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DERMATOPATHOLOGY IN AIDS

Over 90% of persons infected with HIV will develop at least one type of dermatologic
disorder during the course of their HIV infection. These include both common and uncommon
infections, neoplasms, and reactions to drugs given for treatment of HIV and its complications,
and dermatoses. Historically, Kaposi sarcoma has been the most characteristic skin disease
associated with HIV infection. Antiretroviral therapy (ART) may increase of certain
dermatologic diseases, mostly within the first 3 months after initiation, because of immune
restoration that may exacerbate previously dormant conditions such as herpes zoster and
mycobacterial infections. Adverse cutaneous drug reactions secondary to ART may also occur
as does photosensitivity with ART use.[957]

KAPOSI SARCOMA.-- Dermatopathology in AIDS primarily centers around diagnosis
or exclusion of KS. Except for lesions caused by herpesviruses, lesions other than KS are quite
uncommon (Table 5). Kaposi sarcoma, also called "multiple idiopathic hemorrhagic sarcoma,"
was once a rare entity. Kaposi's sarcoma occurs in the following clinical patterns: classic
(sporadic), endemic African (benign nodular, aggressive, florid, and lymphadenopathic),
iatrogenic (seen in immunocompromised patients such as recipients of organ transplants, those
patients on immunosuppressive drug therapy, or patients with connective tissue diseases), and
epidemic (AIDS-associated). All forms of KS have a male predominance, but this is even more
pronounced with AIDS. Though less common in other clinical forms, KS often has visceral
involvement in AIDS. The appearance of all forms of KS is associated with infection by human
herpesvirus 8 (HHV-8), also known as KS-associated herpesvirus (KSHV). [543]
A presumptive clinical diagnosis of KS indicative of AIDS can be made by CDC
definitional criteria as follows:[130]

A characteristic gross appearance of an erythematous or violaceous plaque-like lesion on
skin or mucous membrane. (Note: Presumptive diagnosis of Kaposi's sarcoma should not
be made by clinicians who have seen few cases of it.)

STAGING OF KAPOSI SARCOMA.-- A simple staging system for KS, which is useful
when comparing and classifying the type of KS, is as follows: Stage I: locally indolent
cutaneous KS; Stage II: locally aggressive cutaneous KS with or without regional lymph nodes;
Stage III: generalized mucocutaneous and/or lymph node involvement; Stage IV: visceral KS.
These stages are further subtype by absence (A) or presence (B) of weight loss, persistent fevers,
or night sweats.[543]
Additional criteria for staging of KS have been developed to determine prognosis and
treatment based upon a three tiered (Tn In Sn) system as follows: T being the extent of tumor, I
being the immune system status assessed by CD4 lymphocyte count, with “n” as 0 for CD4
lymphocyte count of 150/µL or less and 1 for higher counts, and S being the severity of systemic
illness, with “n” as 0 - "good risk" or 1 - "poor risk". Good risk factors include all of the
following: tumor confined to skin and/or lymph nodes and/or minimal oral disease (defined as
non-nodular KS confined to the palate; lack of systemic illness defined as no history of
opportunistic infection or thrush, no "B" symptoms, or performance status of at least 70
(Karnofsky). Poor risk factors include any of the following: tumor-associated edema or