Interesting Cutaneous Manifestation in HIV Positive Patients Dr. Sachin Dattatraya Kore Fellow Mentor – Dr. Rajshekaran, Dr.Manoharan Dr. Karunakaran

Cutaneous presentation of IRIS A 36-year-old HIV positive male with a CD4 cell count of only 32/µL was put on D4t/3TC/EFV on April 2007. After 6 months of HAART the patient consulted for multiple asymptomatic hyper pigmented small macular lesions all over the body. The CD4 count had increased to 510 /µl. Dermatologic examination revealed numerous hyperpigmented macular lesions over trunk and face, kobenerization was also present. A clinical diagnosis of IRIS - plane warts (HPV) was made.

Human Papilloma Virus (HPV) infection The prevalence of warts in HIV infected individuals is greatly increased. The lesions are more frequently diffuse, dysplastic and subclinical in HIV infected patients. An unusual pattern of extensive verruca plana and tinea versicolor like warts, similar to the pattern seen in epidermodysplasia verruciformis, as described in our patient has also been reported. With moderate or advanced HIV induced immunodeficiency, warts may become much more numerous and refractory to usual treatment. Treatment of warts appears easier when a person's underlying HIV infection is better controlled.

Interestening manifestation of extrapulmonary tuberculosis 30-year-old HIV positive man presented with progressive swelling in left inguinal region since 15 days and penile swelling with difficulty in retracting the prepuce & a similar swelling right inguinal region since 1 wk. There was no history of genital ulcer, no urethral discharge and no swellings in other part of body. Patient was not revealing his sexual history. He was married 5 years back and wife also tested positive. Physical examination: BMI was 14 , pallor was present , no icterus, no cyanosis, no pedal edema, vitals were stable.

Interestening manifestation of extrapulmonary tuberculosis Systemic examination: no abnormalities. Local examination: there was an ill-defined swelling in left inguinal region measuring 10 x 8 cm, with single opening discharging pus. On palpation swelling was nontender, local temperature was not raised. Similar swelling was also present in opposite region. There was edema of penis with difficulty in retracting the prepuce. Haemoglobin: 7.1 gm%. Peripheral smear: microcytic hypochromic anaemia. Renal and liver functions: normal. CD4 cell count :96 /µl. AFB positive in the pus from inguinal swelling. Final Diagnosis: PLHA with tuberculous inguinal lymphadenopathy

Bubo A tender, enlarged, and inflamed lymph node, particularly in the axilla or groin, due to such infections as Bubonic plague (Yersinia pestis : malignant bubo) Primary syphilis (Treponema pallidum subsp. pallidum : syphilitic bubo) Gonorrhea (Neisseria gonorrhoeae ) Chancriod (Hemophilus ducreyi : chancroidal or virulent bubo) Lymphogranuloma venereum (Chlamydia trachomatis : climatic or tropical bubo) Tuberculosis (Mycobacterium tuberculosis )

Key Points Some cutaneous conditions, such as herpes zoster, mucocutaneous herpes, eosinophilic folliculitis and warts may worsen because immune restoration after HAART therapy. In country like India tuberculosis should be included in differential diagnosis of bubo in immunosuppressed patients.