Josef Yeager

Cutaneous findings in HIV-1-positive patients: A 42-month prospective study

BACKGROUND Cutaneous disease is common in patients infected with HIV-1. OBJECTIVE The aim of our study was to identify cutaneous markers associated with HIV-1 infection and disease progression as measured by Walter Reed (WR) stage. METHODS For 42 months we have observed 912 HIV-1-positive patients in all WR stages. All patients had an extensive past and present medical history taken as well as a complete physical examination, periodic visits, and appropriate diagnostic procedures. RESULTS Increasing dryness of the skin and seborrheic dermatitis are early findings in a large percentage of patients in WR stage 1; the occurrence and severity of both conditions increase with disease progression. Tinea infections, condylomata acuminata, and verrucae are seen early, but with disease progression, although there is no clear increase in occurrence, these infections become more diffuse and resistant to treatment. Flares in acne vulgaris and folliculitis show a peak occurrence in early and mid-stage disease with a decreased occurrence in late-stage disease. Herpes simplex infections, oral candidiasis, molluscum contagiosum, Staphylococcus aureus infections, and oral hairy leukoplakia show a marked increase in occurrence with advanced disease. Conditions that have a statistically significant association with disease progression as measured by a change in a stage include drug eruptions, seborrheic dermatitis, oral candidiasis, oral hairy leukoplakia, molluscum contagiosum, herpes zoster, and hyperpigmentation (nail, oral, skin). CONCLUSION The most frequent and persistent cutaneous disorders were asteatosis (with or without asteatotic eczema) and seborrheic dermatitis. Conditions that were associated with a change in WR stage include drug eruptions, seborrheic dermatitis, oral candidiasis, oral hairy leukoplakia, molluscum contagiosum, herpes zoster, and hyperpigmentation. In addition to Kaposis sarcoma, patients with HIV-1 disease have an increased potential for the development of both cutaneous epithelial and probably melanocytic malignancies. Epithelial tumors were seen in patients in all stages of disease.

Molluscum contagiosum: its clinical, histopathologic, and immunohistochemical spectrum

Although molluscum contagiosum virus (MCV) is considered by some as an unclassified poxvirus, others consider it a member of the orthopoxvirus genus, family Poxiviridae. It is a large double-stranded DNA virus that has a worldwide distribution. With the eradication of small pox, variola virus (VAR), MCV remains by far the most common pox viral pathogen for humans.1–6 Lesions of MCV occur almost exclusively in the skin, and only rare reports have referred to mucous membrane lesions.1–3 Lesions of MCV are most commonly seen in young children, sexually active adults, and in some immune suppressed patient populations (Figs 1–5). Although MCV infections are highest in warm moist climates, and in populations where personal hygiene is difficult to maintain, they have a worldwide distribution.1–3 In children, MCV has a diffuse distribution and may occur on the face, trunk, and extremities, as well as in the genital area (Fig. 1).1–4 In young adults, sexual contact is probably the most common mode of transmission, and genital lesions are common (Fig. 2).1–4 In human immunodeficiency virus type 1-positive (HIV-11) patients, widespread lesions do occur, but head and neck lesions are most common, followed by genital involvement.1–4,7,8 Although the typical umbilicated papules occur in all patient populations, in HIV-11 patients, verrucous, warty papules, as well as giant molluscum greater than 1 cm in diameter, are also seen (Figs 3–5).1–4,7,8 In patients without severe immune suppression, lesions produced by MCV typically regress spontaneously usually within months, rarely years.1–6,9 MCV cannot be grown in tissue culture cells and does not infect animals; however, it has been replicated in human skin grafted to immune deficient mice.5,6,9 MCV is only distantly related to VAR, and lacks DNA cross-hybridization or immunologic cross-reactivity.5,6,9 Four major subtypes of MCV have been defined by recent work, including three MCV-1 variants and MCV-2, MCV-3, and MCV-4 subtypes.9 MCV-1 subtypes dominate worldwide and, in one report, MCV-1 subtypes occurred exclusively in children under the age of 15 years;2,3,10 however, there is evidence that other MCV subtypes are more common in the HIV-11 patient population.3,11 In the light of the new molecular information available on MCV, we returned to review the clinical and histologic features seen in both HIV11 and HIV-1– individuals.

Cutaneous neoplasms in a military population of HIV-1-positive patients******

BACKGROUND In HIV-1-positive patients there have been no prospective studies that show an increase in cutaneous neoplasms. OBJECTIVE We observed HIV-1-positive patients to determine whether or not there was an increased incidence of cutaneous malignancies. METHODS A total of 724 HIV-1-positive patients were examined during a 36-month period for the development of cutaneous malignancies. RESULTS The most common cutaneous neoplasm found was Kaposis sarcoma, especially in patients with late-stage disease. Basal cell carcinomas were the next most frequent tumor. We have also seen three malignant melanomas and two squamous cell carcinomas. Five patients had malignant lymphoma. One patient had a primary lymphoma of subcutaneous soft tissue; in one patient multiple cutaneous lesions developed. CONCLUSION The distribution and prevalent types of cutaneous neoplasms in HIV-1-positive patients appear to differ from those found in other immunosuppressed populations. This may be the result of the different patterns and periods of immunosuppression in these patients and/or associated cocarcinogens to which these patients frequently are exposed.

The Effect of Decreasing Digital Image Resolution on Teledermatology Diagnosis

OBJECTIVE To determine the effect of degraded digital image resolution (as viewed on a monitor) on the accuracy and confidence of dermatologic interpretation. MATERIALS AND METHODS Eight dermatologists interpreted 180 clinical cases divided into three Logical Competitor Sets (LCS) (pigmented lesions, non-pigmented lesions, and inflammatory dermatoses). Each case was digitized at three different resolutions. The images were randomized and divided into (9) 60-image sessions. The physicians were completely blinded concerning the image resolution. After 60 seconds per image, the viewer recorded a diagnosis and level of confidence. The resultant ROC curves compared the effect of LCS, level of clinical difficulty, and resolution of the digital image. One-way analysis of variance (ANOVA) compared the curves. RESULTS The areas beneath the ROC curves did not demonstrate any consistently significant difference between the digital image resolutions for all LCS and levels of difficulty. The only significant effect observed was amongst pigmented lesions (LCS-A) where the ROC curve area was significantly smaller in the easy images at high resolution compared to low and medium resolutions. For all other ROC curve comparisons within LCS-A, at all other levels of difficulty, as well as within the other LCS at all levels of difficulty, none of the differences was significant. CONCLUSION A 720 x 500 pixel image can be considered equivalent to a 1490 x 1000 pixel image for most store-and-forward teledermatology consultations.

Clinical and histopathologic features of hair loss in patients with HIV-1 infection☆

BACKGROUND Hair loss is common in patients with HIV-1 infection, and in black patients this loss may be associated with straightening. Possible causes are frequently present in patients with HIV-1. These causes include chronic HIV-1 infection itself and recurrent secondary infections, nutritional deficiencies, immunologic and endocrine dysregulation, and exposure to multiple drugs. However, histopathologic features have rarely been reported in these patients. OBJECTIVE The objective was to evaluate the changes in the hairs of a group of these patients and to identify the light microscopic and ultrastructural changes in the hairs and the histologic changes in the scalp. METHODS Hair plucks and pulls with scanning electron microscopy of the hairs were done on 10 patients with late-stage HIV-1 infection. In addition, scalp biopsy specimens were examined in both vertical and transverse sections. RESULTS All patients had telogen effluvium. Numerous apoptotic or necrotic keratinocytes were seen in the upper external root sheath follicular epithelium in addition to a mild to moderate perifollicular mononuclear cell infiltrate often containing eosinophils. Variable dystrophy of the hair shafts was also a consistent feature. CONCLUSION Although telogen effluvium is a common response to a wide spectrum of biologic stresses, the presence of apoptotic or necrotic keratinocytes within the upper end of the external root sheath epithelium and dystrophy of hairs may be markers of hair loss in patients with HIV-1 infection.

Benign ectopic thyroid tissue in a cutaneous location: a case report and review

Background:  For many years, lateral, aberrant thyroid tissue in adults was a term used almost exclusively for metastatic thyroid carcinoma. However, aberrant, benign ectopic thyroid tissue does occur, and it is most commonly found as a part of the evaluation of endocrine dysfunction. Rarely, aberrant, benign ectopic thyroid presents as a primary mass.

Pityriasis lichenoides et varioliformis acuta in HIV-1 + patients: a marker of early stage disease

Background

Microbiology of infected eczema herpeticum

Secondary bacterial infection in eczema herpeticum (EH) is common. Staphylococcus aureus alone or mixed with group A β-hemolytic streptococci (GABHS) and Pseudomonas aeruginosa were found to be the major isolates from patients with secondary bacterial infection in EH.1 Previous studies of the microbiology of secondary bacterial infection of EH employed methMicrobiology of infected eczema herpeticum

Immunohistochemical features in inflammatory linear verrucous epidermal nevi suggest a distinctive pattern of clonal dysregulation of growth

BACKGROUND We studied biopsy material from four patients with inflammatory linear verrucous epidermal nevi (ILVEN) that had a psoriasiform appearance histologically and seven cases of linear epidermal nevi (LEN). Of the seven LEN, five showed hyperkeratosis, papillomatosis, and varying degrees of acanthosis; two had features of epidermolytic hyperkeratosis. Because these lesions have distinctive histologic patterns, we wanted to determine whether we could also demonstrate a distinctive pattern of immunohistochemical markers. METHODS On all 11 cases we performed immunohistochemical stains for PCNA, factor XIIIa, MAC-387, UCHL-1, and OPD-4. In addition, on one case of ILVEN we performed ICAM-1, ELAM-1, and HLA-DR stains. RESULTS The pattern of staining of PCNA, factor XIIIa, MAC-387, UCHL-1, and OPD-4 was distinctly different in ILVEN and LEN. Staining for ICAM-1 was present on keratinocytes, and ELAM-1 was present on endothelial cells in two cases of ILVEN. HLA-DR in these same two cases of ILVEN stained mainly dendritic cells in the epidermis. CONCLUSION The different pattern of staining of PCNA, factor XIIIa, MAC-387, UCHL-1, and OPD-4 in LEN and ILVEN indicates a different mechanism of growth dysregulation. Stains for ICAM-1, ELAM-1, and HLA-DR in ILVEN suggest that an inability to down-regulate the inflammatory infiltrate may be important in the growth dysregulation in ILVEN. In addition, the onset of ILVEN at the time of HIV-1 infection in one patient suggests that HIV-1 infection may be one of many factors that initiates ILVEN in a susceptible person.

Clinical features of inflammatory dermatoses in human immunodeficiency virus type 1 disease and their correlation with Walter Reed stage

BACKGROUND As part of a military study of the natural history of human immunodeficiency virus type 1 (HIV-1) disease, all patients entered in the study were examined for cutaneous changes associated with HIV-1 infection. OBJECTIVE Our purpose was to characterize and record the types of inflammatory dermatoses in a large number of HIV-1-infected patients to determine whether there was a correlation with the stage of disease. METHODS The clinical findings in each case were compared with the results of cultures and biopsy specimens and correlated with Walter Reed stage. RESULTS Most of the inflammatory dermatoses were maculopapular eruptions often with prominent follicular involvement, and in some there was a lichenoid component. With increasing Walter Reed stage, many eruptions become papulosquamous, some with psoriasiform scale and some with a hypertrophic lichenoid appearance. CONCLUSION Although most of the inflammatory eruptions were nonspecific clinically, most cases showed features resembling those in graft-versus-host disease.