CUTANEOUS MANIFESTATIONS OF HIV INFECTION

Dr Tashi Agarwal (PG, 2nd year resident), Dr Shweta Sharma (PG, 3rd 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

A panorama of cutaneous lesions in HIV

CLASSIFICATION OF CUTANEOUS LESIONS IN HIV

INFECTIOUS

• Herpes zoster

• Herpes simplex

• Cryptococcus

• Histoplasmosis

• Human papillomavirus

• Impetigo

• Lymphogranuloma venereum

• Molluscum contagiosum

• Syphilis

• Furunculosis

• Folliculitis

• Pyomyositis

• Superficial fungal infections

NEOPLASTIC

• Kaposi’s sarcoma

• Lymphoma

• Squamous cell carcinoma

OTHERS

• Pruritic papular eruption

• Eosinophillic folliculitis

• Seborrheic dermatitis

• Drug eruption

• Vasculitis

• Psoriasis

• Hyperpigmentation

• Photodermatitis

• Atopic Dermatitis

• Hair changes

Kaposi’s sarcoma HIV-associated Kaposi’s sarcoma•95% in homosexual or bisexual menEtiology: 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.

MACULAR STAGE

There are violaceouspatches of

discoloration/ M/E : Promontory sign

PLAQUE STAGE

Lesions become indurated and

confluent/ Hyaline globules(PAS +)

TUMOR STAGE

Solid red-purple nodules are formed/

Vascular slit appearance

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 immunohistochemistryof angiocentricpattern.

Abnormal epidermotropism

Scaling patches and plaques.

Molluscum Contagiosum•Incidence 10-20%

•Common at genitalia, face(periorbitalarea),axilla, groin & buttock

•CD4+ count <200 cells/cu.mm.Clinical Features:Molluscum contagiosum lesions are pearly or flesh-colored, dome-shaped, umbilicatedpapules, ranging from 2 to 5 mm, with a central core. In AIDS, hundreds of lesions of molluscumcontagiosum may be observed, showing little tendency toward involution.M/E:Many epidermal cells contain large, intracytoplasmic inclusion bodies, Molluscumbodies. (H&E 40X)

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.

LeishmaniasisClinical 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 paranuclearkinetoplast. •They represent amastigotes, known as Leishman-Donovan bodies. When numerous, they can also be seen extracellularly.

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

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

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 endothrixinfection. (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

Bacterial skin disease

• Bacterial skin diseases include : Pyogenic diseases, Mycobacterialdiseases, Nocardiosis, Bacillary angiomatosis.

• Staphylococcus aureus is the cause in most bacterial skin infections.

• HIV-infected patients are at risk for disseminated mycobacterialinfections (Miliary tuberculosis).

• Disseminated nontuberculousmycobacterial 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)

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 hyperpigmentedpapules 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)

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 folliculitispresents with sudden onset of disseminated follicle-centeredpustules, typically on the trunk and less commonly the face.

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