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      Recent onset pruritic papular eruptions in apparently healthy Indian adults: A clue to suspect AIDS

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          Abstract

          Sir, Pruritic papular eruption (PPE) is seen in 12%–46% of AIDS patients.[1 2 3 4] The appearance of PPE in HIV patients is an indicator of advanced disease and severe immunosuppression. We report three cases of apparently healthy Indian adults with PPE lesions on skin, ELISA test for HIV was positive and decreased CD4 cell count. Three adults (one male and two females) presented with itchy skin lesions for 1–8 months. The skin lesions included papules, excoriated papules, nodules, postinflammatory hyperpigmentation, hypopigmentation, and scars [Figures 1–3]. They were distributed all over the body with increased predilection for the extensors of the extremities. In addition, the first case had whitish deposit over the tongue (candidiasis) and verrucous papule on the coronal sulcus and adjoining area of the genital mucosa (condyloma acuminata), case 2 had a superficial ulcer of size 6 cm × 7 cm on the genital mucosa with arcuate border, and case 3 had reactivation of pulmonary tuberculosis treated 3 years back. There was no history suggestive of atopy or eczema. Based on the history and examination; cases were suspected of having immunosuppression due to HIV infection. HIV test by ELISA was positive and venereal disease research laboratory test (VDRL) test done to rule out Syphilis was negative. The CD4 counts of the three cases were 73 cells/mm3, 84 cells/mm3, and 131 cells/mm3, respectively. The PPE lesions were treated with oral cetirizine hydrochloride 10 mg/daily and topical application of clobetasol propionate twice daily, and the patients were advised to use protective clothes. Case 1 received oral fluconazole 100mg daily for 14 days, and 20% podophyllum resin application weekly for oral candidiasis and condyloma accuminata, respectively. Case2 was given oral acyclovir 400 mg thrice daily for 14 days for herpes genitalis. Both the cases (1 and 2) improved and all the three cases were referred to anti-retroviral therapy (ART) center for registration and initiation of anti-retroviral drug. Figure 1 Papules, excoriated papules, and healed hypo- and hyperpigmented scars over the dorsum of foot and upper back over scapular area Figure 2 Papules, excoriated papules, nodules, and postinflammatory hyperpigmentation over the extensor of fore arm, arm and shin Figure 3 Excoriated papules over the extensor aspect of the upper and lower extremities DISCUSSION Occurrence of noninfectious and opportunistic infections in HIV/AIDS depend on the immune status of an individual.[5] Especially in HIV/AIDS, the occurrence of noninfectious and infectious skin lesions may be of diagnostic, prognostic value and may indicate immunosuppression. Till date, the diagnoses of HIV/AIDS is mostly from clinical suspicion followed by investigations. Hence, it is necessary for clinicians to get used to the various morphologies of infectious and non-infectious conditions and their implication. Recently, WHO has included PPE in the clinical diagnosis and staging of HIV/AIDS in adults and adolescents (i.e. Stage 2 HIV/AIDS disease).[6] However, PPE alone has not been indicated for the diagnosis of HIV/AIDS. PPE is frequently reported from India, Africa, and Nigeria in AIDS patients and lesions indicated of severe immunosuppression.[1 7 8 9] Jiamton et al. hypothesized PPE lesions in HIV/AIDS are result of hypersensitivity response in severely immunosuppressed (HIV/AIDS) patients to insect bite, and mosquito saliva.[10] Our cases were from rural area and exposed to insect bite. From the present series of three Indian adults with PPE lesions occurring over 1 year, later confirmed HIV by ELISA test and lone PPE was an only the consistent skin finding. Hence, authors hypothesize that the recent onset PPE alone in Indian adults may be a clue to clinical suspect immunosuppression due to HIV/AIDS. However, a large cohort study of HIV/ AIDS patients with PPE is required to validate our findings. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

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          Pruritic skin lesions. A common initial presentation of acquired immunodeficiency syndrome.

          During July 1983 to December 1984, we observed that 62 (46%) of 134 Haitian patients with acquired immunodeficiency syndrome had intensely pruritic eruptions for which neither specific causative nor categoric diagnoses could be established. These lesions were a presenting manifestation of acquired immunodeficiency syndrome in 79% of the patients and appeared a mean of 8 months before the diagnosis of either Kaposi's sarcoma or opportunistic infection. Lesions included erythematous round macules, papules, or nodules that first appeared on the extensor surface of the arms, but subsequently involved the legs, trunk, and face. Histologically, the lesions were characterized by varying degrees of mixed (predominantly eosinophilic) perivascular and perifollicular inflammatory cell infiltrates of the dermis. The lesions did not respond to any therapeutic regimens used and usually persisted throughout the acquired immunodeficiency syndrome illness. Demographic and laboratory data did not distinguish these patients from those without pruritic skin lesions.
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            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.
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              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 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. 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.
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                Author and article information

                Journal
                Indian J Sex Transm Dis AIDS
                IJSTD
                Indian Journal of Sexually Transmitted Diseases and AIDS
                Wolters Kluwer - Medknow (India )
                2589-0557
                2589-0565
                Jan-Jun 2020
                18 June 2020
                : 41
                : 1
                : 125-126
                Affiliations
                [1]Department of Dermatology and Venereology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
                [1 ]Department of Microbiology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
                Author notes
                Address for correspondence: Dr. Chandra Sekhar Sirka, Department of Dermatology and Venereology, All India Institute of Medical Sciences, Bhubaneswar - 751 019, Odisha, India. E-mail: csirka2006@ 123456gmail.com
                Article
                IJSTD-41-125
                10.4103/ijstd.IJSTD_38_16
                7529182
                d1448174-3b5d-4cf4-a1c7-5530bc485179
                Copyright: © 2020 Indian Journal of Sexually Transmitted Diseases and AIDS

                This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

                History
                : 05 April 2016
                : 19 July 2016
                : 04 December 2019
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