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Dermatological problems occur in more than 90% of patients with human immunodeficiency virus (HIV) infection. In some patients, skin is the first organ affected. Skin diseases have proved to be sensitive and useful measures by which HIV progression can be monitored.
CUTANEOUS MANIFESTATIONS OF
Dr Tashi Agarwal (PG, 2nd year resident), Dr Shweta Sharma (PG, 3rd year
resident), Dr Narayani Joshi (HOD), Dr B.P. Nag (Professor), Dr Abha Mathur
(Professor) Dr Anuj Sharma( Asst. Prof)
Department of Pathology, Mahatma Gandhi Medical College and Hospital, Jaipur
HIV-associated Kaposi’s sarcoma
•95% in homosexual or bisexual men
Etiology: genetic marker, immune
dysregulation, retrovirus, HHV-8 (Human
•symptom & sign of respiratory & GIT
•In the classic form, they develop on the
distal lower extremities.
•Cutaneous lesions may progress through
There are violaceous
discoloration/ M/E :
nodules are formed/
*Cutaneous T-Cell Lymphoma(Mycosis
fungoides) *Non-Hodgkin Lymphoma
Causes : Polyclonal proliferation &
lymphoid follicular hyperplasia,
Chromosomal abnormalities, Epstein-
Barr Virus (EBV) infection
• Lesions of mycosis fungoides usually
involve truncal areas and include scaly,
red-brown patches; raised, scaling
plaques that may be confused with
psoriasis and fungating nodules.
• In some individuals, seeding of blood
by malignant T cells is accompanied by
diffuse erythema and scaling of the
entire body surface (erythroderma), a
condition known as Sézary syndrome.
Scaling patches and
•Common at genitalia, face(periorbital
area),axilla, groin & buttock
•CD4+ count <200 cells/cu.mm.
Molluscum contagiosum lesions are pearly or
flesh-colored, dome-shaped, umbilicated
papules, ranging from 2 to 5 mm, with a
In AIDS, hundreds of lesions of molluscum
contagiosum may be observed, showing little
tendency toward involution.
Many epidermal cells contain large,
intracytoplasmic inclusion bodies, Molluscum
bodies. (H&E 40X)
•Deep seated (hemorrhagic)
•Ulcerated tumor like lesion
•Earliest change: nuclear swelling
•Degeneration of keratinocytes:
•Inclusion bodies : eosinolhillic,
surrounded by clear space/ halo.
Co-infection with HSV and HIV frequently occurs. About 70% of HIV-positive patients are
seropositive for HSV-2.
Clinical features: Affects primarily the exposed parts of the
body, such as face, scalp, and arms.
• It appears initially as a painless, erythematous papule which
enlarges to a nodule/ plaque upto 2 cm in diameter.
• The end stage is represented by a scar accompanied by
hypo- or hyper pigmentation.
M/E :The cytoplasm of the histiocytes is filled
with numerous round to oval bodies with a round
basophilic nucleus, and a rod-shaped paranuclear
•They represent amastigotes, known as Leishman-
Donovan bodies. When numerous, they can also
be seen extracellularly.
Crusted (Norwegian) scabies
• HIV-infected patients with advanced disease can experience a variant of scabies
known as crusted norwegian scabies, which is characterized by generalized scaling
and enlarged, hyperkeratotic crusted plaques.
Adult female mite found in skin scrapings
In Norwegian scabies, the thickened horny layer is
riddled with innumerable mites, so that nearly
every section shows several parasites.
The female mite is
located within the
Macrophages containing intracytoplasmic tiny
capsulated histoplasma organisms. ( H&E 40X,
• Disseminated histoplasmosis can be
the most frequent opportunistic
infection in AIDS patients living in highly
Clinical features: skin lesions ~10-20%
•exanthema-like maculopapular eruption
•molluscum-like papulonecrotic lesion
•oral ulcer or oral mass
• Dermatophytosis occurs as tinea corporis, tinea capitis, or onychomycosis.
• Tinea corporis is characterized by erythematous, sometimes annular (circular),
scaling lesions with raised borders.
H&E stain shows arthrospores in endothrix
infection. (H&E x 40)
• Tinea capitis often presents as diffuse,
round, scaly patches of hair loss and may
be associated with tinea on other parts of
Bacterial skin disease
• Bacterial skin diseases include :
Pyogenic diseases, Mycobacterial
diseases, Nocardiosis, Bacillary
• Staphylococcus aureus is the cause
in most bacterial skin infections.
• HIV-infected patients are at risk for
infections (Miliary tuberculosis).
• Disseminated nontuberculous
mycobacterial infections, caused by
Mycobacterium avium complex, M.
kansasii, M. chelonae, M. abscessus,
or M. genavense, may occur in HIV-
infected patients as skin lesions.
(ZN stain 100X)
Pruritic papular eruption
Pruritic papular eruption (PPE) is a chronic eruption
of papular lesions on the skin whose etiology is
• chronic recall reaction to mosquito bite.
• excoriated hyperkeratotic hyperpigmented
papules at extremities & lower back.
• severe itch.
• refractory to treatment.
Between 11% and 45% of HIV-infected patients
present with PPE. PPE is believed to be a
marker of worsening immunosuppression and
is more commonly associated with a CD4+
lymphocyte count of less than 50 cells/μL.
Dermis containing degranulated eosinophils and
lymphocytes. (H&E x 40)
Perivascular and periadnexal inflammatory
infiltrate of lymphocytes and eosinophils.
Eosinophils seen in aggregates within the
sebaceous lobules and hair follicles. (H&E x 10)
•It frequently occurs in association
with HIV disease.
•Eosinophilic pustular folliculitis
presents with sudden onset of
pustules, typically on the trunk and
less commonly the face.
• Lever's Histopathology of the Skin, 9th Edition.
• Rosai and Ackerman's Surgical Pathology, 10th edition.
• Sternberg's Diagnostic Surgical Pathology, 5th Edition
• World Health Organization. WHO Case Definitions of HIV for Surveillance and Revised Clinical
Staging and Immunological Classification of HIV-Related Disease in Adults and Children.
Geneva, Switzerland: World Health Organization, 2006.
• El Hachem M, Bernardi S, Pianosi G, et al. Mucocutaneous manifestations in children with HIV
infection and AIDS. Pediatr. Dermatol. 1998
• Garmen ME, Tying SK. The cutaneous manifestations of HIV infection. Dermatol. Clin. 2002