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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 6  |  Issue : 1  |  Page : 10-14

A study of sexually transmitted diseases and dermatological manifestations in human immunodeficiency virus-infected patients


Department of Dermatology, PESIMSR, Kuppam, Andhra Pradesh, India

Date of Submission07-Dec-2020
Date of Decision19-May-2021
Date of Acceptance21-May-2021
Date of Web Publication25-Feb-2022

Correspondence Address:
Aneeha Ramesh Babu
Department of Dermatology, PESIMSR, Kuppam NH – 219, Kuppam, Andhra Pradesh 517 425
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cdr.cdr_133_20

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  Abstract 


Background: The majority of human immunodeficiency virus (HIV)-infected patients develop skin lesions at some point during the course of the disease. The occurrence of sexually transmitted diseases (STDs) may increase the transmission and progression of HIV. Hence, it is essential to study the various infectious and noninfectious dermatoses. Objectives: (1) To study the various STDs and to familiarize with the atypical presentation of various STDs in HIV infected individuals. (2) To study clinical and epidemiological aspects of various dermatological manifestations in HIV infected individuals. (3) To identify dermatological manifestations as indicators (markers) of HIV/acquired immunodeficiency disease syndrome progression. Materials and Methods: A cross sectional descriptive study was conducted on known HIV-positive individuals attending the outpatient department of Dermatology in Siddhartha Medical College, Vijayawada, with symptoms suggestive of skin disease or sexually transmitted infections. A detailed clinical history and physical examination were done in all cases. Wherever necessary, relevant investigations were done to confirm the diagnosis in patients. Statistical analysis used: Results were tabulated and analyzed using simple statistical methods. Results: A total of 500 patients were recruited in the study among whom 363 (72.6%) had only dermatological manifestations, 127 (25.4%) had sexually transmitted infections (STIs) and 10 (2%) had overlap manifestations. The majority of them were in the age group of 28–37 years. The most common STI observed was herpes genitalis, followed by genital warts and genital molluscum contagiosum. Pruritic Papular Dermatoses were found to be the most common noninfectious dermatosis. Conclusions: There is a need to know the atypical manifestations of various dermatoses in HIV patients, as these conditions may pose a diagnostic dilemma to the treating dermatologist. This ensures correct diagnosis and the necessary treatment.

Keywords: CD4 count, human immunodeficiency virus, pruritic papular dermatoses, sexually transmitted diseases


How to cite this article:
Gangavaram DR, Babu AR, Prasad AM. A study of sexually transmitted diseases and dermatological manifestations in human immunodeficiency virus-infected patients. Clin Dermatol Rev 2022;6:10-4

How to cite this URL:
Gangavaram DR, Babu AR, Prasad AM. A study of sexually transmitted diseases and dermatological manifestations in human immunodeficiency virus-infected patients. Clin Dermatol Rev [serial online] 2022 [cited 2022 Aug 19];6:10-4. Available from: https://www.cdriadvlkn.org/text.asp?2022/6/1/10/338587




  Introduction Top


More than 90% of the human immunodeficiency virus (HIV) infected patients develop skin lesions at some time throughout the course of the disease. Several skin diseases have proved to be sensitive and useful indicators of the progression of HIV infection. Although these conditions may be seen in the general healthy population, their occurrence in patients with acquired immunodeficiency syndrome is often atypical, more severe, and explosive.[1] Skin disease may provide the first suspicion of the diagnosis of HIV infection, cause significant morbidity as the disease progresses, and point to a diagnosis with important systemic implications.[2] The presence of sexually transmitted diseases (STD) facilitates the shedding of HIV and increases HIV-1 disease progression, by increasing plasma viremia.[3] The interest in (Sexually transmitted infections [STIs]) and their management has increased tremendously because of their proven role in the facilitation of HIV infection which, in turn, also increases susceptibility to other (STIs).[4] South Asia is currently home to more than 2.5 million HIV infected persons, 95% of whom are from India. The incidence of various sexually transmitted infections has fluctuated over the past several decades all over the world. Not much data are available regarding the current trend of STIs in this part of the world, and how their epidemiological and clinical picture is being modified in the context of the ongoing HIV/acquired immunodeficiency disease syndrome (AIDS) epidemic, especially during the last decade.[4] Dermatological manifestations are seen at every stage of HIV/AIDS and are often the presenting features. These manifestations not only act as markers but also reflect the underlying immune status.[5] The study was conducted:

  1. To describe clinical and epidemiological aspects of various dermatological manifestations in HIV infected individuals
  2. To identify the more common STD coexisting with HIV, so that appropriate screening and diagnostic testing can be done in HIV infected individuals.



  Materials and Methods Top


A cross sectional descriptive study was conducted on known HIV-positive individuals attending the outpatient department of Dermatology in Siddhartha Medical College, Vijayawada, with symptoms suggestive of skin disease or sexually transmitted infection. The study was conducted for a period of 18 months from January 2017 to August 2018. Ethical clearance for the study was taken from the Institutional Research and Ethical Committee (Certificate number: M130605011). A thorough clinical history and a detailed physical examination were done. The variables recorded were sociodemographic data and CD4 count. Relevant investigations such as HIV, (Venereal disease research laboratory), KOH mount, Tzanck smear, saline mount and gram stain were performed wherever necessary to aid in the diagnosis. A pro forma was prepared to note the relevant details of the patient, examination findings, results of the investigation, and the diagnosis. The statistical data were analyzed by descriptive statistics such as mean, standard deviation, percentages, and tables. Independent t-test was used to determine the significant difference between two groups, P < 0.05 was considered statistically significant. Microsoft Word and Excel were used to prepare tables and graphs.

Inclusion criteria

HIV positive patients aged between 18 and 60 years and symptomatic positive patients willing for examination and follow-up.

Exclusion criteria

  • Patients aged below 18 years and above 60 years
  • HIV-negative patients
  • Asymptomatic HIV positive-patients
  • Patients not willing for follow-up.



  Results Top


A total of 500 HIV-seropositive individuals were included in the study, of whom 265 (53%) were males and 235 (47%) were females. The majority of the males and females belonged to the age group of 28–37 years [Table 1]. Out of 500 patients, 363 (72.6%) had only dermatological manifestations, 127 (25.4%) had STIs and 10 (2%) had overlap manifestations. Among the 500 patients included, 195 (39%) were literates. The majority of male patients were unskilled 100 (37.7%) and majority of females were housewives 130 (55.3%); 90 (18%) were skilled, 75 (15%) were in the business and 40 (8%) were unemployed. Out of the 500 patients recruited, 415 (83%) were married, 40 (8%) were separated/divorced, 30 (6%) were widowed and 15 (3%) were unmarried. When sexual encounters in these patients were looked into, 245 (49%) gave a history of exposure putting them at risk to STI and 255 patients did not have a history of exposure to the risk of STI. Among those with a history of exposure, 236 were males and 9 were females. On performing CD4 counts, 210 patients had CD4 count between 201 and 500, 225 patients had a CD4 count of <200, and 65 of them with more than 500. The mean CD4 count was 314.19 cells/μl and standard deviation was 180.316. Out of 127 patients with STIs, 40 (31.5%) were (Herpes Genitalis [HG]), 30 (23.6%) were genital warts, 15 (11.8%) were genital (Molluscum contagiosum [MC]), 25 (17.3%) were vaginal discharge, 25 (19.6%) were candidal BP (Balanoposthitis), 5 (3.93%) were (Gonococcal urethritis), 5 (3.93%) were (Nongonococcal Urethritis), 10 (7.87%) were syphilis [Figure 1], [Figure 2], [Figure 3]. Among 500 patients included in the study, 315 (63%) had infectious manifestations, 165 (33%) had noninfectious manifestations and 20 (4%) were found with both infectious and noninfectious manifestations. Among the patients with infections, 40 were diagnosed with bacterial, 185 with fungal, 150 had viral and 15 had parasitic infections [Chart 1]. Majority of them were fungal infections (37%). Among a total of 165 patients with noninfectious cutaneous manifestations, 75 were pruritic papular dermatoses, 50 were adverse cutaneous drug reactions, 40 were seborrheic dermatitis, 15 were found to have Xerosis/Ichthyosis cases. A total of 75 patients were diagnosed with pruritic papular dermatoses among which pruritic papular eruption was found to be the most common. The other noninfectious dermatoses found were psoriasis, lichen planus, (discoid lupus erythematosus), and vasculitis. Out of 500, 50 cases of drug reactions were observed. Among them, the majority 25 (50%) were observed to have a maculopapular rash, followed by (Stevens–Johnson syndrome/toxic epidermal necrolysis) in 10 (20%) cases, 10 (20%) with urticarial drug reactions and 5 (10%) with erythroderma. Out of 105 patients with oral manifestations, 60 (57%) were observed to have oral candidiasis, 20 (19%) with oral pigmentary changes, 15 (14.2%) were found to have aphthous ulcers, 5 (4.7%) with herpes labialis, 5 (4.7%) with leukoplakia. Scalp/hair involvement was observed in 45 patients. Out of the 45 patients with scalp/hair involvement, 10 (22%) had diffuse nonscarring alopecia, 10 (22%) had herpes zoster, 10 (22%) were found to have seborrheic dermatitis, 5 (11%) had eyelash trichomegaly, 5 (11%) were observed to have pityriasis capitis, and 5 (11%) had scalp psoriasis. Out of a total of 500 patients, 140 of them were found to have nail involvement. Among them, 45 (32%) were diagnosed with onychomycosis, 45 (32%) had longitudinal melanonychia, 25 (17.85%) were found to have paronychia, 15 (10.71%) had nail dystrophy and 10 (7.14%) had koilonychia. On analyzing the CD4 count of the various dermatoses, we found that pruritic papular dermatoses, oral manifestations, nail changes, parasitic infestations, and xerosis/ichthyosis were found to be statistically significant.
Table 1: Age and sex distribution

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Figure 1: Palmar syphilid

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Figure 2: Secondary syphilis- annular syphilid

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Figure 3: Gonococcal urethritis

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  Discussion Top


The present cross sectional descriptive study included 500 HIV-seropositive patients having STIs and dermatological manifestations, who attended the outpatient department of DVL (Dermatology, Venereology and Leprology). Among the 500 patients included, the majority of cases (190, 38%) belonged to the 28–37 year age group, followed by the 18–27 year age group (135, 27%). Thus 65% of cases belonged to the 21–40 year age group which is very close to the study done by Jing and Ismail[6] The mean age of patients in the study group was 34.2 years and the standard deviation was 9.488. This is comparable to the average age group of 36.35 years in the study conducted by Biju Vasudevan et al.[7] The male-to-female ratio in the present study was 1.14: 1, which is close to the study done by Sen et al. in which it was 1.6:1.[8] The majority of the patients in this study were illiterates (61%). The percentage of illiteracy is slightly higher than that observed in a study by Jindal et al.[9] in which it was 52.6%. The percentage of unskilled workers among HIV-infected patients in the present study (33%) is closely related to that reported by Jindal et al.[9] in which it was 39%. The majority of patients in our study were married (83%). This is more than the percentage reported by Jindal et al.(63%). 49% of patients gave a history of exposure, of whom 96% were males. Exposure history was absent in 51% of total patients, of whom 88% were females. The majority of patients in the study group (46%) had a CD4 count <200 cells/μl. This was in concordance with a study done by Munoz-Perez et al.[10] which showed that 53% of patients had CD4 count <200/μl. The mean CD4 count in the present study is 259.35 cells/μl which is comparable to the study done by Biju Vasudevan et al. i.e. 249 cells/μl[7] and Fernandes et al. 253 cells/μl.[11] Among 500 patients seen, a total of 151 STIs were observed in 127 (25.4%) patients. 15 (3%) patients had dual STIs. (2 had balanoposthitis and genital warts, 5 had HG with genital warts, 1 with secondary syphilis and scabies, 2 with HG and vaginal candidiasis, 2 had balanoposthitis with HG, and 3 had MC with vaginal candidiasis). This is lower than that observed in a study by Vasudevan et al. in which it was 10.68%. The mean age of patients with STI was 35.63 years. This is very close to the mean age of 30.60 years observed in HIV patients with STI in the study done by Sabyasachi Banerjee, Saswati Halder, Atin Halder.[4] Among STIs, HG was the most common and was observed in 40 cases (29%). The findings in our study were almost similar to the one done by Gilmore and Kulwichit. (18%–27%).[12] Genital warts were seen in 30 (21.8%) patients with STI. A case of multiple warts over the penis with a penile horn was seen. Anogenital warts were seen in women and in those with MSM (Men who have sex with men) history. Among the ten patients (7.3%) who had syphilis, 4 were males and 6 were females.In our study, syphilis was observed in 2% of the population which is in concordance with that observed by Chopra et al[13] in HIV positive patients in 2012 (2.22%). Among the 500 patients observed, 298 (59.6%) patients had infectious manifestations, 182 (36.4%) had noninfectious manifestations and 20 (4%) had both infectious and noninfectious manifestations. In this study, the infectious dermatoses were the most common dermatological manifestation which is in concordance with the study done by Vasudevan et al.[7] Pyoderma was the most common bacterial infection (12 cases) seen in our study and was seen in 2.4% of the study population. This is in contrast to the study by Sivayathom A 5.6% and Kumaraswamy et al. 2.9%.[14] The mean CD4 cell count associated with bacterial infections in our study was found to be 345.38. The mean CD4 count in those with dermatophyte infections was 330.19. Extensive involvement, secondary infection, and infection at multiple sites were noted. Out of the 500 people recruited in our study, fungal infections were found in 37% which was not in concordance with the findings of Shobhana and Guha 13%.[15] Herpes zoster was the most common viral infection observed where in 5 (11%) of patients had a CD4 count below 200 cells/μl, 30 (66%) had CD4 count between 200 and 500 cells/μl and 10 (22%) had CD4 count of above 500 cells/μl. Herpes Zoster in the present study was seen in 9% which was in concordance with the study done by Vasudevan et al. where it was found to be 11.11%. Ophthalmic zoster and mandibular maxillary zoster, hemorrhagic lesions, pustular lesions, necrotic lesions, and chronic ulcerative lesions with resistance to treatment were seen. MC lesions were seen in 20 patients of whom 13 had genital involvement and 7 had facial lesions. It was observed in 4% which was similar to the observation made by Goh et al.(3%).[16] Among the parasitic infestations, scabies was found in 2.4% with a mean CD4 count of 460.33 cells/μl which was in concordance with the study done by Fernandes and Bhat. There were 185 patients with noninfectious skin manifestations among which pruritic papular dermatoses were the most common observed in 24.3% and included (Pruritic Papular Eruptions [PPE]), eosinophilic folliculitis, prurigo simplex. PPE was the most common with a prevalence of 9% and a mean CD4 count of 180.67 cells/μl. Seborrheic dermatitis was present in 40 patients with a prevalence of about 8% which was comparable to the study conducted by Vasudevan et al. (9.83%). In the present study, the mean CD4 count in those with seborrheic dermatitis was 471.62 cells/μl. Atypical presentations with increased severity, rapid progression with extensive involvement were seen. They responded to a prolonged course of treatment and recurrences were noted. The patients with oral manifestations had a mean CD4 count of 261.81 cells/μl with a P = 0.001 which was found to be statistically significant. Among them oral candidiasis was the most common which was consistent with many previous studies. The mean CD4 count in those with oral candidiasis was found to be 118.36. This is slightly lower than the mean CD4 count of 144.2 observed in a study by Fernandes and Bhat.[11] Nail changes were seen in 140 (28%) patients among which Onychomycosis (32.14%) was the most common observation, followed by longitudinal melanonychia, paronychia, dystrophy, and koilonychia. The number of patients with onychomycosis was similar to other studies, in the range of 15%–40%. Proximal subungual onychomycosis which is pathognomonic of HIV infection was not present in any of the patients, thus underlying its rarity in the Indian setting. This was similar to the study done by Biju Vasudevan et al.[7] Specific markers of AIDS-like bacillary angiomatosis and Kaposi's sarcoma were not present in this study which is similar to many other Indian studies.


  Conclusions Top


In this study, oral candidiasis and PPE were more commonly associated with HIV which could serve as markers of HIV infection in resource-poor settings and in high-risk groups. They also occurred more frequently in those with advanced HIV/AIDS and can be taken as markers of disease progression. HG was the most frequent STI found in HIV patients with the majority of them representing reactivation of previously acquired infection requiring suppressive therapy. The patients with parasitic infestations, pruritic papular dermatoses, oral manifestations, nail changes, and xerosis/ichthyosis had lower CD4 counts and a P < 0.05 which was considered statistically significant.

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 initial s 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.



 
  References Top

1.
Kore SD, Kanwar AJ, Vinay K, Wanchu A. Pattern of mucocutaneous manifestations in human immunodeficiency virus-positive patients in North India. Indian journal of sexually transmitted diseases and AIDS 2013;34:19.  Back to cited text no. 1
    
2.
Jensen BL, Weismann K, Sindrup JH, Søndergaard J, Schmidt K. Incidence and prognostic significance of skin disease in patients with HIV/AIDS: A 5-year observational study. Acta dermato-venereologica 2000;80:140-3.  Back to cited text no. 2
    
3.
Naswa S, Khambhati R, Marfatia YS. Pruritic papular eruptions as presenting illness of HIV. Indian Journal of Sexually Transmitted Diseases and AIDS 2011;32:118.  Back to cited text no. 3
    
4.
Banerjee S, Halder S, Halder A. Trend of sexually transmitted infections in HIV seropositive and seronegative males: A comparative study at a tertiary care hospital of North East India. Indian Journal of Dermatology 2011;56:239.  Back to cited text no. 4
    
5.
Raju PK, Rao GR, Ramani TV, Vandana S. Skin disease: Clinical indicator of immune status in human immunodeficiency virus (HIV) infection. International journal of dermatology 2005;44:646-9.  Back to cited text no. 5
    
6.
Jing W, Ismail R. Mucocutaneous manifestations of HIV infection: A retrospective analysis of 145 cases in a Chinese population in Malaysia. International journal of dermatology 1999;38:457-63.  Back to cited text no. 6
    
7.
Vasudevan B, Sagar A, Bahal A, Mohanty AP. Cutaneous manifestations of HIV—a detailed study of morphological variants, markers of advanced disease, and the changing spectrum. Medical Journal Armed Forces India 2012;68:20-7.  Back to cited text no. 7
    
8.
Sharma G, Oberoi SS, Vohra P, Nagpal A. Oral manifestations of HIV/AIDS in Asia: Systematic review and future research guidelines. Journal of Clinical and Experimental Dentistry 2015;7:e419.  Back to cited text no. 8
    
9.
Jindal N, Aggarwal A, Kaur S. HIV seroprevalence and HIV associated dermatoses among patients presenting with skin and mucocutaneous disorders. Indian Journal of Dermatology, Venereology & Leprology 2009;75:283-6.  Back to cited text no. 9
    
10.
Munoz-Perez MA, Rodriguez-Pichardo A, Camacho F, Colmenero MA. Dermatological findings correlated with CD4 lymphocyte counts in a prospective 3 year study of 1161 patients with human immunodeficiency virus disease predominantly acquired through intravenous drug abuse. The British journal of dermatology 1998;139:33-9.  Back to cited text no. 10
    
11.
Fernandes MS, Bhat RM. Spectrum of mucocutaneous manifestations in human immunodeficiency virus-infected patients and its correlation with CD4 lymphocyte count. International journal of STD & AIDS 201;26:414-9.  Back to cited text no. 11
    
12.
Gilmore ES, Kulwichit W. Immunocompromised patients: Human immunodeficiency virus and non-human immunodeficiency virus positive. Manual of Dermatologic Therapeutics 2007;7:118-27.  Back to cited text no. 12
    
13.
Chopra S, Arora U. Skin and mucocutaneous manifestations: Useful clinical predictors of HIV/AIDS. Journal of clinical and diagnostic research: JCDR 2012;6:1695.  Back to cited text no. 13
    
14.
Kumarasamy N, Solomon S, Madhivanan P, Ravikumar B, Thyagarajan SP, Yesudian P. Dermatologic manifestations among human immunodeficiency virus patients in south India. International journal of dermatology 2000;39:192-5.  Back to cited text no. 14
    
15.
Shobhana A, Guha SK, Neogi DK. Mucocutaneous manifestations of HIV infection. Indian Journal of Dermatology, Venereology & Leprology 2004;70:82.  Back to cited text no. 15
    
16.
Goh BK, Chan RK, Sen P, Theng CT, Tan HH, Wu YJ, et al. Spectrum of skin disorders in human immunodeficiency virus-infected patients in Singapore and the relationship to CD4 lymphocyte counts. International journal of dermatology 2007;46:695-9.  Back to cited text no. 16
    


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