LETTER TO EDITOR
|Year : 2020 | Volume
| Issue : 1 | Page : 125-126
Recent onset pruritic papular eruptions in apparently healthy Indian adults: A clue to suspect AIDS
Chandra Sekhar Sirka1, Swetalina Pradhan1, Baijayantimala Mishra2
1 Department of Dermatology and Venereology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
2 Department of Microbiology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
|Date of Submission||05-Apr-2016|
|Date of Acceptance||04-Dec-2019|
|Date of Web Publication||18-Jun-2020|
Dr. Chandra Sekhar Sirka
Department of Dermatology and Venereology, All India Institute of Medical Sciences, Bhubaneswar - 751 019, Odisha
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sirka CS, Pradhan S, Mishra B. Recent onset pruritic papular eruptions in apparently healthy Indian adults: A clue to suspect AIDS. Indian J Sex Transm Dis 2020;41:125-6
|How to cite this URL:|
Sirka CS, Pradhan S, Mishra B. Recent onset pruritic papular eruptions in apparently healthy Indian adults: A clue to suspect AIDS. Indian J Sex Transm Dis [serial online] 2020 [cited 2021 Jun 12];41:125-6. Available from: https://www.ijstd.org/text.asp?2020/41/1/125/287007
Pruritic papular eruption (PPE) is seen in 12%–46% of AIDS patients.,,, 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 [Figure 1], [Figure 2], [Figure 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 |
Click here to view
|Figure 2: Papules, excoriated papules, nodules, and postinflammatory hyperpigmentation over the extensor of fore arm, arm and shin|
Click here to view
|Figure 3: Excoriated papules over the extensor aspect of the upper and lower extremities |
Click here to view
| Discussion|| |
Occurrence of noninfectious and opportunistic infections in HIV/AIDS depend on the immune status of an individual. 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). 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.,,, 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. 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
Conflicts of interest
There are no conflicts of interest.
| References|| |
Colebunders R, Mann JM, Francis H, Bila K, Izaley L, Kakonde N, et al
. Generalized papular pruritic eruption in African patients with human immunodeficiency virus infection. AIDS 1987;1:117-21.
Hira SK, Wadhawan D, Kamanga J, Kavindele D, Macuacua R, Patil PS, et al
. Cutaneous manifestations of human immunodeficiency virus in Lusaka, Zambia. J Am Acad Dermatol 1988;19:451-7.
Bason MM, Berger TG, Nesbitt LT Jr. Pruritic papular eruption of HIV-disease. Int J Dermatol 1993;32:784-9.
Liautaud B, Pape JW, DeHovitz JA, Thomas F, LaRoche AC, Verdier RI, et al
. Pruritic skin lesions. A common initial presentation of acquired immunodeficiency syndrome. Arch Dermatol 1989;125:629-32.
Chopra S, Arora U. Skin and mucocutaneous manifestations: Useful clinical predictors of HIV/AIDS. J Clin Diagn Res 2012;6:1695-8.
World Health Organization. (2010). Antiretroviral therapy for HIV infection in adults and adolescents: Recommendations for a public health approach - 2010 revision, 2010 rev. World Health Organization. https://apps.who.int/iris/handle/10665/44379
. [Last accessed on 2020 Apr 04].
Lakshmi SJ, Rao GR, Ramalakshmi, Satyasree, Rao KA, Prasad PG, et al
. Pruritic papular eruptions of HIV: A clinicopathologic and therapeutic study. Indian J Dermatol Venereol Leprol 2008;74:501-3.
] [Full text]
Essen NE. Prevalence of Dermatological Disorders in HIV/AIDS Patients and Correlation with Immunosuppression in Lagos, Nigeria. Dissertation for Part II Finals of National Postgraduate Medical College of Nigeria; 2006.
Farsani TT, Kore S, Nadol P, Ramam M, Thierman SJ, Leslie K, et al
. Etiology and risk factors associated with a pruritic papular eruption in people living with HIV in India. J Int AIDS Soc 2013;16:17325.
Jiamton S, Kaewarpai T, Ekapo P, Kulthanan K, Hunnangkul S, Boitano JJ, et al
. Total IgE, mosquito saliva specific IgE and CD4+ count in HIV-infected patients with and without pruritic papular eruptions. Asian Pac J Allergy Immunol 2014;32:53-9.
[Figure 1], [Figure 2], [Figure 3]