|Year : 2016 | Volume
| Issue : 3 | Page : 186-189
A clinico-epidemiological study of dermatoses in pediatric HIV patients in a tertiary care center
Sukumaran Pradeep Nair, Rony Mathew
Department of Dermatology and Venereology, Government Medical College, Trivandrum, Kerala, India
|Date of Web Publication||5-Jul-2016|
Sukumaran Pradeep Nair
Department of Dermatology and Venereology, Government Medical College, Trivandrum - 695 011, Kerala
Source of Support: None, Conflict of Interest: None
Introduction: Cutaneous lesions are very common in pediatric HIV infection, and many of the dermatoses are linked to the underlying levels of CD4 counts.
Aims: The primary aim was to study the clinico-epidemiological patterns of dermatoses in pediatric HIV infection, and the secondary aim was to ascertain if any dermatoses is a marker of HIV infection.
Materials and Methods: This is a retrospective descriptive, 1-year study. All data regarding the clinico-epidemiological features of pediatric HIV patients in the study period were analyzed.
Results: There were 65 patients in this study, comprising 44 males (67.69%) and 21 females (32.31%). The age group 7–12 constituted the maximum number of cases, 35 (53.84%). Parental to child transmission was the most common mode of transmission seen in 54 patients, (83.07%). Cutaneous manifestations were seen in 43 patients (66.15%). Exaggerated insect bite reaction (IBR) was the most common cutaneous manifestation seen in this study accounting for 19 patients (29.23%), with a mean CD4 count in patients in the age group 1–5 being 425 cells/mm3 and 212 cells/mm3 in the age group 6–12.
Conclusions: IBR in pediatric HIV infection indicates very low CD4 counts and in the absence of other caused for immunosuppression can be a marker of HIV infection.
Keywords: CD4 counts, insect bite reaction, pediatric HIV
|How to cite this article:|
Nair SP, Mathew R. A clinico-epidemiological study of dermatoses in pediatric HIV patients in a tertiary care center. Indian J Paediatr Dermatol 2016;17:186-9
|How to cite this URL:|
Nair SP, Mathew R. A clinico-epidemiological study of dermatoses in pediatric HIV patients in a tertiary care center. Indian J Paediatr Dermatol [serial online] 2016 [cited 2020 Jan 28];17:186-9. Available from: http://www.ijpd.in/text.asp?2016/17/3/186/179487
| Introduction|| |
The prevalence of pediatric HIV cases in India is on the rise due to the increasing the prevalence of HIV in mothers of child-bearing age group. Since children are the most vulnerable group regarding HIV infection, it is of paramount importance to detect and treat pediatric HIV infection as early as possible. Universally, the most common mode of transmission of HIV infection in children is by the parent to child transmission (PTCT), and hence, detection and treatment of the infection in mothers as early as possible is of equal importance. Transmission of HIV in children occurs mainly during pregnancy, perinatally, and by breastfeeding. Transmission by sexual abuse is also possible, but rare in India. The prevalence rates of pediatric HIV infection in India varies from 5.4% to 11.2%., Pediatric HIV infection is more severe compared to adult HIV and progression to AIDS is faster. The most common organ to be affected by HIV in children is the skin (60–93%), and certain dermatoses can be a marker for undetected HIV infection. Moreover, certain dermatoses in pediatric HIV indicates a very low CD4 count and diagnosis of this dermatoses can be a clinical clue to start antiretroviral therapy (ART) in resource-poor situations, where the CD4 counts or the plasma HIV RNA counts cannot be done. We do encounter pediatric HIV patients in our tertiary care center, and this prompted us to do this study. The primary objective of this study was to ascertain the prevalence and clinico-epidemiological pattern of dermatoses in pediatric HIV patients and the secondary objective was to ascertain if any dermatoses was a marker for HIV infection.
| Materials and Methods|| |
This is a 1-year retrospective descriptive study done in a tertiary care center. The study population included all consecutive pediatric HIV patients (up to 12 years of age) who attended the outpatient/inpatient (OP/IP) department of the aforementioned center in the study period. Patients on ART were excluded from the study. Data were collected from the OP/IP records of these patients. Age, sex, mode of transmission, and duration of illness were the main demographic data collected. The clinical details and laboratory investigations of these patients were thoroughly studied. The pediatric HIV patients who presented with skin lesions were subjected to Gram stain, pus culture and sensitivity, KOH mount test, demonstration for Sarcoptes scabiei and Demodex mites, and skin biopsy whenever required. Chest X-ray, Mantoux test, and ultrasound abdomen were the systemic tests done. The data collected were entered in a standard proforma. The data collected were analyzed in terms of descriptive statistics. Permission to conduct this study was forwarded to the Institutional Review Board of this Institute who recommended that since this is a retrospective case record-based study, with no direct patient interaction, permission was not required.
| Results|| |
There were a total of 65 pediatric HIV patients in this 1-year retrospective study (n = 65). There were 44 males (67.69%) and 21 females (32.31%), the male: female ratio being 2:1. The age group distribution is given in [Table 1]. The age group 7–12 constituted the maximum number of cases, 35 (53.84%). The youngest was 1-year of age and the oldest 12 years of age. The mean duration of illness was 2.6 years, the shortest being 1-year and the longest 5 years. The modes of transmission are given in [Figure 1]. Parental to child transmission was the most common mode of transmission seen in 54 patients, (83.07%). Cutaneous manifestations were seen in 43 patients (66.15%), only systemic manifestations in 12 patients (18.46%), and ten patients were asymptomatic (15.39%). Exaggerated insect bite reaction (IBR) was the most common cutaneous manifestation seen in this study accounting for 19 patients (29.23%). The various dermatoses seen in the pediatric HIV population in this study are given in [Table 2]. The most common systemic manifestation seen in this study was pulmonary tuberculosis accounting for five patients (7.69%), followed by bacterial pneumonia in four patients (6.15%), Pneumocystis jirovecii pneumonia in two patients (3.07%), and one case (1.53%) of diffuse infiltrative lymphocytic syndrome. Three patients with IBR (4.61%) had also pulmonary tuberculosis. The mean CD4 count in this study was 699 cells/mm 3, in males it was 671 cells/mm 3 and in females 799 cells/mm 3. The mean CD4 count in patients with IBR in the age group 1–5 was 425 cells/mm 3 and 212 cells/mm 3 in the age group 6–12.
| Discussion|| |
This retrospective study comprised 65 consecutive pediatric HIV patients in a tertiary care center thus accounting for a prevalence of 2.60%. This prevalence rate is lower than other studies done in India which ranged from 5.6% to 11.2%. However, it is possible for the prevalence rate in this institute to be higher as pediatric HIV patients without skin lesions are also seen in the Pediatric Department and the antiretroviral clinic. The prevalence rates of pediatric HIV in the study by Agrawal et al., Parthasarathy et al., and Karande et al. from India were 5.4%, 8.9%, and 11.2%, respectively.,, Males outnumbered females in this study, and this is similar to other studies done in India., In this study, the majority of the patients belonged to the age group 7–12, which is similar to the study conducted by Karande et al. The most common mode of transmission in this study was PTCT which is similar to other studies, and this is the mode of transmission universally in pediatric HIV infection. Transmission of HIV from parent to a child most commonly occurs during the perinatal period, even though in utero and transmission by breast milk is also implicated. In the present study, in the cases were the exact mode of transmission could not be ascertained, there was no positive history of any sexual abuse, but these cases gave a history of frequent visit to hospitals and injections being taken. The mean duration of disease in this study was 2.6 years. This is also similar to other studies. The mean duration of illness in pediatric HIV is always shorter than adult HIV as clinical signs and symptoms occur much earlier due to the immaturity of the immune system. The clinical presentations are also more severe than adult HIV infection. The prevalence of cutaneous manifestations in this study was 66.15%. The prevalence of dermatoses in pediatric HIV patients, in other studies, varies from 60% to 93%., 3, ,, The most common cutaneous manifestation of pediatric HIV in this study was exaggerated IBR with a prevalence of 29.23% [Figure 2]. This is similar to other studies in India and most tropical countries where there is a high mosquito population., IBR belongs to the category of the so-called “pruritic papular eruptions of HIV.” These group of conditions presents with severe pruritic papular eruptions on the trunk and extremities where no infective etiology can be identified. IBR is a subset where the patient presents with severely pruritic papules, pustules, and sometimes vesicles predominantly on the exposed parts of the body usually at the sites of mosquito bites. However, to make a diagnosis of IBR, the following conditions such as bacterial folliculitis, pityrosporum folliculitis, Demodex folliculitis, scabies, drug reactions, and eosinophilic pustular folliculitis have to be ruled out by doing relevant investigations. In the present study, IBR was associated with very low CD4 counts indicating profound immunosuppression. The mean CD4 counts were 212 cells/mm 3 in the age group 6–12 years and 425 cells/mm 3 in the age group 1–5, technically AIDS. This is similar to other studies where the consistent finding was low CD4 counts in association with IBR in the absence of ART., IBR in HIV patients is due to the predominant Th2 response, which liberates interleukin-4 (IL-4) and IL-5, which in turn stimulates IgE. This hyper IgE causes degranulation of mast cells liberating histamine which causes pruritus and the clinical signs and symptoms of IBR. This Th2 response due to mosquito bites in HIV infection is attributed to the altered host immune response to salivary antigens of the mosquito. IBR is a very distressing condition and can continue even with the initiation of ART. The mainstay of treatment is the prevention of mosquito bites by insect repellents and mosquito nets. IBR is a strong marker of HIV infection in the absence of other causes for immunosuppression. However, in other studies, especially in nontropical countries, oral candidiasis is the most common cutaneous manifestation of pediatric HIV infection., Oral candidiasis was the second most common dermatoses seen in this study. All the cases of oral candidiasis seen in this study were of the pseudomembranous type. This is similar to other studies., Pyodermas were also very common in the present study. Staphylococcus folliculitis was the most common pyoderma seen in this study. Ecthyma is another common presentation in pediatric HIV [Figure 3]. This is similar to other studies done in India., In fact, bacterial infections are more common in pediatric HIV infection than viral and fungal infections when compared to adult HIV infection. There were 4 cases of molluscum contagiosum (MC) in this study. Giant MC (>1 cm) is very commonly seen in pediatric HIV patients [Figure 4] and can be a marker of HIV in undetected cases. However, it should borne in mind that cutaneous cryptococcosis, histoplasmosis, and penicilliosis can present with MC like lesions in HIV patients with very low CD4 counts and thus persistence of MC lesions in spite of standard treatment may warrant a skin biopsy. The two cases of herpes zoster seen in this study were of the single dermatome type. However, herpes zoster in a child as well as multidermatomal herpes zoster is a strong marker of HIV infection.
|Figure 2: Multiple discrete papules of insect bite reaction on the lower extremities|
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|Figure 4: Giant molluscum contagiosum (arrow) in a pediatric HIV patient|
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| Conclusions|| |
The small sample size is the limitation of this study. This study had a male predominance, the age group 7–12 the most common affected, PTCT was the most common mode of transmission, and IBR was the most common dermatoses to be encountered and was associated with very low CD4 counts indicating profound immunosuppression. IBR in pediatric HIV patients can be taken as a cutaneous marker of severe immunosuppression and in resource-poor situations where CD4 and plasma HIV RNA counts cannot be done, ART can be started.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Agrawal S, Sawant S, Shastri J. Pediatric HIV in Mumbai. Indian J Sex Transm Dis 2011;32:57-8.
Karande S, Bhalke S, Kelkar A, Ahuja S, Kulkarni M, Mathur M. Utility of clinically-directed selective screening to diagnose HIV infection in hospitalized children in Bombay, India. J Trop Pediatr 2002;48:149-55.
Mendiratta V, Mittal S, Jain A, Chander R. Mucocutaneous manifestations in children with human immunodeficiency virus infection. Indian J Dermatol Venereol Leprol 2010;76:458-66.
Parthasarathy P, Mittal SK, Sharma VK. Prevalence of pediatric HIV in New Delhi. Indian J Pediatr 2006;73:205-7.
Sehgal R, Baveja UK, Chattopadhya D, Chandra J, Lal S. Pediatric HIV infection. Indian J Pediatr 2005;72:925-30.
Madhivanan P, Mothi SN, Kumarasamy N, Yepthomi T, Venkatesan C, Lambert JS, et al.
Clinical manifestations of HIV infected children. Indian J Pediatr 2003;70:615-20.
Sturt AS, Anglemyer A, Berk DR, Maldonado YA. Temporal trends in mucocutaneous findings among human immunodeficiency virus 1-infected children in a population-based cohort. Pediatr Dermatol 2013;30:451-6.
Wananukul S, Deekajorndech T, Panchareon C, Thisyakorn U. Mucocutaneous findings in pediatric AIDS related to degree of immunosuppression. Pediatr Dermatol 2003;20:289-94.
Samanta M, Kundu C, Sarkar M, Bhattacharyya S, Chatterjee S. Papular pruritic eruptions: A marker of progressive HIV disease in children: Experience from Eastern India. Indian J Sex Transm Dis 2009;30:79-83.
Boonchai W, Laohasrisakul R, Manonukul J, Kulthanan K. Pruritic papular eruption in HIV seropositive patients: A cutaneous marker for immunosuppression. Int J Dermatol 1999;38:348-50.
Nair SP. Insect bite reaction and HIV infection. Indian J Dermatol Venereol Leprol 2015;81:95.
Pol RR, Shepur TA, Ratageri VH. Clinico-laboratory profile of pediatric HIV in Karnataka. Indian J Pediatr 2007;74:1071-5.
Shah SR, Tullu MS, Kamat JR. Clinical profile of pediatric HIV infection from India. Arch Med Res 2005;36:24-31.
Prose NS. HIV infection in children. J Am Acad Dermatol 1990;22:1223-31.
Grossman MC, Grossman ME. Chronic hyperkeratotic herpes zoster and human immunodeficiency virus infection. J Am Acad Dermatol 1993;28:306-8.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]