Rash in a Patient with HIV Infection

A 50-year-old man presented  for the diagnosis and treatment of a rash on his legs and back for about 1 and 1/2 years. His past medical history was significant for HIV infection which had been treated with Highly Active Anti-Retroviral Therapy (HAART). He stated that his viral counts were undetectable and that his infection was in remission.

In addition, the patient stated that he had a recent skin biopsy of the right leg by a surgeon, but he hadn’t been given the result. He had also been seen by an oncologist who recommended that an intravenous port be placed in anticipation of chemotherapy needed for the presumed diagnosis of Kaposi’s sarcoma (KS). He declined and instead sought my opinion.

My examination showed many darkly pigmented patches, bumps and raised plaques on the lower legs

Pigmented papillose and plaques on the lower legs

Pigmented papules and plaques on the lower legs

(left) and back

Darker pigmentation and dry scaling skin of the back

Darker pigmentation and dry scaling skin of the back

(right). Some areas were itchy and showed scaling on the surface.

Before proceeding, I wanted to obtain the previous biopsy result. If the biopsy already showed KS, then there would be no need to subject this patient to another biopsy. After calling his primary care doctor and waiting for a fax report, I learned that his previous skin biopsy showed a seborrheic keratosis, a common non-cancerous skin growth. I then performed punch biopsies of representative lesions on the leg and back.

Both of my biopsies showed chronic eczematous dermatitis with post-inflammatory hyperpigmentation. This is a type eczema or dermatitis that is related to dry skin and itch. When it is repeatedly rubbed or scratched, the skin becomes more raised and bumpy and begins to darken as a result. This condition may also be called lichen simplex chronicus. I treated the patient with a high-potency topical steroid ointment called clobetasol. After one month, his itching was gone, the rash was 75% improved, and there was marked lightening of his skin.

Background

Before the development of the modern cocktails of antiviral medicines called HAART, it was not uncommon for very sick, profoundly immunosuppressed patients with AIDS, to develop Kaposi’s sarcoma in the final stages of the disease. You may recall the popular movie Philadelphia where Tom Hanks portrays a lawyer with the disease. KS is a cancer of the blood vessel cells that can start in the skin or mucous membranes and spread to other organs of the body. It is now known that KS in AIDS patients is caused by a different virus called Human Herpesvirus 8 (HHV-8).

Nowadays, KS is rarely seen in AIDS patients who are treated with HAART because their immune systems are stronger and can combat other infections such as HHV-8 on their own. In our case, with undetectable HIV in his blood, it would be extremely unlikely for him to develop KS. On the other hand, eczema is common in all people, especially those with a family history of atopic dermatitis, asthma, or seasonal allergies.

Comment

I cannot over-emphasize the need to review outside skin biopsy reports whenever they are available. In this case, the first biopsy performed by the surgeon was not representative of the rash, but at least it did not show Kaposi’s sarcoma. The additional biopsies of the rash itself, not the incidental benign age-related keratosis, gave the more definitive diagnosis of chronic eczema. The rapid response to the steroid ointment also proved that the diagnosis was correct and that the patient did not have KS.

Summary

  • We confirmed the presence of a benign, treatable rash (eczema) in a man at risk.
  • We proved the absence of the cancer of concern (Kaposi’s sarcoma).
  • We prevented the risks associated with an intravenous port and the administration  of chemotherapeutic drugs.
  • We treated the rash with a safe external medicine and improved the quality of his life.

 

 

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