Section 16. Cutaneous Manifestations of HIV Infection

This figure illustrates a form of infection with varicella zoster virus that is unique to patients with immune suppression from HIV. The 6-year-old child pictured here developed recurrent vesicular and ulcerative lesions of the trunk and extremities following an episode of chickenpox. The lesions contain numerous multinucleated giant cells and are culture-positive for varicella zoster virus. This form of infection responds to treatment with intravenous acyclovir but tends to recur when therapy is discontinued.

In addition to chronic infections with varicella zoster, many patients develop unusual forms of herpes zoster infection. These patients also develop prolonged episodes of shingles that do not respond quickly to appropriate antiviral agents; they may also develop generalized herpes zoster infections. In addition, these patients are at risk for the development of herpes simplex infections that are resistant to the more commonly used antiviral agents.

This 3-year-old girl developed herpes zoster as an early manifestation of her immune deficiency. Despite therapy with intravenous acyclovir, severe scarring resulted. Herpes zoster occurs more frequently in children who have had chickenpox very early in life. Although herpes zoster is certainly seen in the healthy child, its occurrence in a child who is at risk for HIV infection should signal concern.

Candidiasis is the most common mucocutaneous manifestation of pediatric HIV infection. Children with AIDS or lesser forms of HIV-related disease frequently develop oral thrush, which recurs or persists despite topical antifungal therapy. Recalcitrant infections of the diaper area and neck folds are also common. Illustrated here are chronic paronychias with a resultant nail dystrophy.

Drug eruptions, usually due to therapy with trimethoprim-sulfamethoxazole, are particularly common among children with HIV infection. This young girl developed a rash subsequent to treatment with that drug combination for Pneumocystis carinii pneumonia. Biopsy analysis of the skin lesion illustrated here revealed an interface dermatitis. A generalized blanchable erythema and true Stevens-Johnson syndrome may also be seen. The frequency of drug eruptions in children with AIDS illustrates the complex effect of HIV on the immune system.

Children in general are more prone to infection with the virus causing molluscum contagiosum. Children infected with the human immunodeficiency virus are more likely to develop persistent, widespread eruptions due to molluscum contagiosum.

Children with AIDS frequently suffer from persistent herpetic infections of the mucous membranes or skin. The gingivostomatitis shown here would be typical of primary infection in a healthy child. One would then expect recurrences to be considerably milder. By contrast, the child with HIV infection may have recurrent episodes of gingivostomatitis or may develop infection that does not respond at all to acyclovir.

Seborrheic dermatitis occurs with particular severity in individuals who are infected with HIV. The infantile form consists of severe scaling and erythema of the scalp and flexural areas and sometimes of the entire skin surface. Illustrated here is an older child with recalcitrant inflammation in the skin folds behind the ears. She also had severe crusting and scaling of the entire scalp.

Occasionally, chronic leukocytoclastic vasculitis occurs in children who are infected with HIV. It is not certain whether this is the direct result of this virus or of some other, concurrent infection. The palpable purpura seen here on the lower extremities are indistinguishable from those observed in Henoch-Schönlein purpura. The chronicity of this patient's eruption, however, was atypical and pointed to the possibility of HIV-related disease.

Children who are infected with the human immunodeficiency virus are prone to a wide variety of viral infections. Lesions caused by human papillomavirus may be unusually widespread and persistent. A case of condylomata acuminata in a 1-year-old girl is illustrated here. Extensive flat warts or periungual warts may also be seen.