts of patients with genital herpes and warts (187/mL and 152/mL respectively) were also low.


   Discussion Top


Almost 40% of the HIV positives in this study had mucocutaneous manifestations like in other Indian reports.[3] Commonest lesion was oral candidiasis- present in 36% patients comparable to prior Indian reports.[6],[7],[8],[9] Dermatophytosis was the second common infection (13%) along with gingivitis. Although dermatophytosis has been recorded by most researchers, similar high prevalence of gingivitis has perhaps not been documented.[10],[11],[12] High prevalence of tinea cruris extending from groin to involve trunk has been described.[13] Patients with herpes zoster (6%) included multidermatomal and recurrent cases. Herpes zoster shows variable incidence; some studies recording as high as 20% occurrence in injecting drug users contracting HIV.[7],[10],[11] The present study recorded scabies, molluscum contagiosum, staphylococcal skin infections and oral herpetic lesions like the others but there was no patient with crusted scabies.[3],[10],[11] We recorded one case of giant molluscum - a peculiarity of MC in HIV. Papular pruritic dermatoses and guttate psoriasis - other unique manifestations associated with HIV disease were quite frequently seen.[8],[10],[11],[14] Straightening of hair, although described as a cosmetic problem and not of great clinical importance,[1] was noticed in a significant (36%) proportion of male patients. This has, so far, not been documented as a potential marker of presence of HIV infection although lusterless hair and alopecia have been described in HIV infection.[15]

Genital diseases in HIV hold importance as they share the mode of transmission of HIV. Compared to prior studies GUD was commoner with genital herpes accounting for 8% of cases, chancre and chancroid being recorded in similar frequency.[3],[10],[14] While genital growths included warts, molluscum contagiosum, condyloma acuminata, proportion of patients with GDD was also high. However we did not record any genital malignancy as reported previously.[4] Of note, was the positivity of VDRL in GUD (47%), growths (69%) and GDD (46%). Another feature was the past history of GUD/GDD in 19% patients, of whom 46% had reacted positive to VDRL test. This underscores the importance of STDs in the transmission of HIV as well as the need for screening patients for VDRL reactions as this would open an avenue for a potentially curable co-infection of HIV. However, it is to be remembered that VDRL test may be false positive or negative in HIV-infected persons. Hence, treponemal tests like TPHA become necessary for confirmation in co-infection of HIV and syphilis.

OHL, oral candidiasis and herpes zoster with median CD4 counts of 62/ml, 98/ml and 198/ml respectively were markers of declining immunity.[3],[11] CD4 counts in tinea infections, molluscum contagiosum and seborrhoeic dermatitis were comparable to other studies.[3],[11],[16] We would like to highlight the median CD4 counts as low as 134 and 203 cells/ml in cases of straightening of hair and generalized pigmentation - perhaps these features are associated with declining immunity. Genital herpes and warts were seen with low median CD4 count of 187/ml and 152/ml and this was in keeping with the trends from other Indian works.[3],[16] Although primary chancre is rarely seen in HIV infection we observed it with a low CD4 count of 54/ml - proof of the unpredictable manifestations in HIV/AIDS.

We did not record Kaposi's sarcoma and Penicillium marnefeii infection although Indian incidences of these conditions are on the record.[3],[14],[17]

Recognition of the protean mucocutaneous diseases in HIV/AIDS helps earlier diagnosis of HIV as well as a measure of the immune status of individuals. Simple indicators like straight hairs, discolored hairs or generalized hyperpigmentation in suspected HIV infection cannot be overemphasized, as is the need for thorough oral, cutaneous and genital examinations in HIV. The spectrum of genital diseases especially STDs sound a warning for behavioral change in key subpopulations which will go miles in preventing and managing HIV disease. There should be universal access to treatment of opportunistic infections especially STDs which will not only decrease the HIV burden but also improve the quality of life in those already infected.


   Acknowledgements Top


We acknowledge the help of Mr. Adhir Ghosh, laboratory technician and Mrs. Anurita Mukherjee, counselor of the department of Virology, School of Tropical Medicine, Kolkata for technical assistance. We sincerely acknowledge the generous help extended by the faculties of the department of Dermatology of School of Tropical Medicine. 

   References Top

1.Fauci AS, Clifford Lane H. Human Immunodeficiency Virus (HIV) disease: AIDS and related disorders. In: Braunwald E, Hauser SL, Fauci AS, Long DL, Kasper DL, Jameson JL, editors. Harrison's Principles of Internal Medicine. 15th ed. New York: McGraw- Hill; 2001. Vol 2. p.1852-912.  Back to cited text no. 1    
2.HIV Estimates in India for the year 2002. NACO document; created on 20/12/2003, http://www.naco.nic.in/indianscene/esthiv.htm; accessed on 23/01/2004.  Back to cited text no. 2    
3.Kumarasamy N, Solomon S, Madhivanan P, Ravikumar B, Thyagrajan SP, Yesudian P. Dermatological manifestations among human immunodeficiency virus patients in South India. Int J Dermatol 2000;39:192-5.  Back to cited text no. 3    
4.Singh A, Thappa DM, Hamide A. Mucocutaneous Disorders in HIV infected patients at various stages of the disease: A preliminary report. Indian J Dermatol 1998;43:152-5.  Back to cited text no. 4    
5.Rajagopalan B, Jacob M, George S. Skin lesions in HIV positive and negative patients in South India. Int J Dermatol 1996;35:489-92.  Back to cited text no. 5    
6.Sengupta D, Rewari BB, Mishra SN, Joshi PL, Prasada Rao JVR. Spectrum of opportunistic infections in AIDS: Trends from India. JIACM 2000;4:99-103.  Back to cited text no. 6    
7.Sengupta D, Rewari BB, Shaukat M, Mishra SN. HIV in India. J Postgrad Med 2001;15:90-8.  Back to cited text no. 7    
8.Kulkarni MG, Kavishwar VS, Chogle AR, Parab VV, Aigal U, Koppikar GV. Seroprevalence of human immunodeficiency virus in an infectious diseases hospital. J Assoc Physicians India 2000;48:1160-3.  Back to cited text no. 8    
9.Hira SK, Dupont HL, Dholakia YN, Lanjewar DN. Severe weight loss: the predominant clinical presentation of tuberculosis in patients with HIV infection in India. Natl Med J India 1998;11:256-8.  Back to cited text no. 9    
10.Panda S, Kamei G, Pamei M, Sarkar S, Sarkar K, Singh ND, et al. Clinical features of HIV infection in drug users of Manipur. Natl Med J India 1994;7:267-9.  Back to cited text no. 10    
11.Giri TK, Pande I, Mishra NM, Kailash S, Uppal SS, Ashokekumar. Spectrum of clinical and laboratory characteristics of HIV infection in northern India. J Commun Dis 1995;27:131-41.  Back to cited text no. 11    
12.Agarwal AK, Singh NY, Bijaya Debi L, Shyamkamei KH, Singh YM, Bhattacharya SK. Clinical features and HIV progression as observed longitudinally in a cohort of injecting drug users in Manipur. Indian J Med Res 1998;108:51-7.  Back to cited text no. 12    
13.Kaviarasan PK, Jaishankar TJ, Thappa DM, Sujata S. Clinical variations in dermatophytosis in HIV infected patients. Indian J Dermatol Venerol Leprol 2002;68:213-4.   Back to cited text no. 13    
14.Nair SP, Moorty KP, Suprakasan S. Clinico-epidemiological study of HIV patients in Trivandrum. Indian J Dermatol Venerol Leprol 2003;69:100-3.   Back to cited text no. 14    
15.Criton S, Mohan KB, Asokan PU. Dermatological manifestations of human immunodeficiency virus infected / acquired immunodeficiency syndrome patients in a referral center of central Kerala. Indian J Dermatol Venerol Leprol 1995;61:89-90.  Back to cited text no. 15    
16.Biswas J, Madhavan HN, George AE, Kumarasamy N, Solomon S. Ocular lesions associated with HIV infection in India: a series of 100 consecutive patients evaluated at a referral centre. Am J Ophthalmol 2000;129:9-15.  Back to cited text no. 16    
17.Singh TJK, Devi HN. Profile of HIV/AIDS patients in Regional Institute of Medical Services, Imphal. J Assoc Physicians India 2001;49:102.  Back to cited text no. 17    

 

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