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ORIGINAL ARTICLE
Year : 2020  |  Volume : 21  |  Issue : 4  |  Page : 301-306

The pattern of mucocutaneous disorders in pediatric HIV patients in a tertiary care center


Department of Skin and STD, Vinayaka Mission's Kirupananda Variyar Medical College and Hospital, Vinayaka Mission's Research Foundation (Deemed to be University), Salem, Tamil Nadu, India

Date of Submission10-Feb-2019
Date of Decision11-Feb-2019
Date of Acceptance26-Apr-2020
Date of Web Publication30-Sep-2020

Correspondence Address:
Dr. Seethalakshmi Ganga Vellaisamy
11 Mullai Nagar, Near Chandra Mahal, Seelanaickenpatty, Salem - 636 201, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpd.IJPD_13_19

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  Abstract 


Background: Dermatological manifestations constitute one of the most common clinical features in HIV-infected children. An early recognition of such features is important for an early diagnosis and also to assess the prognosis of HIV infection. Objective: The present study was conducted to determine the prevalence and pattern of mucocutaneous manifestations in HIV-infected children and also to assess the association between those manifestations and degree of cellular immune deficiency. Materials and Methods: This was a cross-sectional study conducted in the Outpatient Department of SKIN and STD between April 2017 to March 2018. A total of 100 HIV patients <18 years of age were included in the study. After screening, skin diseases were classified under four broad categories: (i) Infectious dermatoses, (ii) inflammatory dermatoses, (iii) neoplastic conditions, and (iv) drug-related dermatoses. Data were coded and analyzed. Results: The prevalence of cutaneous manifestation in our study was found to be 82% among the HIV-infected children. In toto, inflammatory disorders (58%) were more common, followed by nail disorders (40%), infectious dermatoses, (36%) and drug-related conditions (23%). Among the individual disorders, diffuse pigmentation of nails (24%) was the most common condition and zidovudine was the most common implicated drug in 22% of children. Conclusion: Due to antiretroviral therapy (ART), the occurrence of infectious dermatoses has come down, but we are encountering adverse effects due to drugs. Due to the ability of ART to reconstitute the immune system, there have been undoubtedly significant changes in the nature and prevalence of skin disorders.

Keywords: CD4 count, HIV/AIDS, Pediatric HIV, Zidovudine


How to cite this article:
Saravanabhavan S, Vellaisamy SG, Gopalan K, Kandasamy M. The pattern of mucocutaneous disorders in pediatric HIV patients in a tertiary care center. Indian J Paediatr Dermatol 2020;21:301-6

How to cite this URL:
Saravanabhavan S, Vellaisamy SG, Gopalan K, Kandasamy M. The pattern of mucocutaneous disorders in pediatric HIV patients in a tertiary care center. Indian J Paediatr Dermatol [serial online] 2020 [cited 2020 Oct 22];21:301-6. Available from: https://www.ijpd.in/text.asp?2020/21/4/301/296846




  Introduction Top


The prevalence rate of pediatric HIV infection in India varies from 5.4% to 11.2%.[1],[2] As per the NACO annual report of 2015–2016, nearly 77,729 HIV-infected children are active in HIV care at antiretroviral therapy (ART) centers and of whom, 49,909 are receiving free ART.[3] Pediatric HIV infection is more severe when compared to adult HIV and progression to AIDS stage is also faster.[4] Dermatological manifestations constitute one of the most common clinical features in HIV-infected children and the severity of such dermatoses is more or less in accordance with their CD4+ counts.

Approximately 90% of patients will develop one or more skin diseases during the course of their illness and 37% of patients present with skin lesions as a marker of HIV infection.[5] Children with HIV infection are more prone to adverse cutaneous drug reactions, both to ART and to other drugs that are given concomitantly for comorbid illnesses. Thus, an early recognition of such features is important for an early diagnosis and also to assess the prognosis of HIV infection.[6]

Mucocutaneous manifestations in children are classified in to four categories: (1) infectious dermatoses, (2) inflammatory dermatoses, (3) neoplastic conditions, and (4) drug-related manifestations. The most common cutaneous manifestation in HIV-infected children is pruritic papular eruption which is an exaggerated insect bite reaction (IBR) followed by infectious dermatoses such as oral candidiasis, pyoderma, molluscum contagiosum, and drug-related manifestations. These dermatoses are often more severe and recalcitrant to treatment in such children. Moreover, certain dermatoses in pediatric HIV indicate a very low CD4+ count, and the diagnosis of these dermatoses can be a clinical clue to start ART in resource poor situations where the CD4+ counts or the plasma HIV RNA counts cannot be done.[4]

Extrapolating from adult cases is difficult because the prevalence and pattern of mucocutaneous lesions vary among children and adults. This study attempts to shed light on the dermatological manifestations of HIV-infected children.

Objectives

The objective of the study is:

  1. To determine the prevalence and pattern of mucocutaneous manifestations of HIV-infected children and also to ascertain if any dermatoses could be a marker of HIV infection
  2. To assess the association between different mucocutaneous manifestations and degree of cellular immune deficiency.



  Materials and Methods Top


This was a cross-sectional study conducted in the Outpatient Department of SKIN and STD after getting approval from ethical committee of our institution. This study included all the HIV patients <18 years of age who attended the outpatient department during the study period of April 2017 to March 2018. Those HIV-positive patients who were of more than 18 years of age were excluded from the study. Written informed consent was obtained from all the participants or their caretakers for the clinical examination.

Baseline information regarding demographic features (residence, age, and sex), route of transmission, history of ART, and duration of illness was collected from all the individuals on a pretested structured questionnaire. The previous CD4+ counts of each patient (maximum of 6 months) were recorded from the patient's medical records. Each child was then subjected to a complete dermatological examination including the skin, nail, and mucosa in adequate daylight. Diagnosis was made based on clinical features. After screening, skin diseases were classified under four broad categories for the purpose of analysis: (i) infectious dermatoses, (II) inflammatory dermatoses, (iii) neoplastic conditions, and (IV) drug-related dermatoses.

Statistical analysis

Data were entered using SPSS Version 16 (SPSS, Inc., Chicago, IL, USA). Fisher's exact test was carried out find the association between various factors. The level of significance was estimated with 95% confidence intervals and P < 0.05 was considered to be statistically significant.


  Results Top


A total of 100 HIV-infected patients of age 0–18 years who attended the Outpatient Department of SKIN and STD during April 2017–March 2018 were included in the study. In our study, 65 patients were male and 35 patients were female. There was a male preponderance, and the male: female ratio was 1:0.5. Of the 100 patients, majority of the study population were in the age group of 11–14 years (43%). The mean age of the study population was 12.4 years. Among the 100 patients, majority of the study population were affected with HIV due to vertical transmission (98%). Only 2% of the patients acquired HIV through blood transfusion. In our study population, 99% of the patients were asymptomatic. Ninety percent of the children were of more than 5 years after diagnosis, 7% patients were of <1 year after diagnosis, and 3% of the patients were in between three to 5 years after diagnosis.

All the children in our study (100%) were on ART. Fifty-four percent of the patients were on zidovudine, lamivudine, and nevirapine regimen; 18% of the patients were on zidovudine, lamivudine, and efavirenz regimen; 14% of the patients were on tenofovir, lamivudine, and efavirenz regimen; 7% of the patients were on abacavir, lamivudine, and efavirenz regimen; 6% of the patients were on abacavir, lamivudine, and nevirapine regimen; and 1% of the patients were on tenofovir, lamivudine, and nevirapine regimen. In our study population, 35 patients (35%) were on ART between 3 and 5 years, 30% on ART more than 5 years, 29% on ART between 1 and 3 years, and 6% on ART <1 year. Of the study population, 82 children had some dermatological issues.

Among these 82 children, 52 had only one dermatosis, 28 patients had two dermatoses, and two patients had three dermatoses. Regarding the category-wise distribution of the dermatoses among the study population, inflammatory disorders (58%) were more common among the study population, followed by nail disorders (40%), infectious dermatoses (36%), drug-related conditions (23%), mucosal involvement (9%), and hair disorders (3%) [Table 1]. Majority of the dermatoses were more common among boys except hair disorders. Nail disorders were more common among boys and this was statistically significant (P < 0.05). Regarding infectious dermatoses, bacterial infections (14%) were more common when compared to other infectious dermatoses and impetigo (11%) was the most common bacterial infection followed by furunculosis (4%) and folliculitis (1%). Among viral infection, verruca vulgaris was seen in 3% of the study population, followed by herpes labialis (2%) and molluscum contagiosum (1%). Regarding fungal infection, tinea versicolor and dermatophytosis were seen in 3% of the study population followed by candidal intertrigo (1%). Among parasitic infestation, scabies was seen in 9% of the study population [Figure 1] followed by pediculosis capitis (2%).
Table 1: Category-wise distribution of the dermatoses among the study population

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Figure 1: Scabies

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Eczema was the most common inflammatory dermatosis (18%) which included pityriasis alba (14%), atopic dermatitis (2%), lip-lick dermatitis (1%), and pompholyx (1%). IBR (13%) was the second most common inflammatory dermatosis followed by post-inflammatory hyperpigmentation (11%) and xerosis (8%). Scars were seen in 7% of the study population which included post varicella scars, postherpetic scars, and keloid and atrophic scars. In our study, we did not observe any neoplastic conditions.

Among drug-related conditions, 22 patients (22%) had pigmentation of nails [Figure 2] due to zidovudine followed by 1% of the patients who had hyperpigmentation over both palms and gynecomastia in one patient. Regarding hair-related disorders, premature graying (3%) was the only hair problem seen in our patients. In our study population, 60% of the patients had normal nails. Diffuse nail pigmentation was seen in 24% of the patients followed by leukonychia (8%), nail dystrophy (4%), and longitudinal melanonychia (4%) [Table 2]. In our study population, 81% of the patients had normal mucosal examination. Mucosal pigmentation (oral mucosa) was seen in 18% of the individuals [Figure 3] and geographic tongue was seen in 1% of the study population. Among the 100 patients, two patients (2%) had pulmonary tuberculosis and 98 (98%) did not have any opportunistic infections during the study period.
Figure 2: Diffuse pigmentation of nails

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Table 2: Distribution of nail disorders among the study population

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Figure 3: Hyperpigmentation over the tongue

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In our study, 93 (93%) patients were in the WHO Stage II and 7 (7%) patients were in the WHO Stage III. Regarding the distribution of the study population according to CD4+ T-lymphocyte count, 75% of the patients had CD4+ count of more than 500, 22% had CD4+ between 200 and 500, and 3% had <200 CD4+ counts. It was observed that more number of patients had CD4+ count of >500 cells/mm 3. Most of the infectious dermatoses were greater common among the individuals (26%) who had CD4+ count of more than 500. 10% of the individuals who had infectious dermatoses were in the CD4+ count range of 200–500 cells. This is because in our study, more number of patients (75%) had CD4+ count in the range of more than 500 cells. Fisher's exact test was used and the value of “P” was found to be 0.756 which was not statistically significant.

Most of the inflammatory dermatoses were more common among the individuals (43%) who had CD4+ count more than 500. 13% of the individuals who had inflammatory dermatoses were in the CD4+ count range of 200–500 cells. This is because in our study, more number of patients had CD4+ count in the range of more than 500 cells. Fisher's exact test was used and the value of “P” value was found to be 0.874 which was not statistically significant. Most of the drug-related dermatoses were more common among the individuals (17%) who had CD4+ count more than 500. 5% of the individuals who had drug-related dermatoses were in the CD4+ count range of 200–500 cells. Fisher's exact test was used and the value of “P” was found to be 0.486 which was not statistically significant.


  Discussion Top


In 1981, when the first reports about HIV/AIDS were published in medical literature, cutaneous diseases played an important role in the clinical diagnosis of AIDS. 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.[7]

Majority of the HIV infected children are prone to develop at least one type of dermatologic disorder during the course of their illness. Unusual anatomical sites, disseminated skin lesions, increased frequency and severity, unexplained clinical presentation, rapid onset, and finally, treatment failure are characteristics of skin conditions in HIV/AIDS children.[8] Awareness of these manifestations would help in early diagnosis and management of HIV infection which would decrease the morbidity and improve the quality of life in such patients.

Prevalence

In this prospective study, of the 100 HIV-infected children whom we screened, 82 patients had some dermatological problem. The prevalence of cutaneous manifestations in this study was found to be 82% among the HIV-infected children, which is comparable to Panya et al.,[9] (85%), Montri and Tarunotai [10] (83%), and Carvalho et al.[11] (81%). However, in Nair and Mathew [4] (66.15%), Endayehu et al.[6] (72.6%), Paula Muñoz et al.[12] (68.2%), Josephine et al.[13] (68.8%), Wananukul and Thisyakorn [14] (51.65%), and Umoru et al.[15] (64%) studies, the prevalence was less, whereas in El Hachem et al.[16] (89%) study, the prevalence was more when compared to our study [Table 3]. These differences in the prevalence of HIV-related cutaneous manifestations in children may be explained by many factors, such as lifestyle, access to health care (ART), and the level of immune suppression. Recruitment of an appropriate study population is a crucial point in any study design. Different populations, genetics, geographic variation, race, socioeconomic status, and quality of care are the major confounding factors.
Table 3: Overall prevalence of cutaneous manifestations in HIV-positive children from comparable studies done elsewhere

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Age and sex ratio

In our study, most of the patients belonged to the age group of 11–14 years, which is similar to the study conducted by Nair and Mathew,[4] and Endayehu et al.,[6] whereas in Sehgal et al,[17] it was 18 months to 5 years. This is due to the difference in the recruitment of the study population. Regarding the sex ratio, male children were most commonly affected than females in our study, and this is similar to the study conducted by Nair and Mathew,[4] Panya et al.,[9] Sehgal et al.,[17] and Madhivanan et al.,[18] whereas female predominance was seen in Endayehu et al.[6] and Paula Muñoz et al. study.[12]

Mode of transmission

The most common mode of transmission in our study was parent-to-child transmission which is similar to the study conducted by Nair and Mathew [4] and Paula Muñoz et al.[4],[12] and this is the mode of transmission universally in pediatric HIV infection. About 2% of the study population acquired the infection through blood transfusion in our study which is similar to Nair and Mathew,[4] whereas in Sehgal et al.[17] study, it was 39%. This difference in this mode of transmission is mainly due to the difference in implementation of safe blood transfusion practices.

Prevalence of common dermatological condition

The most common cutaneous manifestation of pediatric HIV in our study was diffuse pigmentation of nails which constitutes 24%, which was mainly caused by zidovudine (22%) which is one of the unique thing in our study because other studies in literature are showing mainly either infectious dermatoses or IBR as the common manifestation. This unusual feature in our study is mainly due to the availability of ART in our health-care settings as per the NACO guidelines where all the HIV-infected persons should be started on ART irrespective of the CD4 count. Due to ART, the occurrence of infectious dermatoses has come down, but we are encountering adverse effects due to drugs.

Among noninfectious dermatoses, eczema was the most common (18%) which included pityriasis alba (14%), atopic dermatitis (2%), lip-lick dermatitis (1%), and pompholyx (1%). Mucosal pigmentation, especially pigmentation, over the tongue is seen in 18% of the study population who developed this pigmentation even before the initiation of ART. Even though there is a high mosquito population in India, the prevalence of IBR was 13% in our study which is less when compared Nair and Mathew,[4] Endayehu et al.,[6] Carvalho et al.,[11] and Umoru et al.[15] Oral candidiasis was also one of the most common dermatoses seen in Paula Muñoz et al.,[12] Wananukul and Thisyakorn,[14] Umoru et al.,[15] and El Hachem et al.[16] studies, whereas in our study, we did not see a single case of oral candidiasis, attributed to immune upregulation due to 100% ART coverage in our health-care setup. In fact, bacterial infections are more common in pediatric HIV infection than viral and fungal infections when compared to adult HIV infection.[4] In our study, bacterial infection was seen in 16% of the children, but it is less when compared with Nair and Mathew [4] (18.46%).

Kaposi sarcoma which is a common cutaneous neoplasm in HIV-infected adults is rare in children. In Tanzania study, only one child was found to have kaposi sarcoma.[7],[9] In this study, there was not even a single case of kaposi sarcoma, indicating that cutaneous neoplasms are rare in children. Some studies indicate that highly active ART (HAART) decreases the prevalence of mucocutaneous disorders, especially infections in HIV-infected individuals.[19] There was a statistically significant difference in the prevalence of mucocutaneous disorder among children on HAART and pre-ART care. For ART to have a significant effect on mucocutaneous disorders, it needs to be administered for a longer period of time and patients should be adherent to treatment. In our study, 94% of the children were on ART for more than 1 year. In a study by Donic et al.,[20] it was found that the use of ART for about 2 years reduced significantly the presence of oral candidiasis and seborrheic dermatitis [Table 4].
Table 4: Overall prevalence of most common skin condition in HIV-positive children from comparable studies done elsewhere

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Correlation between CD4+ count and dermatoses

In our study, 75% of the patients had CD4+ count of more than 500, 22% had CD4+ count between 200 and 500, and 3% had <200 CD4+ counts. Most of the infectious dermatoses were more common among the individuals (26%) who had CD4+ count more than 500. 10% of the individuals who had infectious dermatoses were in the CD4+ count range of 200–500 cells. This is because in our study, more number of patients (75%) had CD4+ count in the range of more than 500 cells. Most of the inflammatory dermatoses were more common among the individuals (43%) who had CD4+ count more than 500. 13% of the individuals who had inflammatory dermatoses were in the CD4+ count range of 200–500 cells.

Most of the drug related dermatoses were more common among the individuals (17%) who had CD4+ count more than 500. 5% of the individuals who had drug-related dermatoses were in the CD4+ count range of 200–500 cells. This is due to the ability of HAART to reconstitute the immune system, and through its effects, there have been undoubtedly significant changes in the nature and prevalence of skin disorders affecting the HIV-infected population.


  Conclusion Top


There is a statistically significant difference in the prevalence of mucocutaneous disorder among children on HAART and pre-ART era. The change in the pattern of dermatoses is mainly due to the availability of ART in our health-care settings as per the NACO guidelines where all the HIV-infected persons should be started on ART irrespective of the CD4 count. Due to the ART, the occurrence of infectious dermatoses has come down, but we are encountering adverse effects due to drugs. This is due to the ability of HAART to reconstitute the immune system, and through its effects, there have been undoubtedly significant changes in the nature and prevalence of skin disorders affecting the HIV-infected children.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Umoru D, Oviawe O, Ibadin M, Onunu A, Esene H. Mucocutaneous manifestation of pediatric human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) in relation to degree of immunosuppression: A study of a West African population. Int J Dermatol 2012;51:305-12.  Back to cited text no. 15
    
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