Page 243 - AIDSBK23C

Page 243

establish an infection of the nail bed that spreads distally. This produces a white hue under the
proximal nail plate in the region of the lunula. Long-term treatment with fluconazole and
itraconazole can be effective treatment.[987]
Non-dermatophyte infections with Malassezia furfur may be associated with some cases
of seborrheic dermatitis, with pityriasis versicolor, and with Malassezia folliculitis. Antifungal
therapy with ketoconazole may be effective therapy.[987]
Superficial Candida infections can occur in HIV-infected persons, though oral
candidiasis is far more frequent. The most common form of involvement of the skin is in
intertriginous areas of groin or axilla. The hallmark of Candida intertrigo is the presence of
satellite pustules. Pruritus ani can result from mixed infections with both bacterial and fungal
organisms. Topical antifungal creams can help treat these superficial infections.[987]
The appearance of lesions of the skin may correlate with the level of immunosuppression.
Seborrheic dermatitis and onychomycosis tend to occur in the early stages of HIV infection when
the CD4 lymphocyte count is above 400/µL. Candidiasis and pruritus ani are more likely to
appear when HIV infection has become symptomatic and the CD4 count is between 200 and
400/µL. Eosinophilic folliculitis typically occurs in association with clinical AIDS and CD4
counts below 200/µL.[987]
Cryptococcal skin involvement may present in as many as 10 to 20% of patients with
disseminated disease. The lesions are most often seen on the face, neck and scalp as
erythematous papules, though pustules and umbilicated papules resembling molluscum
contagiosum can be seen. Additional presentations include cellulitis, erythematous papules,
nodules, pustules, and ulcers. Similar findings may be seen with disseminated
coccidioidomycosis, where cutaneous morbilliform eruptions, papules, pustules, violaceous or
ulcerating plaques, and nodules have been described.[973] The presence of capsule deficient
forms of C neoformans makes recognition difficult. Partially treated C neoformans may give
rise to an inflammatory pseudotumor that mimics that of myofibroblastic tumor and infection
with Mycobacterium avium-complex, but few organisms are typically present.[982]
Histoplasmosis that involves skin and mucous membranes typically occurs in the
advanced stage of AIDS when the CD4 lymphocyte count is below 150/µL. The morphologic
appearances of mucocutaneous lesions can include nodules, plaques, vesicles, hemorrhagic
macules, papules, and pustules, with or without ulceration. Erythematous scaly plaques,
pyoderma gangrenosum-like lesions, erythroderma, cellulitis, petechiae, purpura, ecchymoses,
and necrotizing vasculitis also have been described. Additional clinical findings include weight
loss, fever, chills, lymphadenopathy, hepatosplenomegaly, and anemia. Pathologic findings with
skin biopsy may include: (1) necrotizing and non-necrotizing granulomatous inflammation with
a paucity of intra histiocytic microorganisms, (2) diffuse dermal and intravascular accumulation
of macrophages densely parasitized by H capsulatum, and (3) diffuse dermal karyorrhexis,
collagen necrosis and interstitial, extracellular H capsulatum. The skin lesions may respond
dramatically to treatment with antifungal therapy.[973,988]

MISCELLANEOUS FINDINGS.-- Infectious and inflammatory dermatologic diseases
are more likely to require medical attention and hospitalization in patients with AIDS than in
patients without AIDS. Opportunistic infectious agents in AIDS with widespread dissemination,
including fungal infections and Pneumocystis, may involve the skin and may produce
appearances that can sometimes mimic KS or herpetic ulcers.[979]