|Year : 2019 | Volume
| Issue : 4 | Page : 197-200
Cutaneous manifestations of human immunodeficiency virus/Aids patients in Albania
Erjona Shehu1, Arjan Harxhi1, Artan Simaku2
1 University Hospital Centre “Mother Theresa”, Tirana, Albania
2 Department of Epidemiology, Institute of Public Health, Tirana, Albania
|Date of Submission||25-Aug-2018|
|Date of Decision||03-Mar-2019|
|Date of Acceptance||16-Aug-2019|
|Date of Web Publication||11-Oct-2019|
Dr. Artan Simaku
Institute of Public Health, Tirana
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Context: Dermatologic diseases are common in the human immunodeficiency virus (HIV)-infected population. Cutaneous manifestations of HIV disease may result from HIV infection itself or from opportunistic disorders secondary to the declined immunocompetence due to the disease. Aims: The aim of this study is to determine the pattern of c0utaneous manifestations in HIV in an adult HIV Clinic in Tirana. Subjects and Methods: This is a retrospective study including 355 HIV-positive patients with cutaneous manifestations who referred to the Ambulatory Clinic for HIV/AIDS, at the Infective Service and Dermatology Service of University Hospital Centre “Mother Theresa,” Tirana, Albania over the period 2008–2015. Results: The mean age of patients was 43.08 (±11.8) years, with a range 15–79 years. Two hundred and forty-seven (69.6%) of patients were male and 108 (30.4%) female. Male-to-female ratio is 2.3:1. The study found a significant trend of increasing incidence of dermatological pathologies with increasing stage of the disease. Fifty-five (15.5%) of patients with cutaneous lesions were in Stage 1, 132 (37.2%) in Stage 2, and 168 (47.4%) in Stage 3 (P < 0.001). As for the HIV transmission method, the majority of patients (71%) were infected through heterosexual contact, followed by homosexual contact (16.3%), blood transfusion (3.4%), injecting drug user (2.3%), while for 7% of patients the mode of transmission was unknown. Conclusions: Early recognition of the cutaneous manifestation can help in better management of HIV infection in resource-poor setting, as it can indicate the progression of the disease and underlying immune status.
Keywords: Cutaneous manifestations, human immunodeficiency virus/AIDS, opportunistic infections
|How to cite this article:|
Shehu E, Harxhi A, Simaku A. Cutaneous manifestations of human immunodeficiency virus/Aids patients in Albania. Int J App Basic Med Res 2019;9:197-200
|How to cite this URL:|
Shehu E, Harxhi A, Simaku A. Cutaneous manifestations of human immunodeficiency virus/Aids patients in Albania. Int J App Basic Med Res [serial online] 2019 [cited 2019 Dec 6];9:197-200. Available from: http://www.ijabmr.org/text.asp?2019/9/4/197/268938
| Introduction|| |
The burden of skin disease in developing countries has a serious impact on the quality of life resulting in loss of productivity at work and school and disfigurement., Infectious dermatoses, particularly superficial fungal infections, scabies, and impetigo, are the most common skin problems due to overcrowding with a hot and humid environment, poor sanitary conditions, sharing of personal effects or fomites, and poor access to medical supplies and treatment.
The skin problems here are further compounded by the high prevalence of human immunodeficiency virus (HIV) which commonly causes skin lesions. It was reported that approximately 90% of people living with HIV have skin changes and symptoms during the course of their disease. Skin diseases are significantly higher among HIV-positive than HIV-negative individuals. Differences in skin pigmentation, climate, hygiene, and genetic, environmental, demographic, and behavioral factors cause different clinical presentations and epidemiologic patterns of HIV-associated skin disease in different countries. Skin findings are regarded by the WHO as useful in assessing severity of HIV infection in patients in resource-limited environment. Skin disease can be uniquely associated with HIV disease, but more often represents common disorders, which may be more severe and recalcitrant to treatment. The spectrum of skin conditions includes skin findings associated with primary HIV infection and a broad range of skin problems related to the immune deficiency of advanced AIDS. Knowledge of the skin and mucosal signs of HIV/AIDS is important, as mucocutaneous lesions are usually the first manifestation of HIV, ensures early diagnosis and prompt treatment, and reveals complications as HIV causes atypical and severe presentations of these conditions. Although HIV dermatoses have been widely documented, reports of the type of dermatoses in HIV patients in Albania are scarce in this area of study. The aim of this study is to determine the pattern of cutaneous manifestations in HIV in an adult HIV clinic in Tirana.
| Subjects and Methods|| |
This is a retrospective study including 355 HIV-positive patients who referred to the Ambulatory Clinic for HIV/AIDS, at the Infective Service and Dermatology Service of University Hospital Centre “Mother Theresa,” Tirana, Albania over the period 2008–2015. It is the only national tertiary care center in Albania that treats HIV/AIDS patients all over the country. Furthermore, it is a reference center for all regional hospitals in the country and as such is a nationwide representative for management and care data for HIV/AIDS-infected people. For this reason, it was not necessary to determine the sample of the study to achieve a reliable and representative sample size. The Center for Disease Control and Prevention Classification System for HIV Infection was used in the study.
Data were analyzed using the IBM SPSS Statistics for Windows, (Version 20.0. Armonk, NY: IBM Corp., USA). Categorical variables are presented as absolute frequencies and percentages. Chi-square test was used to compare the proportions between categorical variables. Descriptive statistics of continuous variables are summarized as mean and standard deviation. Kolmogorov–Smirnov test was used to test the distribution of continuous variables. The Student's t-test was used to compare the means of the continuous variables. The statistical tests are two-sided.
| Results|| |
The mean age of patients was 43.08 (±11.8) years with a range 15–79 years. Two hundred and forty-seven (69.6%) of patients were male and 108 (30.4%) female. Male-to-female ratio is 2.3:1 [Table 1].
The study found a significant trend of increasing incidence of dermatological pathologies with increasing stage of the disease. Fifty-five (15.5%) of patients with cutaneous lesions were in Stage 1, 132 (37.2%) in Stage 2, and 168 (47.4%) in Stage 3 (P < 0.001).
As for the HIV transmission method, the majority of patients (71%) were infected through heterosexual contact, followed by homosexual contact (16.3%), blood transfusion (3.4%), injecting drug users (2.3%), while for 7% of patients the mode of transmission was unknown.
In the study predominate the patients with one cutaneous lesion (54.6%) followed by patients with two lesions (27.9%), patients with three lesions (12.4%) and patients with four lesions (4.5%), P < 0.001.
[Table 2] shows the type of dermatologic manifestations. Our findings were classified into infectious and noninfectious causes based on their etiologies. Viral infections were observed in 37.5% of cases and bacterial infections in 16.9% of cases.
Most frequent infections were oropharyngeal candidosis (53.5%), herpes zoster (19.7%), seborrheic dermatitis (17.2%), syphilis (12.4%), anal condyloma (5.6%) and leukoplakia (5.1%). Coinfection with hepatitis B virus was observed in 12.4% of patients, with hepatitis C virus in 2.3%, with syphilis in 20.6%, and with tuberculosis in 7.6% of patients.
The mean CD4 value in patients was M = 179.5 (±183.5), median 142, interquartile range (52–146). Kaposi's sarcoma (KS) was diagnosed in 32 (9%) patients (95% confidence interval [CI] 6.24–12.47), with a mean age 43.4 (±12.7) years and range 24–79 years. The man CD4 cell counts of patients with KS was M = 107.8 (±77.1) cells/mm3. All patients received antiretroviral therapy. The adherence toward therapy was good in majority of patients (85.8%), (95% CI 82.35–88.79), (P < 001). In this study, 60 patients (16.9%) had a history of drug reaction. Overall, 41 (11.5%) of patient had a fatal outcome.
| Discussion|| |
Dermatologic manifestations can be considered as good clinical indices to predict the status of immunity in HIV-positive patients in less developed countries. At present, there are ample amount of evidence about the relationship between dermatologic manifestations and weakened immune system in adults and children. CD4 cell count is a proper criterion for the diagnosis of a weakened immune system or disease progression. KS can be transmitted through sexual contact which is more common in homosexuals than heterosexuals. Anal sex is a major risk factor. The skin infections in people with HIV/AIDS which exacerbate and become resistant to treatment could be a sign of disease progression., Those involved in health care of HIV patients must therefore know the type, pattern, and prevalence of skin diseases in their locality. Mucocutaneous diseases have been correlated with CD4 counts in many studies, while few studies documented the clinical correlation of these diseases to the WHO clinical stages. Cutaneous manifestations of HIV disease may result from HIV infection itself or from opportunistic disorders secondary to the decline in immunocompetence from the disease.,, Cutaneous disorders may be the initial signs of HIV-related immunosuppression. Recognizing HIV-related skin changes may lead to the diagnosis of HIV infection in the early stages, allowing initiation of appropriate antiretroviral therapy. Many associated skin diseases are more severe in this group. HIV-associated dermatoses are very common. Recognition of characteristic eruptions can facilitate early diagnosis of HIV. A broad variety of neoplastic, infectious, and noninfectious diseases can manifest in the skin and may alert the clinician to decline of the immune system., Diagnosis of cutaneous disease can be challenging. While some conditions reliably present with stereotyped lesions, other diseases may have highly variable manifestations, leading to diagnostic uncertainty that may necessitate specialist consultation and skin biopsy. The approach to diagnosis of skin lesions includes the assessment of location, extent, primary lesions, and secondary changes. The extent and severity of lesions can be helpful diagnostic clues and can provide insight regarding the severity of immunosuppression.,,,
| Conclusions|| |
Dermatological complications of HIV/AIDS arise from a variety of conditions with various etiologies. Therefore, careful considerations should be given to timely diagnosis and prompt treatment of dermatological complications among HIV patients. Besides the clinical difficulty in preventing and treating skin diseases, the skin also affects the patient's general appearance and their quality of life. The high prevalence of skin diseases, severity of complications, and overall influence on the patient's quality of life highlight the need for further investigation of the role of the immune system in dermatologic manifestations among HIV patients.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Mankahla A, Mosam A. Common skin conditions in children with HIV/AIDS. Am J Clin Dermatol 2012;13:153-66.
Cedeno-Laurent F, Gómez-Flores M, Mendez N, Ancer-Rodríguez J, Bryant JL, Gaspari AA, et al.
New insights into HIV-1-primary skin disorders. J Int AIDS Soc 2011;14:5.
Rodgers S, Leslie KS. Skin infections in HIV-infected individuals in the era of HAART. Curr Opin Infect Dis 2011;24:124-9.
Bolognia J, Jorizzo J, Schaffer J. Dermatology. 3rd
ed. Dong ChengChina: Elsevier; 2012.
Kaushik SB, Cerci FB, Miracle J, Pokharel A, Chen SC, Chan YH, et al.
Chronic pruritus in HIV-positive patients in the Southeastern United States: Its prevalence and effect on quality of life. J Am Acad Dermatol 2014;70:659-64.
Fridkin SK, Hageman JC, Morrison M, Sanza LT, Como-Sabetti K, Jernigan JA, et al.
Methicillin-resistant Staphylococcus aureus
disease in three communities. N
Engl J Med 2005;352:1436-44.
Buehlmann M, Frei R, Fenner L, Dangel M, Fluckiger U, Widmer AF. Highly effective regimen for decolonization of methicillin-resistant Staphylococcus aureus
carriers. Infect Control Hosp Epidemiol 2008;29:510-6.
Vyas KJ, Shadyab AH, Lin CD, Crum-Cianflone NF. Trends and factors associated with initial and recurrent methicillin-resistant Staphylococcus aureus
(MRSA) skin and soft-tissue infections among HIV-infected persons: An 18-year study. J Int Assoc Provid AIDS Care 2014;13:206-13.
Kazem S, van der Meijden E, Feltkamp MC. The Trichodysplasia spinulosa
-associated polyomavirus: Virological background and clinical implications. APMIS 2013;121:770-82.
Wieland U, Silling S, Hellmich M, Potthoff A, Pfister H, Kreuter A. Human polyomaviruses 6, 7, 9, 10 and Trichodysplasia spinulosa
-associated polyomavirus in HIV-infected men. J Gen Virol 2014;95:928-32.
Yang C, Mosam A, Mankahla A, Dlova N, Saavedra A. HIV infection predisposes skin to toxic epidermal necrolysis via depletion of skin-directed CD4+
T cells. J Am Acad Dermatol 2014;70:1096-102.
Vicente A, Pau-Charles I, González-Enseñat MA, Muñoz-Almagro C, Cañadas MP, Noguera-Julian A, et al.
High-risk alpha-human papillomavirus types: Detection in HIV-infected children with acquired epidermodysplasia verruciformis. J Am Acad Dermatol 2013;68:343-5.
Jacobelli S, Laude H, Carlotti A, Rozenberg F, Deleuze J, Morini JP, et al.
Epidermodysplasia verruciformis in human immunodeficiency virus-infected patients: A marker of human papillomavirus-related disorders not affected by antiretroviral therapy. Arch Dermatol 2011;147:590-6.
Smith KJ, Skelton HG, Yeager J, Ledsky R, Ng TH, Wagner KF. Increased drug reactions in HIV-1-positive patients: A possible explanation based on patterns of immune dysregulation seen in HIV-1 disease. The Military Medical Consortium for the Advancement of Retroviral Research (MMCARR). Clin Exp Dermatol 1997;22:118-23.
Grulich AE, van Leeuwen MT, Falster MO, Vajdic CM. Incidence of cancers in people with HIV/AIDS compared with immunosuppressed transplant recipients: A meta-analysis. Lancet 2007;370:59-67.
Grabar S, Abraham B, Mahamat A, Del Giudice P, Rosenthal E, Costagliola D. Differential impact of combination antiretroviral therapy in preventing Kaposi's sarcoma with and without visceral involvement. J Clin Oncol 2006;24:3408-14.
Polesel J, Franceschi S, Suligoi B, Crocetti E, Falcini F, Guzzinati S, et al.
Cancer incidence in people with AIDS in Italy. Int J Cancer 2010;127:1437-45.
Rane SR, Agrawal PB, Kadgi NV, Jadhav MV, Puranik SC. Histopathological study of cutaneous manifestations in HIV and AIDS. Int J Dermatol 2014;53:746-51.
Franceschi S, Lise M, Clifford GM, Rickenbach M, Levi F, Maspoli M, et al.
Changing patterns of cancer incidence in the early- and late-HAART periods: The Swiss HIV cohort study. Br J Cancer 2010;103:416-22.
Hleyhel M, Belot A, Bouvier AM, Tattevin P, Pacanowski J, Genet P, et al.
Risk of AIDS-defining cancers among HIV-1-infected patients in France between 1992 and 2009: Results from the FHDH-ANRS CO4 cohort. Clin Infect Dis 2013;57:1638-47.
Rogers HW, Weinstock MA, Harris AR, Hinckley MR, Feldman SR, Fleischer AB, et al.
Incidence estimate of nonmelanoma skin cancer in the United States, 2006. Arch Dermatol 2010;146:283-7.
Silverberg MJ, Leyden W, Warton EM, Quesenberry CP Jr., Engels EA, Asgari MM. HIV infection status, immunodeficiency, and the incidence of non-melanoma skin cancer. J Natl Cancer Inst 2013;105:350-60.
[Table 1], [Table 2]