Indian Journal of Paediatric Dermatology

ORIGINAL ARTICLE
Year
: 2020  |  Volume : 21  |  Issue : 2  |  Page : 92--97

A cross-sectional study of dermatological manifestations in children with human immunodeficiency virus/acquired immunodeficiency syndrome


Santoshdev P Rathod1, Bela B Padhiar2, Bela J Shah3,  
1 Department of Dermatology, SVPIMSR, Smt. NHL Municipal Medical College, Ahmedabad, Gujarat, India
2 Department of Dermatology, GMERS, Civil Hospital, Gandhinagar, Gujarat, India
3 Department of Dermatology, B. J. Medical College, New Civil Hospital, Ahmedabad, Gujarat, India

Correspondence Address:
Bela B Padhiar
Department of Dermatology, GMERS, Civil Hospital, Gandhinagar, Gujarat
India

Abstract

Background: In children, human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) is a significant cause of acquired immunodeficiency in children. HIV/AIDS is associated with change in the clinical presentation of the opportunistic infections and increased likelihood of development of certain inflammatory dermatoses in children. Aims and Objectives: The primary objective of this study was to study dermatological manifestations in children with HIV/AIDS. The secondary objectives were to study the association of dermatological manifestation with degree of immunosuppression and any clinical alteration in the disease presentation. Materials and Methods: This was a cross-sectional, descriptive study carried out in the setting of a state government hospital with an attached antiretroviral therapy referral center. The duration of the study was 30 months, and the sample size was based on children enrolled in the study during this duration. Inclusion Criteria: Children <15 years of age having HIV/AIDS and any cutaneous manifestation associated with HIV/AIDS were included in the study. Exclusion Criteria: Dermatological manifestations in children with inherited cause of immunodeficiency, drug-induced immunosuppression, and juvenile diabetes mellitus were excluded from the study. Results: Recurrent skin and soft-tissue infections in 26.11% (n = 11) were the most common dermatological manifestation, followed by pruritic papular eruption of HIV (n = 7, 16.66%), herpes zoster (n = 6, 14.28%), seborrheic dermatitis (n = 4, 9.52%), and human papillomavirus infections (n = 4, 9.52%), which were other common manifestations. The mean CD4 count of patients with pruritic papular eruption was 517 cells/cm3. Extrapulmonary tuberculosis was the most common form in 66.66% (n = 8) of children of total 12 children with tuberculosis. Conclusion: Pruritic papular eruption of HIV in children is seen at all ranges of CD4 count and does not correlate or suggest an advanced degree of immunosuppression. Older children aged 10–14 years acquired HIV through high-risk sexual behavior which suggests a need of sex education.



How to cite this article:
Rathod SP, Padhiar BB, Shah BJ. A cross-sectional study of dermatological manifestations in children with human immunodeficiency virus/acquired immunodeficiency syndrome.Indian J Paediatr Dermatol 2020;21:92-97


How to cite this URL:
Rathod SP, Padhiar BB, Shah BJ. A cross-sectional study of dermatological manifestations in children with human immunodeficiency virus/acquired immunodeficiency syndrome. Indian J Paediatr Dermatol [serial online] 2020 [cited 2020 Dec 4 ];21:92-97
Available from: https://www.ijpd.in/text.asp?2020/21/2/92/281731


Full Text



 Introduction



Pediatric human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) is a significant cause of childhood morbidity and mortality.[1] Dermatologic diseases are common in the HIV-infected population. The most common organ affected by HIV in children is the skin (60%–93%), and certain dermatoses can be a marker for undetected HIV infection.[2] Despite improved disease control of HIV in recent years, opportunistic infections continue to be a relevant morbidity in the HIV infection. In the postantiretroviral era, pruritus has become the most common skin-related symptom reported by patients with HIV.[3],[4] Similarly, pruritic papular dermatitis is reported as one of the most common skin manifestations of Indian HIV patients with skin lesions, not on antiretroviral therapy (ART) in the study by Rane SR et al.[5]

India has an estimated 145,000 children <15 years of age who are infected by HIV/AIDS, and about 22,000 new infections occur every year. Children account for 7% of all the new HIV infections.[6] More than 90% of the HIV infections in children are the result of mother-to-child transmission (MTCT).[7] With adequate antiretroviral prophylaxis, MTCT risk can be reduced to <2% as is seen in the high-income countries along with other effective measures which include elective cesarean section and avoidance of all breastfeeding.

The objective of this study was to assess the prevalence of dermatological manifestations in children with HIV/AIDS, to find the correlation with the degree of immunosuppression in selected entities such as pruritic papular eruption and childhood herpes zoster, and to study the association between tuberculosis and HIV in children.

 Material and Methods



This was a descriptive cross-sectional study carried out in the setting of a state government hospital with an attached ART referral center. The duration of the study was 30 months, and the sample size was based on total number of children enrolled in the study during this duration. Inclusion criteria: Children <15 years of age having HIV/AIDS and any cutaneous manifestation associated with HIV/AIDS were included in the study. Exclusion criteria: Dermatological manifestations in children with inherited cause of immunodeficiency, drug-induced immunosuppression, and juvenile diabetes mellitus were excluded from the study. All consecutive new patients aged <15 years whose parents/guardians gave written informed consent (and assent obtained for those aged 10–14 years) for the use of medical records and taking photographs were enrolled in the study. Detailed clinical information was collected using standard case record forms. These included demographic and socioeconomic data,[8] source and reason for referral, immunization history, nutritional history, history of risk factors for HIV infection, presenting complaints, details of symptoms, any comorbid state, and a thorough physical examination.

Based on the cutaneous examination, patients were subjected to relevant investigations such as blood and serum chemistry, radiology, bedside tissue smear, and histopathological examination when required to arrive at a confirmation of clinical diagnosis. CD4+ T-cell count was registered at every visit. The study was carried out as a part of thesis protocol submitted to the affiliated university. Statistical analysis of the data was done with simple analytical methods for descriptive study, for example, calculation of mean, median, and prevalence of individual condition in the study. The data were entered in Microsoft Excel 2011, and percentages for individual condition were calculated. Institutional ethics committee approval was obtained prior to initiation of the study.

 Results



During the study duration of 30 months, a total number of people living with HIV/AIDS patients visiting the dermatology outpatient department were 484. Of them, there were 42 pediatric patients (aged up to 15 years) living with HIV/AIDS. Hence, the overall prevalence of children with HIV/AIDS in the current study was 8.67% (n = 42). Of the 42 patients, there were 64.28% of males (n = 27) and 35.71% were female (n = 15). The most common mode of acquisition of HIV was through mother-to-child transmission (MTCT) in 90.47% (n = 38) of children through high-risk sexual behavior in 4.76% (n = 2) and through blood transfusion in 4.76% (n = 2) of children. While most of the patients were referred to the dermatology outpatient department for their dermatological manifestations, two children were diagnosed primarily by a dermatologist of which one child had herpes zoster and one had presented with herpes genitalis.

Of all the pediatric HIV cases, MTCT was the most common mode of transmission in 90.47% of cases, 4.76% of cases were sexually transmitted, and 4.76% of cases were acquired due to blood transfusion [Table 1]. The overall mode of acquisition of HIV through vertical transmission in our study was 7.85%. The most common dermatological manifestation was recurrent skin and soft-tissue infection in the form of folliculitis, pyoderma, and impetigo in 26.11% (n = 11) of patients [Figure 1]. The other two common significant findings were pruritic papular eruption in 16.66% (n = 7) and the occurrence of herpes zoster in pediatric patients in 14.28% (n = 6) of cases [Figure 2]. Seborrheic-like dermatitis [Figure 3] was seen in 9.52% (n = 4) of patients and human papillomavirus (HPV) infection was mostly seen as verruca plana in 3 patients and as verruca vulgaris in 1 patient and overall in 9.52% (n = 4) of patients [Figure 4]. This was followed by scabies 7.14% (n = 3), oral candidiasis 7.14% (n = 3), xerosis 4.76% (n = 2), acquired trichomegaly 4.76% (n = 2) [Figure 3], Demodex folliculitis 2.38% (n = 1), superficial dermatophytosis 2.38% (n = 1) [Figure 5], molluscum contagiosum 2.38% (n = 1), and herpes genitalis 2.38% (n = 1) of pediatric HIV patients [Table 2].{Table 1}{Figure 1}{Figure 2}{Figure 3}{Figure 4}{Figure 5}{Table 2}

Of 42 patients with pediatric HIV, 28.57% (n = 12) were coinfected with tuberculosis, of which 66.66% (n = 8) were extrapulmonary, namely 3 cases of abdominal tuberculosis, 3 cases of miliary tuberculosis [Figure 6], and 2 cases of tuberculous lymphadenitis. About 33.33% (n = 4) cases were of pulmonary tuberculosis [Table 3].{Figure 6}{Table 3}

On comparison of cutaneous manifestations in pediatric HIV patients with adolescent (11–18 years) and adult patients, In children, inflammatory dermatoses (43.33%) were the most common presentation, followed by bacterial infections (26.66%), viral infections (16.66%), parasitic infections (10%), and fungal infections (6.66%), whereas in adolescents, viral infections (42.85%) were seen most commonly, followed by inflammatory dermatoses (28.57%) and fungal infections (21.42%). Bacterial and parasitic infections showed an equal distribution in 7.14% of cases, and in adults, viral infections (61.36%) were the most common, followed by inflammatory dermatoses (37.27%) and fungal infections (25.45%). Bacterial infections (17.5) and parasitic infections (2.72%) were the least common [Graph 1].[INLINE:1]

Nevirapine-induced maculopapular rash progression to Stevens–Johnson syndrome was seen in one patient.

 Discussion



The prevalence of pediatric HIV in this study was 8.67%, which is comparable to other studies in India.[9] Vertical transmission was responsible for 7.85% pediatric HIV in the current study as compared to National AIDS Control Organisation (NACO) of India estimates of 5.04%. In India, only 9% of all the positive pregnant women access the prevention of mother-to-child transmission (PMTCT) services. The PMTCT is a highly effective intervention and has a huge potential to improve both maternal and child health.

Pyoderma and recurrent skin and soft-tissue infections were the most common presentation in the current study which is similar to other studies in India.[8]

Inflammatory dermatosis and pediatric human immunodeficiency virus

Pruritic papular eruption of HIV was the most common inflammatory dermatosis in children with HIV in our study. The major difficulty lies in differentiating this from scabies which is more common in the pediatric age group. In the study by Boonchai et al.,[10] analyses of 20 HIV-positive patients with characteristic pruritic papular eruption revealed that overall 81.25% had an advanced degree of immunosuppression with CD4 count below 100/mm3 and 75% of them had CD4 count below 50/mm3. Based on this results Boonchai et al.[10] suggested that pruritic papular eruption should be regarded as a cutaneous marker of advanced HIV infection; However;[10] in our study, the average CD4 count of children with pruritic papular eruption was 517 cell/mm3. We suggest that with wider coverage of ART, pruritic papular eruption can now even be seen at higher CD4 count and does not indicate an advanced degree of immunosuppression when found clinically.

Pediatric herpes zoster and pediatric human immunodeficiency virus

The incidence of pediatric herpes zoster among pediatric HIV patients was 14.28%, and as seen in previous studies, the average CD4 count of all patients was more than 350 cell/mm3.[11] The clinical presentation of herpes zoster was not altered and continued the same course, as in immunocompetent children, these findings are similar to a study by Vora et al.[12]

The incidence of seborrheic dermatitis is not well studied in the setting of children with HIV/AIDS. In our study, incidence of seborrheic dermatitis was 9.52%. Our study shows that it is not related to degree of immunosuppression and presentation and management is unaltered. It forms an important differential diagnosis of pruritic papular eruption of HIV. Amongst the Human palliloma Virus infections (HPV) in children with HIV, verruca plana affecting face was most common morphological presentation.

Nevirapine rash is the most frequently associated with adverse cutaneous drug reactions which are usually mild-to-moderate maculopapular rash occurring within the first 6 weeks of therapy. However, in some cases, it can be moderate to severe with or without hepatitis and progress to Stevens–Johnson syndrome as described in our patient [Figure 7]. Such forms of adverse drug reaction require discontinuation of nevirapine.[13]{Figure 7}

Pediatric human immunodeficiency virus and tuberculosis

HIV alters the pathogenesis of tuberculosis, increasing the risks of developing active tuberculosis in those with latent infection as well as in those newly exposed to tuberculosis. In the HIV-uninfected population, only around 10% of people infected with Mycobacterium tuberculosis will develop clinical tuberculosis disease. However, in HIV-positive people, there is a 20–30-fold increased relative risk of developing tuberculosis disease from latent state compared with that in people without HIV, an increase that outweighs those of other risk factors such as malnutrition. Estimated rates of tuberculosis among children with HIV vary widely depending on endemicity of the region or coverage of highly active retroviral therapy in the given region. This ranges from 3% in low endemic areas of the US to 23% in the South African studies as compared to 28.57% of children being affected in our study.[14],[15]

Early diagnosis of tuberculosis in children with HIV poses a difficulty due to overlapping clinical manifestations of persistent cough, fever, weight loss and lymphadenopathy.

In the limited pediatric literature, studies have reported no significant differences in the frequency of extrapulmonary tuberculosis between HIV-positive and HIV-negative children.[16],[17] Some forms of cutaneous tuberculosis, tubercular ulcers, papulonecrotic tuberculosis, and miliary forms are more frequent and severe in HIV-positive individuals.[18] However, others have suggested that HIV-infected children with more advanced HIV disease are at higher risk of extrapulmonary tuberculosis and combination of extrapulmonary and pulmonary tuberculosis disease.[19],[20] Nearly 66.66% of children with tuberculosis in our study had extrapulmonary tuberculosis suggesting a higher incidence of extrapulmonary tuberculosis.

Mode of acquisition of HIV in two children was high risk sexual behavior. They were aged 10 & 14 years and suffered from childhood herpes zoster & herpes genitalis respectively. This finding suggests the onset of sexual activity at an early age in children putting them at risk of developing HIV. This finding also outlines the importance of sex education for children.

 Conclusion



There is a need of wider and better coverage of the prevention of mother-to-child transmission practices. Pruritic papular eruption of HIV does not indicate an advanced degree of immunosuppression and can also be seen at higher CD4+ T-cell counts. The course of childhood herpes zoster is not altered in pediatric HIV as opposed to adults with herpes zoster. Inflammatory dermatosis represents the most common form of dermatological manifestations in patients with HIV/AIDS.

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.

Limitation of the study

We were not able to perform viral load (HIV RNA level) in all patients. The sample size of individual dermatological manifestations was small.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Marinda E, Humphrey JH, Iliff PJ, Mutasa K, Nathoo KJ, Piwoz EG, et al. Child mortality according to maternal and infant HIV status in Zimbabwe. Pediatr Infect Dis J 2007;26:519-26.
2Mendiratta 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.
3Mankahla A, Mosam A. Common skin conditions in children with HIV/AIDS. Am J Clin Dermatol 2012;13:153-66.
4Kaushik SB, Cerci FB, Miracle J, Pokharel A, Chen SC, Chan YH, et al. Chronic pruritus in HIV-positive patients in the Southeastern United States: Its prevalence and effect on quality of life. J Am Acad Dermatol 2014;70:659-64.
5Rane SR, Agrawal PB, Kadgi NV, Jadhav MV, Puranik SC. Histopathological study of cutaneous manifestations in HIV and AIDS patients. Int J Dermatol 2014;53:746-51.
6NACO Annual Report; 2012-13. Available from: http://www.naco.gov.in/upload/Publication/Annual%20Report/Annual%20report%202012-13_English.pdf. [Last accessed on 2015 Sep 18].
7World Health Organization. UNICEF, UNAIDS. Towards Universal Access. Scaling up Priority HIV/AIDS Interventions in the Health Sector. Progress Report 2011. Geneva: World Health Organization; 2011.
8Pol RR, Shepur TA, Ratageri VH. Clinico-laboratory profile of pediatric HIV in Karnataka. Indian J Pediatr 2007;74:1071-5.
9Sehgal R, Baveja UK, Chattopadhya D, Chandra J, Lal S. Pediatric HIV infection. Indian J Pediatr 2005;72:925-30.
10Boonchai 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.
11Katakam BK, Kiran G, Kumar U. A prospective study of herpes zoster in children. Indian J Dermatol 2016;61:534-9.
12Vora RV, Kota RK, Jivani NB. A clinicomorphological study of childhood herpes zoster at a rural based tertiary center, Gujarat, India. Indian J Paediatr Dermatol 2016;17:273-6.
13Kumar KB, Kiran AG. Cutaneous adverse drug reaction to antiretroviral therapy in children. Indian J Paediatr Dermatol 2014;15:96-9.
14Thomas P, Bornschlegel K, Singh TP, Abrams EJ, Cervia J, Fikrig S, et al. Tuberculosis in human immunodeficiency virus-infected and human immunodeficiency virus-exposed children in New York City. The New York City pediatric spectrum of HIV disease consortium. Pediatr Infect Dis J 2000;19:700-6.
15Walters E, Cotton MF, Rabie H, Schaaf HS, Walters LO, Marais BJ. Clinical presentation and outcome of tuberculosis in human immunodeficiency virus infected children on anti-retroviral therapy. BMC Pediatr 2008;8:1.
16Jeena PM, Pillay P, Pillay T, Coovadia HM. Impact of HIV-1 co-infection on presentation and hospital-related mortality in children with culture proven pulmonary tuberculosis in Durban, South Africa. Int J Tuberc Lung Dis 2002;6:672-8.
17Soeters M, de Vries AM, Kimpen JL, Donald PR, Schaaf HS. Clinical features and outcome in children admitted to a TB hospital in the Western Cape the influence of HIV infection and drug resistance. S Afr Med J 2005;95:602-6.
18Kumar B, Kumar S. Pediatric cutaneous tuberculosis: Indian scenario. Indian J Paediatr Dermatol 2018;19:202-11.
19Chan SP, Birnbaum J, Rao M, Steiner P. Clinical manifestation and outcome of tuberculosis in children with acquired immunodeficiency syndrome. Pediatr Infect Dis J 1996;15:443-7.
20Hesseling AC, Westra AE, Werschkull H, Donald PR, Beyers N, Hussey GD, et al. Outcome of HIV infected children with culture confirmed tuberculosis. Arch Dis Child 2005;90:1171-4.