Amitabh Sagar

Cutaneous manifestations of HIV—a detailed study of morphological variants, markers of advanced disease, and the changing spectrum

BACKGROUND Cutaneous manifestations are early and easily identifiable markers of human immunodeficiency virus (HIV) infection. They can help in predicting severity and progress of the disease and can be correlated well with CD4 counts. This study was undertaken to study the cutaneous manifestations of HIV infection and to correlate them with CD4 counts. It also aimed to study the changing spectrum of these manifestations and describe cutaneous manifestations seen in advanced disease. METHOD A total of 234 HIV-positive patients not on anti-retroviral therapy, who attended the outpatient department or were admitted as inpatients at Military Hospital, Shillong during the period between May 2008 and October 2009 were included. Cutaneous, mucosal, and genitourinary manifestations in these patients were studied in detail and were correlated with CD4 counts. RESULTS Infections were the most common group of mucocutaneous manifestations, while onychomycosis was the commonly observed individual manifestation. A different set of cutaneous markers for advanced HIV disease was observed and new parameters for therapy were also arrived at. CONCLUSION Specific morphological variants of cutaneous markers may provide a better clue to early diagnosis of HIV and can help in diagnosing advanced stages of the disease. Fresh cutaneous markers are required for indicating cut-off levels of CD4 count at 350/μL for starting therapy.

Zidovudine-induced myopathy: A study in Indian patients.

Context: Literature is replete with studies on zidovudine-induced myopathy after prolonged use (use beyond 270 days on an average). However, all these studies have been done on patients of Caucasian, American and African ethnic origin. No such study has been carried out in Indian patients to our knowledge. Aims: To determine the correlation of zidovudine usage with serum creatine phosphokinase (CK) levels, clinical muscular weakness and muscle histology in Indian patients, we studied 147 physically active, Human Immunodeficiency Virus infected men on prolonged zidovudine-based antiretroviral therapy (ART). Settings and Design: Cross-sectional study on hospital follow-up patients of HIV infection. Materials and Methods: All cases on ART who reported to our canter during a period of 18 months were evaluated for symptoms (muscle fatigue, myalgia), objective muscle strength (testing clinically) and serum CK levels, and a select group was evaluated by muscle biopsy. These patients were on zidovudine for 1 to 7 years. Results: None of the patients studied had significant symptoms or objective muscle weakness and only a small fraction (10.8% of cases) had marginally raised serum CK levels. All muscle biopsies were normal on light microscopy. Conclusions: Zidovudine myopathy may be a constraint for use of the drug in the western population; however, it is a well-tolerated drug as regards myopathy in our study on Indian patients.

Nevirapine-induced rash with eosinophilia and systemic symptoms (DRESS)

Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome is an adverse reaction commonly occurring with antiepileptic agents. It was earlier referred to by various names such as dilantin hypersensitivity syndrome and anticonvulsant hypersensitivity syndrome. It is characterized by the triad of fever, skin eruption, and systemic involvement. DRESS syndrome has also been reported with a number of other drugs including allopurinol, minocycline, terbinafine, sulfonamides, azathioprine, dapsone, and antiretroviral agents such as abacavir and nevirapine. We describe a rare case of nevirapine-induced hypersensitivity syndrome that was successfully treated with oral steroids.

Ocular manifestations in 321 male consecutive cases of human immunodeficiency virus infection/acquired immunodeficiency syndrome at an HIV-referral centre

BACKGROUND Most studies on the ocular manifestations of human immunodeficiency virus (HIV) infection are on cases of acquired immunodeficiency syndrome (AIDS), not including asymptomatic carriers of HIV. With this background, we proceeded to study all the HIV-infected individuals attending our centre, with the aim: a. To study the ocular manifestations of HIV. b. To correlate those manifestations with the CD4+ T-lymphocyte counts. c. To compare our findings with other studies. METHOD A cross-sectional study involving a detailed ocular examination of 321 cases of HIV/AIDS was done. Automated perimetry, digital fundus photography and fundus fluorescein angiography were done for relevant cases. The last 125 cases were subjected to Schirmers test and tear film break-up time. RESULTS We studied 321 male HIV cases (642 eyes), with a mean age of 36.78 years, mean CD4+ count of 276.54 cells/μL, 78.82% of them being on anti-retroviral therapy. Ocular manifestations were seen in 87 out of 321 cases, 72.41% of them being asymptomatic carriers of HIV. The ocular findings seen were conjunctival microvasculopathy, molluscum contagio-sum, dry eye, neuro-ophthalmic manifestations, anterior uveitis, posterior uveitis, and HIV retinopathy, only the last three of which had a significant association with CD4+ counts. The overall prevalence of ocular lesions also had a significant association with CD4+ counts. CONCLUSION Ocular manifestations are common in asymptomatic carriers of HIV. Anterior uveitis, posterior uveitis and HIV retinopathy have a significant association with CD4+ counts and are reliable indicators of low CD4+ count.

Profile of HIV patients on second line antiretroviral therapy: the Indian experience.

Background: The proportion of patients on second line in resource limited settings are estimated between 1-5%. The present study describes the profile and outcomes of Indian patients receiving second line ART. Methods: Information on HIV patients on second line ART was gathered. Socio demographic data, probable transmission route, baseline clinical parameters and comorbidities during therapy are studied along with first-line ART regimen initially introduced, its adherence and the reason for switch and components of the second-line ART regimen. Results: Out of the total 2174 HIV patients 53% were on first line ART and of these 51 patients on second line ART were studied. The average time of initiation of first line ART was 17.67 months with median of 2 months whereas switch to second line ART was in 53.75 months with median of 60 months. Almost 71% of the patients on second line ART had been diagnosed with HIV infection with low CD4 count of <200. However 54%, 67% and 58% patients show more than 50% rise in their CD4 count post switch to second line after 3, 6 and 12 months of treatment which is a substantial improvement. Twenty-five per cent of patients showed non adherence. Tenofovir based regimens had a slight advantage with lesser number of side effects being reported. Conclusion: Early diagnoses of infection, early initiation of ART and drug adherence are the cornerstones for success in managing HIV patients. Understanding the profile and drug resistance pattern is necessary for ensuring effective and long term survival.

A case of linear immunoglobulin A disease with dapsone hypersensitivity and its management strategies

We report this case to stress the need to consider ICL, in any patient (with no known immunodeficiency) presenting with opportunistic infections. Had it not been diagnosed earlier, lymphocytopenia in our patient would have been attributed to the lymphoma. Meticulous documentation and analysis of the clinical features and disease progression in those affected, may help us to improve the diagnostic definition and treatment options for this rare condition.

Extragenital lichen sclerosus with aetiological link to Borrelia

Lichen sclerosus more popularly known as lichen sclerosus et atrophicans (LSA) or Csillags disease is an idiopathic inflammatory dermatosis of unknown aetiology affecting women 10 times more commonly than men and usually seen over 50 years of age.1 It is clinically characterised by small, porcelain white, sclerotic lesions occurring mainly on genital areas. Extragenital involvement, though occurring additionally in a few cases rarely occurs in isolation. Genetic factors and autoimmunity have been described as possible aetiologies. Symptoms commonly described are itching, burning and bleeding though dyspareunia, dysuria, and urinary obstruction have been reported to be associated with the disease.2 Diagnosis is clinico-pathological. Symptomatic treatment with emollients, antihistaminics, and topical corticosteroid ointments form the mainstay of treatment. Classical cutaneous manifestations associated with Borrelia are borrelial lymphocytoma, acrodermatatitis chronica atrophicans, and erythema migrans, though morphea and similar other conditions have rarely been attributed to this bacteria.3 We herein present a case of extragenital lichen sclerosus with varied morphological features and probable aetiological link to Borrelia.