Pruritic Papular Eruption Research Articles

English

BACKGROUND: Human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) are frequently associated with mucocutaneous manifestations. However, there is paucity of data on skin disorders and association with CD4 cell counts from India. OBJECTIVE: To evaluate the occurrence of mucocutaneous disorders and their relationship with CD4 count. METHODS: A cross-sectional study was performed at Government Medical College Kota from January 2011 to January 2012. Collected information included demographic data, HIV- associated mucocutaneous disorders, CD4 cell count and highly active antiretroviral therapy (HAART). RESULTS: One hundred cases (male: female, 1.7: 1) were enrolled. The most common mode of HIV transmission was heterosexual (89%), followed by homosexual/bisexual contacts (5%), perinatal (5%) and blood transfusion (1%). The distribution of patients in terms of CD4 cell counts was as follows: 30% with less than 200 × 10 6 /L, 55% with between 200 and 500 × 10 6 /L, and 15% with more than 500× 10 6 /L. Most common skin disorders were fungal infection (46%), followed by bacterial infection (30%), viral infection (26%). Pruritic papular eruption (13%) was most common non infectious dermatoses followed by seborrheic dermatitis (8%). A CD4 cell count of less than 200×106/L was significantly associated with a higher number of mucocutaneous disorders (P = 0.005) and the development of oral candidiasis (P = 0.005) and generalized seborrheic dermatitis ( P = 0.005). There was no case of cutaneous malignancy in our study. CONCLUSION: A wide range of mucocutaneous disorders were observed in HIV-infected cases which are the indicator of AIDS and overall survival. A preponderance of infectious and inflammatory dermatoses with an absence of skin tumors characterized this study.

Serum selenium and skin diseases among Nigerians with human immunodeficiency virus/acquired immune deficiency syndrome

BackgroundThe role of selenium as an antioxidant micronutrient has garnered the unprecedented focus of researchers in recent times. No clinical study has related serum selenium concentration to skin diseases in human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) patients.MethodsIn this study, 134 newly diagnosed HIV patients that satisfied the inclusion criteria were included. Skin diseases were clinically diagnosed and fasting venous blood was taken for assessment of serum selenium using an atomic absorption spectrophotometer.ResultsThe mean age of HIV subjects with and without skin disease were not significantly different: 32.72 ± 9.21 versus 35.86 ± 8.55 years, P = 0.077, respectively. The mean of serum selenium (0.51 ± 0.48 versus 0.81 ± 0.39), CD4+ count (228.06 ± 212.89 versus 446.41 ± 182.87), and body mass index (BMI; 21.09 ± 3.58 versus 23.53 ± 3.35) were significantly lower (P < 0.001) for HIV/AIDS participants with skin disease than those without skin disease. We found significant clustering of symptoms and signs: fever (P = 0.037), weight loss (P = 0.009), oral candidiasis (P = 0.038), pallor (P = 0.037) among HIV/AIDS subjects with skin diseases than those without. Low serum selenium concentration was significantly associated with primary skin disease of HIV/AIDS, such as pruritic papular eruption of AIDS (P = 0.003), xeroderma (P = 0.030), fluffy hair (P = 0.021), blue-black nail hyperpigmentation (P = 0.033) and secondary skin disease, such as oral candidiasis (P = 0.002). There was a significant association between low serum selenium concentration and increasing frequency of skin diseases (P = 0.002), but serum selenium was not significantly related to extents of distribution of skin diseases (P > 0.05).Conclusionserum selenium concentration was lower among HIV subjects with skin diseases than those without skin disease. Pruritic papular eruption, xeroderma, fluffy hair, blue-black nail hyper pigmentation, and oral candidiasis were significantly associated with low serum selenium concentration.

Total IgE, mosquito saliva specific IgE and CD4+ count in HIV-infected patients with and without pruritic papular eruptions

Pruritic Papular Eruption (PPE) is a skin disorders found in HIV infected patients. However, the exact etiology of PPE is not documented. It has been suggested that PPE might result from arthropod bites. The aim of this study was to investigate those factors in the HIV patient contributing to the occurrence of PPE, including specific IgE against mosquito saliva allergens, total IgE, CD4 cell counts and their associations. Specific IgE against saliva allergens of Cx. quinquefasciatus mosquito was measured in 25 HIV patients with PPE and in 60 HIV without PPE by a time-resolved fluorescence immunoassay (TRIFA). The total IgE levels and CD4cell counts were also determined. Among the HIV patients with PPE, 84% (21/25) had CD4 cell counts less than 200 cells/μl in contrast to 30% (18/60) of the HIV without PPE patients. These differences were statistically significant (p =0.0005, χ2 test). The total IgE scores for the HIV patients with PPE were significantly higher than for those without PPE. A comparison of the mean arbitrary scores of the specific IgE in HIV patients, with and without PPE, was non-significant (p = 0.152). However, 44% (11/25) of the HIV patients with PPE had an arbitrary score above the mean score of mosquito bite allergic subjects, as compared to only 3.3% (2/60) of HIV patients without PPE. It may be concluded that the etiology of PPE in the HIV patient may be heterogeneous or multi-causal with allergic responses to the mosquito saliva allergen being only partially responsible.

Pruritic papular eruption in HIV: a case successfully treated with NB-UVB

Pruritic papular eruption (PPE) is a skin disease characterized by the eruption of itching papules on the extremities, face, and trunk; it is quite frequent in HIV-positive patients especially during the advanced immunosuppressive stage. PPE usually improves or heals when antiretroviral therapy restores the immune system function, but in some cases, it can take several months, and a symptomatic treatment for PPE is required. Systemic antihistamines, topical steroids, topical tacrolimus, itraconazole, pentoxyphilline, and ultraviolet B phototherapy have been proposed in cases of persisting PPE, but an elective treatment has not yet been found. We describe the case of a black patient affected by PPE, nonimproving with antiretroviral treatment, and resistant to topical steroids and oral antihistamines; a satisfactory and speedy result was achieved with narrow-band ultraviolet B phototherapy.

Dermatological manifestations in human immunodeficiency virus infected patients: Morphological spectrum with CD4 correlation

Background:More than 90% of human immunodeficiency virus (HIV) infected patients develop skin lesions at some time throughout the course of the disease. Several skin diseases have proved to be sensitive and useful indicators of progression of HIV infection. Although these conditions may be seen in general healthy population, their occurrence in patients with acquired immunodeficiency syndrome is often atypical, more severe and explosive.Aims:The present study was carried out to categorize the skin lesions by histopathology using punch biopsy or cytology when feasible in HIV infected patients and to see the correlation for various skin lesions with CD4 counts.Materials and Methods:In total 110 known HIV positive patients with the symptomatic skin lesions, cytology and punch biopsy was correlated with CD4 counts.Results:Maximum patients were between 31 and 40 years. 53 (48.18%) patients had infectious and 37 (34.55%) patients had non-infectious lesions. Out of 110 patients, CD4 counts were available in 70 patients. The spectrum of various non-infectious and infectious lesions such as viral, bacterial, fungal, protozoa and their association with CD4 counts is discussed.Conclusions:CD4 counts below 200 were associated with the maximum infectious lesions, whereas CD4 counts more than 350 showed more of the non-infectious lesions. Most common infectious lesion was Molluscum contagiosum. The most common non-infectious lesion was pruritic papular eruptions.

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

IntroductionPapulopruritic 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.MethodsThis 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 χ2 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.ResultsForty-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).DiscussionPPE 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.

Dermatological manifestations in human immunodeficiency virus infected patients: Morphological spectrum with CD4 correlation

More than 90% of human immunodeficiency virus (HIV) infected patients develop skin lesions at some time throughout the course of the disease. Several skin diseases have proved to be sensitive and useful indicators of progression of HIV infection. Although these conditions may be seen in general healthy population, their occurrence in patients with acquired immunodeficiency syndrome is often atypical, more severe and explosive. The present study was carried out to categorize the skin lesions by histopathology using punch biopsy or cytology when feasible in HIV infected patients and to see the correlation for various skin lesions with CD4 counts. In total 110 known HIV positive patients with the symptomatic skin lesions, cytology and punch biopsy was correlated with CD4 counts. Maximum patients were between 31 and 40 years. 53 (48.18%) patients had infectious and 37 (34.55%) patients had non-infectious lesions. Out of 110 patients, CD4 counts were available in 70 patients. The spectrum of various non-infectious and infectious lesions such as viral, bacterial, fungal, protozoa and their association with CD4 counts is discussed. CD4 counts below 200 were associated with the maximum infectious lesions, whereas CD4 counts more than 350 showed more of the non-infectious lesions. Most common infectious lesion was Molluscum contagiosum. The most common non-infectious lesion was pruritic papular eruptions.

Insect bite reactions

Insects are a class of living creatures within the arthropods. Insect bite reactions are commonly seen in clinical practice. The present review touches upon the medically important insects and their places in the classification, the sparse literature on the epidemiology of insect bites in India, and different variables influencing the susceptibility of an individual to insect bites. Clinical features of mosquito bites, hypersensitivity to mosquito bites Epstein-Barr virus NK (HMB-EBV-NK) disease, eruptive pseudoangiomatosis, Skeeter syndrome, papular pruritic eruption of HIV/AIDS, and clinical features produced by bed bugs, Mexican chicken bugs, assassin bugs, kissing bugs, fleas, black flies, Blandford flies, louse flies, tsetse flies, midges, and thrips are discussed. Brief account is presented of the immunogenic components of mosquito and bed bug saliva. Papular urticaria is discussed including its epidemiology, the 5 stages of skin reaction, the SCRATCH principle as an aid in diagnosis, and the recent evidence supporting participation of types I, III, and IV hypersensitivity reactions in its causation is summarized. Recent developments in the treatment of pediculosis capitis including spinosad 0.9% suspension, benzyl alcohol 5% lotion, dimethicone 4% lotion, isopropyl myristate 50% rinse, and other suffocants are discussed within the context of evidence derived from randomized controlled trials and key findings of a recent systematic review. We also touch upon a non-chemical treatment of head lice and the ineffectiveness of egg-loosening products. Knockdown resistance (kdr) as the genetic mechanism making the lice nerves insensitive to permethrin is discussed along with the surprising contrary clinical evidence from Europe about efficacy of permethrin in children with head lice carrying kdr-like gene. The review also presents a brief account of insects as vectors of diseases and ends with discussion of prevention of insect bites and some serious adverse effects of mosquito coil smoke.

A Clinical Prediction Score in Addition to WHO Criteria for Anti-Retroviral Treatment Failure in Resource-Limited Settings - Experience from Lesotho

ObjectiveTo assess the positive predictive value (PPV) of a clinical score for viral failure among patients fulfilling the WHO-criteria for anti-retroviral treatment (ART) failure in rural Lesotho.MethodsPatients fulfilling clinical and/or immunological WHO failure-criteria were enrolled. The score includes the following predictors: Prior ART exposure (1 point), CD4-count below baseline (1), 25% and 50% drop from peak CD4-count (1 and 2), hemoglobin drop≥1 g/dL (1), CD4 count<100/µl after 12 months (1), new onset papular pruritic eruption (1), and adherence<95% (3). A nurse assessed the score the day blood was drawn for viral load (VL). Reported confidence intervals (CI) were calculated using Wilsons method.ResultsAmong 1'131 patients on ART≥6 months, 134 (11.8%) had immunological and/or clinical failure, 104 (78%) had blood drawn (13 died, 10 lost to follow-up, 7 did not show up). From 92 (88%) a result could be obtained (2 samples hemolysed, 10 lost). Out of these 92 patients 47 (51%) had viral failure (≥5000 copies), 27 (29%) viral suppression (<40) and 18 (20%) intermediate viremia (40–4999). Overall, 20 (22%) had a score≥5. A score≥5 had a PPV of 100% to detect a VL>40 copies (95%CI: 84–100), and of 90% to detect a VL≥5000 copies (70–97). Within the score, adherence<95%, CD4-count<100/µl and papular pruritic eruption were the strongest single predictors. Among 47 patients failing, 8 (17%) died before or within 4 weeks after being switched. Overall mortality was 4 (20%) among those with score≥5 and 4 (5%) if score<5 (OR 4.3; 95%CI: 0.96–18.84, p = 0.057).ConclusionA score≥5 among patients fulfilling WHO-criteria had a PPV of 100% for a detectable VL and 90% for viral failure. In settings without regular access to VL-testing, this PPV may be considered high enough to switch this patient-group to second-line treatment without confirmatory VL-test.

Analysis of serum chemokine levels in patients with HIV‐associated eosinophilic folliculitis

Patients with human immunodeficiency virus (HIV) infection exhibit various skin diseases. HIV-associated eosinophilic folliculitis (EF) and pruritic papular eruption (PPE) are frequently seen. To understand the mechanisms underlying HIV-associated EF and PPE. In order to know frequencies of EF and PPE among patients with HIV infection, we first collected HIV(+) patients who visited dermatology clinic in National Center for Global Health and Medicine during February 2007. We next collected 25 serum samples from HIV(+) patients with skin diseases from May 2008 to May 2010. Eight of 25 patients had EF (EF group), four had PPE (PPE group) and others had non-itchy skin problems such as condyloma acuminatum (no itch group). We first confirmed high frequencies of EF (10.7%) and PPE (5.3%) among 75 HIV(+) patients who visited our clinic during one month. We then measured serum levels of CCL11, CCL17, CCL26 and CCL27. Serum CCL17 levels in EF were significantly higher than those of PPE and no itch group. Serum CCL26 and CCL27 levels in EF were higher than those of no itch group. The number of CD4(+) cells in EF was significantly lower than that in no itch group. High serum levels of CCL17, CCL26 and CCL27, and low CD4(+) cell counts may account for the development of HIV-associated EF.

Pattern of skin diseases at university of Benin teaching hospital, Benin city, Edo State, South-South Nigeria: a 12 month prospective study.

Background and Objective:This study aims to look at the pattern and incidence of skin diseases seen in Dermatology/Venereology clinic at the University of Benin Teaching Hospital, Benin City, Edo State, South-South Zone, Nigeria and compare it with other zones of Nigeria.Materials and Methods:This was a prospective study on pattern and incidence of skin diseases in new patients presenting at the Dermatology/Venereology outpatient clinic of the University of Benin Teaching Hospital, Benin City, Edo State, South-South, Nigeria, from September 2006 to August 2007. All patients were seen by the researchers. Diagnosis were made clinically and sometimes with the support of histopathology.Results:A total number of 4786 patients were seen during the study period and these comprised 2647 HIV/AIDS patients and 2112 pure Dermatological patients. Out of 4786 patients, 755 (15.8%) were new patients. The new patients comprised 96 (12.7%) children patients (< 15 years) and 659 (83.7%) adult patients (>15years). The ages of the patients ranged from 2 weeks to 80 years and more than two-third were < 40 years. There were 354 males (46.9%) and 401 females (53.1%). This represents female: male ratio of 1.1: 1. Eczematous dermatitis accounted for 20.9% of the skin diseases and was the most common of the skin diseases observed. This is consistent with observation from other zones in Nigeria. Other skin diseases observed in order of frequencies include: Papulosqamous disorder (9.0%), Infectious skin diseases like fungal, viral, bacterial and parasitic infestation, at 7.9%, 7.7%, 2.3% and 2.1% respectively. Pigmentary disorders (5.0%), hair disorders (4.2%) and Benign neoplastic skin disease (6.5%). All the patients that had neurofibromatosis were females (1.9%). HIV-related skin diseases were observed to have increased remarkably (7.9%) with Kaposi’s sarcoma, papular pruritic eruptions and drug eruptions being the commonest mode of presentation.Conclusion:The current pattern of skin diseases in Benin City, South-South Nigeria seems to follow a similar pattern observed in other Geo-political zones in Nigeria. The eczematous dermatitis took the lead and the impact of HIV-related skin diseases were vividly noticed to be on the increase. Connective tissue disorder and cutaneous malignancies were low in their occurrences. Our findings showed no major differences in the pattern of skin diseases when compared with other zones of Nigeria. Allergic skin diseases were observed to be on the increase in all the geo-political zones; possibly due to increase in urbanization and its attending socio-economic burden.

Pruritic papular eruption and eosinophilic folliculitis associated with human immunodeficiency virus (HIV) infection: A histopathological and immunohistochemical comparative study

Among the papular-pruriginous dermatoses related to human immunodeficiency (HIV) infection, two entities remain poorly differentiated leading to confusion in their diagnosis: HIV-related pruritic papular eruption (HIV-PPE or prurigo) and eosinophilic folliculitis (HIV-EF). To establish histopathological and immunohistochemical parameters to differentiate between two conditions associated with HIV infection, the pruritic papular eruption (HIV-PPE) and eosinophilic folliculitis (HIV-EF). Clinically typical HIV-PPE (18 cases) and HIV-EF (10 cases) cases were compared with each other in terms of the following topics: clinical and laboratory features (gender, age, CD4+ cell and eosinophil count), histopathological features (hematoxylin-eosin and toluidine blue staining) and immunohistochemical features (anti-CD1a, anti-CD4, anti-CD7, anti-CD8, anti-CD15, anti-CD20, anti-CD30, anti-CD68/macrophage and anti-S-100 reactions). Among the HIV-EF patients, we found an intense perivascular and diffuse inflammatory infiltration compared with those patients with HIV-PPE. The tissue mast cell count by toluidine staining was higher in the HIV-EF patients, who also presented higher expression levels of CD15 (for eosinophils), CD4 (T helper), and CD7 (pan-T lymphocytes) than the HIV-PPE patients. Only quantitative differences and not qualitative differences were found. These data indicate that HIV-related PPE and EF could possibly be differentiated by histopathological and immunohistochemical findings in addition to clinical characteristics. In fact, these two inflammatory manifestations could be within the spectrum of the same disease because onlyquantitative, and not qualitative, differences were found.

Mucocutaneous manifestation of pediatric human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) in relation to degree of immunosuppression: a study of a West African population

Mucocutaneous lesions occur at one point or the other during the course of human immunodeficiency virus (HIV) disease. These lesions can be the initial presenting features but could also be a pointer to the presence of immunosuppression. This study was carried out to determine the pattern of mucocutaneous manifestation in children who have human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) in relation to their level of immunosuppression. One hundred children who were HIV seropositive aged 18months to 16years were evaluated for mucocutaneous lesions, and their degree of immunosuppression was also determined using total CD(4+) count or CD(4+) percentage. Another group of age and gender matched 100 HIV-negative children were also examined for mucocutaneous lesions. The mucocutaneous manifestations were more common among the subjects compared to controls (P=0.000). The overall prevalence among the seropositive and seronegative subjects was 64% and 12% respectively. The prevalence of mucocutaneous findings in children with severe, moderate, and no immunosuppression were 93.8%, 55.2%, and 46.2%, respectively. The lesions were significantly more common among those with moderate and severe immunosuppression compared to those with no immunosuppression (P=0.000). Multiple lesions were more frequent among those with severe immunosuppression. Oral thrush was the most frequent lesion (25.6%) among the subjects followed by pruritic papular eruption (20.7%) and dermatophytosis (14.1%). Severe and atypical forms of dermatophytosis and herpes ulcer were also observed among the subjects. This study shows that mucocutaneous lesions are common in children with HIV/AIDS and could be an early indicator of immune suppression. It is important to recognize them early in order to enhance early case detection and treatment.

An Intensely Pruritic Papular Eruption – Is There a Distant Cause?

An Intensely Pruritic Papular Eruption – Is There a Distant Cause?

Mucocutaneous manifestations of HIV‐infected patients in the era of HAART in Guangxi Zhuang Autonomous Region, China

Human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) are frequently associated with diverse mucocutaneous manifestations. However, few studies of HIV/AIDS-related mucocutaneous manifestations have been reported in China. To investigate the occurrence of mucocutaneous disorders and their relationship with the degree of immunosuppression in 348 HIV-infected Chinese patients. The influence of highly active antiretroviral therapy (HAART) on the spectrum of mucocutaneous manifestations was also evaluated. A cross-sectional study was performed on 348 HIV-infected Chinese patients seen at the Guangxi Longtan Hospital from August 2010 to November 2010. Collected information included demographic data, HIV-associated mucocutaneous disorders, CD4 cell count, AIDS-defining illness and antiretroviral therapy. In this study, 62.9% of all patients had mucocutaneous disorders. The prevalence of mucocutaneous disorders in the patients who had received HAART was lower than in those without HAART (54.05% vs. 88.76%, P < 0.001). The prevalence of mucocutaneous disorders was higher in the patients with CD4 < 200 cells/mm(3) in comparison to those with CD4 ≥ 200 cells/mm(3) (P < 0.05). The most common mucocutaneous disorders were oral candidiasis (28.47%), Penicillium marneffei infection (11.49%), drug eruptions (10.06%) and pruritic papular eruption (PPE 5.75%). Oral candidiasis, P. marneffei infection and PPE were significantly more prevalent in patients with a CD4 cell count below 200 cells/mm(3) , but frequency of drug eruptions was not related to the level of CD4 cell counts. Patients treated with HAART had decreased rates of herpes simplex, oral candidiasis and P. marneffei infection, but increased rates of drug eruptions. A wide range of mucocutaneous disorders were observed in HIV-infected Chinese patients. Oral candidiasis, P. marneffei infection and PPE may be the signs of advanced HIV infection. HAART had an impact on the spectrum of HIV-associated mucocutaneous disorders.

Skin and Mucocutaneous Manifestations: Useful Clinical Predictors of HIV/AIDS

The HIV infection is associated with several dermatological conditions which may be the first pointer towards the existence of HIV. These may present with unusual and atypical manifestations in the course of the HIV infection. Keeping this in mind, the seroprevalence of HIV in these persons and the spectrum of the skin and the mucocutaneous lesions in the HIV positive patients was studied. The current prospective study was conducted over a period of 3 years (2006-2008). A total of 604 persons who had any kind of skin and mucocutaneous infections were screened for the HIV infection as per the NACO guidelines after recording their clinical and epidemiological profiles. Out of the 604 patients who were screened, 90(14.90%) were seropositive for the HIV-I antibodies and none was positive for the HIV-2 antibodies. Seventy three point thirty three percent 73.33 of the seropositive patients were in the age group of 15-40 years, with a male-female ratio of 1:1.05. The heterosexual route was the most common mode of transmission (86.6%).A wide range of infectious and noninfectious lesions were observed. In the HIV seropositive patients, oral candidiasis (32.22%) was the most common infectious disease which was observed, followed by herpes zoster (13.33%), genital warts (7.77%) and genital herpes (6.66%). The most common noninfectious manifestation was seborrhoic dermatitis (8.88%), followed by pruritic papular eruptions (7.77%). As there is a high prevalence of the HIV infection in patients who have skin and mucocutaneous disorders, the doctors, during the investigation of these patients, must have a high level of suspicion for the HIV infection in their mind. An early detection of HIV optimizes the chemoprophylaxis for many opportunistic mucocutaneous disorders.

More than just a coincidence: Herpes zoster and acne rosacea appearing together as Wolf's isotopic response in an Asian female

Introduction: Wolf’s isotopic response is a rare dermatologic phenomenon defined as the occurrence of a new, unrelated disease at the site of healed lesions of some other disease. We report the first case of Wolf’s isotopic response in a female presenting with rosacea localized to the site of healing zoster lesions. Case Report: A 35­year­old previously healthy Filipino­American woman with no prior history of a dermatologic condition presented to our clinic with a 9­month history of a painful and pruritic unilateral erythematous papular eruption on her right upper cutaneous lip and cheek that respected the midline. At initial presentation she was started on 800 mg acyclovir five times daily for one week for presumed zoster. Four days into her seven­day acyclovir course, her primary care physician obtained cultures for VZV and HSV, but these tests were negative. The vesicular eruptions completely resolved following treatment with acyclovir, leaving only hyperpigmented scars in the unilateral maxillary distribution. Two months after the completion of her acyclovir treatment, she noticed pink dots, which had a prickly and itchy sensation located in the same unilateral distribution as her previous eruptions. Her condition was refractory to a myriad of topical treatments and a skin biopsy was performed which suggested acne rosacea. She was started on isotretinoin and continued for five months with almost complete resolution of papules and symptoms. Conclusion: The pathogenesis of Wolf’s isotopic response is unknown. We review the various etiologies that have been postulated including direct action of viral, particles, immune activation, alterations in neurologic system and vascular changes. Early recognition of Wolf’s isotopic response may result in more timely and effective treatment for patients. Further studies are needed to define the pathogenesis of isotopic response.

Validation of World Health Organisation HIV/AIDS Clinical Staging in Predicting Initiation of Antiretroviral Therapy and Clinical Predictors of Low CD4 Cell Count in Uganda

IntroductionThe WHO clinical guidelines for HIV/AIDS are widely used in resource limited settings to represent the gold standard of CD4 counts for antiviral therapy initiation. The utility of the WHO-defined stage 1 and 2 clinical factors used in WHO HIV/AIDS clinical staging in predicting low CD4 cell count has not been established in Uganda. Although the WHO staging has shown low sensitivity for predicting CD4<200cells/mm3, it has not been evaluated at for CD4 cut-offs of <250cells/mm3 or <350 cells/mm3.ObjectiveTo validate the World Health Organisation HIV/AIDS clinical staging in predicting initiation of antiretroviral therapy in a low-resource setting and to determine the clinical predictors of low CD4 cell count in Uganda.ResultsData was collected on 395 participants from the Joint Clinical Research Centre, of whom 242 (61.3%) were classified as in stages 1 and 2 and 262 (68%) were females. Participants had a mean age of 36.8 years (SD 8.5). We found a significant inverse correlation between the CD4 lymphocyte count and WHO clinical stages. The sensitivity the WHO clinical staging at CD4 cell count of 250 cells/mm3 and 350cells/mm3 was 53.5% and 49.1% respectively. Angular cheilitis, papular pruritic eruptions and recurrent upper respiratory tract infections were found to be significant predictors of low CD4 cell count among participants in WHO stage 1 and 2.ConclusionThe WHO HIV/AIDS clinical staging guidelines have a low sensitivity and about half of the participants in stages 1 and 2 would be eligible for ART initiation if they had been tested for CD4 count. Angular cheilitis and papular pruritic eruptions and recurrent upper respiratory tract infections may be used, in addition to the WHO staging, to improve sensitivity in the interim, as access to CD4 machines increases in Uganda.

The burden of co-existing dermatological disorders and their tendency of being overlooked among patients admitted to Muhimbili National Hospital in Dar es Salaam, Tanzania.

BackgroundSkin diseases are underestimated and overlooked by most clinicians despite being common in clinical practice. Many patients are hospitalized with co-existing dermatological conditions which may not be detected and managed by the attending physicians. The objective of this study was to determine the burden of co-existing and overlooked dermatological disorders among patients admitted to medical wards of Muhimbili National hospital in Dar es Salaam.Study design and settingsA hospital-based descriptive cross-sectional study conducted at Muhimbili National hospital in Dar es Salaam, Tanzania.MethodsPatients were consecutively recruited from the medical wards. Detailed interview to obtain clinico-demographic characteristics was followed by a complete physical examination. Dermatological diagnoses were made mainly clinically. Appropriate confirmatory laboratory investigations were performed where necessary. Data was analyzed using the 'Statistical Package for Social Sciences' (SPSS) program version 10.0. A p-value of < 0.5 was statistically significant.ResultsThree hundred and ninety patients admitted to medical wards were enrolled into the study of whom, 221(56.7%) were females. The mean age was 36.7 ± 17.9 (range 7-84 years). Overall, 232/390 patients (59.5%) had co-existing dermatological disorders with 49% (191/390) having one, 9% (36/390) two and 5 patients (1%) three. A wide range of co-existing skin diseases was encountered, the most diverse being non-infectious conditions which together accounted for 36.4% (142/390) while infectious dermatoses accounted for 31.5% (123/390). The leading infectious skin diseases were superficial fungal infections accounting for 18%. Pruritic papular eruption of HIV/AIDS (PPE) and seborrheic eczema were the most common non-infectious conditions, each accounting for 4.3%. Of the 232/390 patients with dermatological disorders, 191/232 (82.3%) and 154/232 (66.3%) had been overlooked by their referring and admitting doctors respectively.ConclusionDermatological disorders are common among patients admitted to medical wards and many are not detected by their referring or admitting physicians. Basic dermatological education should be emphasized to improve knowledge and awareness among clinicians.

Pruritic papular eruptions as presenting illness of HIV

Mucocutaneous manifestations can be the first markers of HIV. We are reporting the case of an adolescent girl who presented with chronic, recurrent, intensely pruritic papular lichenified eruptions over extremities, face and trunk, which were exudative and crusted at places. She had delayed milestones with growth failure and no pubertal features. She did not have any risk factors to be suspected for HIV. The lesions were refractory to treatment, so she was tested for HIV and she came out to be HIV positive. This case reports pruritic papular eruptions as presenting illness of HIV.