9/15/2016

Severe dyshidrosis in two patients with HIV infection shortly after starting highly active antiretroviral treatment [eScholarship]

DermatologyOnlineJournal
UCDavis

SeveredyshidrosisintwopatientswithHIVinfectionshortlyafterstartinghighlyactiveantiretroviral
treatment
RobertColebundersMDPhD1,2,MariaZolfoMD1,andLutLynenMD1
DermatologyOnlineJournal11(2):31

1.DepartmentofClinicalSciences,InstituteofTropicalMedicine,Antwerp,Belgium.mzolfo@itg.be2.TropicalDiseaseUnit,UniversityHospital
Antwerp,Wilrijkstraat10,B2950Edegem,Belgium
Abstract
Theuseofhighlyactiveantiretroviraltherapy(HAART)isthegoldstandardtreatmentforHIVinfectedpatients.WeheredescribetwoHIVpositive
patientswhosehistoriesaresuggestivefordyshidrosisasanimmunereconstitutioninflammatorysyndrome(IRIS).Severalfactorshavebeen
associatedwiththeexacerbationofdyshidrosislesionsbutnodirectrelationshipwithHAARThasbeenreporteduntilnow.

Introduction
Skineruptionsappearingshortlyafterthestartofhighlyactiveantiretroviraltherapy(HAART)areoftencausedbyanallergicreactiontooneofthe
antiretrovirals.However,thedifferentialdiagnosisphysiciansshouldalsoconsideranimmunereconstitutioninflammatorysyndrome(IRIS)[1].The
IRISphenomenonistheoccurrenceofinflammationatsitesofinfectionshortlyaftertheinitiationofHAART[2].Thehypothesisisthattherecoveryof
theimmunesysteminducesalocalorsystemicinflammatoryresponsetotheseorganisms.RecentlyithasbeensuggestedthatDemodexfolliculitis
couldbeamanifestationofIRIS[3].WedescribetwocasesofseveredyshidrosisshortlyaftertheintroductionofHAART.
Case1
A53yearoldCaucasianman,livinginNigeria,wasdiagnosedwithHIVinfectioninNovember2002.Atpresentationhecomplainedofanorexiaand
weightloss(8kg,<10%).HisCD4+lymphocytecountwas117/landhisviralload50,000copies/ml.InJanuary2003hewasstartedontreatment
withnevirapine,lamivudine,stavudineandcotrimoxazole.After17dayshedevelopedlargepruriticblistersonthesolesofhisfeet.Bothfeetbecame
edematousbecauseofassociatedinflammation.Therewerenootherskinormucosallesions.Hewasswitchedfromnevirapinetoindinavir.
However,thefootlesionspersisted.FourmonthsafterthestartoftheantiretroviraltherapyhewasseenattheoutpatientclinicoftheInstituteof
TropicalMedicineinAntwerp,Belgium.HisCD4+lymphocytecountis341/l,hisviralloadundetectable.Onphysicalexaminationlargebullousand
excoriatedlesionsarestillpresentatbothfeet.Healsopresentsfacialseborrheicdermatitis,onychomycosisandatineacruris.Usingamiconazole
creamforthetineaandacorticosteroidcreamforthedishydrosisfinallythelesionsonhisfeetdisappear.Theindinavir,lamivudine,stavudineand
cotrimoxazoletreatmentiscontinued,andterbinafineisstartedfortheonychomycosiswithgoodresult.
Thepatienthadnohistoryofatopicdermatitis,dishydroticeczemaornickelallergyinthepast.
Case2
A42yearoldCaucasianman,livinginBelgium,isdiagnosedwithHIVinfectionin1997.InMay1998hisCD4+lymphocytecountis300/landhis
viralload145253copies/ml.Heistreatedwithstavudine,lamivudineandindinavir.After5dayshedevelopslargepruriticblistersonbothhandsand
smalleronesonbothfeet.Sincetheageof26,heexperiencedsimilarbutmuchsmallerlesions,butneverinrelationtotheintakeofdrugs.InApril
2002hisantiretroviralsarestoppedbecauseofunexplainedfatigue.HisCD4+lymphocytecountis619/l.InMay2003antiretroviraltreatment
(stavudine,lamivudineandnevirapine)isreintroducedbecausehisCD4+lymphocytecountdropsto272/l.Threeweekslaterhedevelopsagain
pronounceddyshidrosislesionsonthepalmsofhishandsandfeet,similartothosehedevelopedin1998whenhefirststartedtotakeantiretrovirals.

Discussion
Theetiologyofdyshidrosisremainsobscure[4].Patientsmaypresentsevere,suddenoutbreaks,oftenwithlongdiseasefreeperiods[5].
Recurrencescanoccurduringtimesofstress[6].Dyshidrosismayoccurinthepresenceofadermatophyticinfectionormaybeamanifestationofan
allergiccontactdermatitis[7].Innoneofourpatientstherewasapersonalorfamilialhistoryofcontactdermatitisbutourfirstpatientpresentedwitha
concomitantfungalskininfection.
SofarnoincreasedincidenceofdyshidrosisinpersonswithHIVinfectionhasbeendescribed.Anassociationwiththeuseofantiretroviralshasnever
beenreportedbutpompholyxhasbeennotedafterintravenousimmunoglobulintherapy(8).Thefactthatinourtwopatients,dyshidrosislesions
developedshortlyaftertheintroductionofHAARTcouldbesimplyacoincidenceorcouldbecausedbyIRIS.
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Severe dyshidrosis in two patients with HIV infection shortly after starting highly active antiretroviral treatment [eScholarship]

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