Cutaneous Manifestations of HIV Infection in Children Part 2: Noninfectious Complications

Wolfgang P. Rennert, MD, DMSC, DTM&H
Georgetown University

Dr Rennert is professor of pediatrics at Georgetown University Medical Center in Washington, DC. He earned his doctorate degree (DMSc) in Germany and a DTM&H degree in tropical medicine and hygiene in South Africa.

The skin is a common site for clinical manifestations of HIV infection. Cutaneous findings may occur at the onset of the infection—or they may indicate progression of the disease with impairment of the patient’s immunity.

Typically, skin disease in HIV-infected children is more severe and more recalcitrant to treatment than in age-matched uninfected controls. Most skin manifestations in infected children fall into 1 of 6 groups:

•Infections. (These were the subject of a Photo Essay that appeared in the October 2012 edition of this journal.)
•Proliferative disorders.
•Vascular disorders.
•Drug eruptions.
•Nutritional deficiencies.

Skin infections and proliferative conditions, such as atopic dermatitis, are most commonly described in children with HIV. They also occur in otherwise healthy patients, of course, but they manifest with atypical severity and distribution and/or at an unusual age in those who have HIV infection. Thus, unusual manifestations of common pediatric skin disorders may be a marker for the presence of HIV.

The following pictures were tak-en of children with noninfectious complications of pediatric HIV infection. None had access to antiretroviral ther-apy. Clearly, the use of antiretro-viral drugs will delay the manifestations and progression of HIV disease. 

xerosis, seborrheic dermatitis

Proliferative Disorders

Proliferative disorders ranging from mild xerosis to severe seborrheic dermatitis and acquired ichthyosis are very common in children with HIV infection. Figure A shows the last condition in a 10-year-old boy with advanced HIV disease.

Figure B shows an HIV-infected 4-month-old infant with generalized seborrheic dermatitis. This baby died 1 month later of Pneumocystis carinii pneumonia.

The severity of the dermatitis correlates with the level of immunosuppression. Response to emollients is often inadequate, and debilitating pruritus is common. 

henoch-schonlein purpuraVascular Disorders

Leukocytoclastic vasculitis resembling Henoch-Schönlein purpura (HSP) is caused by a vasculitic response to the human immunodeficiency virus itself, as shown in this Figure. Typically, it can be seen early on in the disease in infants, before the child’s immunity becomes compromised and before other clinical manifestations of HIV occur. Leuko-cytoclastic vasculitis may easily be mistaken for HSP, but the lesions are more generalized and occur in infancy when HSP is uncommon (mean age of occurrence is 4 years).

Angiomatous lesions and throm-bophlebitis are more common in adults with HIV than in similarly infected children. 

p carinii pneumonia

Drug Eruptions

Drug eruptions in response to sulfonamides, antituberculous drugs, and antiepileptics are much more common in children with HIV than in the general population. Drug eruptions also occur with antiretroviral agents, especially nevirapine and efavirenz. Rashes are particularly common in patients with Pneumocystis carinii infection who are treated with trimethoprim-sulfamethoxazole (TMP-SMX). Eruptions tend to resolve after the drug is discontinued.

The Figure shows a mild drug eruption in an infant with P carinii pneumonia who was treated with TMP-SMX. 

kaposi sarcomaNeoplasms

Neoplasms of the skin are rare in HIV-positive children. Nevertheless, Kaposi sarcoma has been described and can affect children as young as 5 years. The Figure is a close-up of the chest wall of a 10-year-old boy with full-blown AIDS; it shows the bluish nodules of Kaposi sarcoma.

Kaposi lesions are typically multiple and widespread. They may occur in areas of previous trauma or injection sites, or in dermatomes previously affected by herpes zoster. Progression to systemic disease is the rule. 

dermatosis of kwashiorkorNutritional Deficiencies

alnutrition with or without diarrhea is a common feature of advanced HIV disease with severe immunosuppression. Children with HIV are prone to multiple infections that lead to recurrent lung disease, frequent episodes of gastroenteritis, and chronic diarrhea. Acrodermatitis enteropathica from zinc deficiency and pellagra and scurvy have all been described in HIV infection. In developing countries, children with HIV are at greater risk for kwashi-orkor than their uninfected peers.

The 6-year-old girl pictured in the Figure has pitting edema and weeping dermatosis of kwashiorkor at an age when kwashiorkor is un-usual—even in countries where this condition is endemic. 



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