Characteristics of HIV Infected Patients with Biopsy Diagnosed Spongiotic Dermatitis

doi:10.4236/wja.2011.14021

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World Journal of AIDS, 2011, 1, 146-148

doi:10.4236/wja.2011.14021 Published Online December 2011 (http://www.SciRP.org/journal/wja)

Characteristics of HIV Infected Patients with

Biopsy Diagnosed Spongiotic Dermatitis*

Gus W. Krucke1, Benjamin L. Cooper1, Deanna E. Grimes2, Richard M. Grimes1#

1Department of Medicine, Medical School, University of Texas Health Science Center at Houston, Houston, USA; 2Department of

Nursing Systems, School of Nursing, University of Texas Health Science Center at Houston, Houston, USA.

E-mail: #[email protected]

Received August 11th, 2011; revised September 14th, 2011; accepted October 5th, 2011.

ABSTRACT

Purpose: Twenty-six HIV patients with biopsy diagnosed spongiotic dermatitis (SD) were studied to determine their

demographic and clinical characteristics. The condition was also investigated to determine if it was linked to the im-

mune reconstitution inflammatory syndrome (IRIS). Methods: All patients whose skin biopsies were diagnosed by a

pathologist as SD were identified. Medical records were reviewed to extract demographic descriptors, viral loads and

CD4+ counts at the time that SD occurred. In an attempt to determine if the condition could be linked to Immune Re-

constitution Syndrome (IRIS), the time from nadir CD4+ count to the occurrence of SD was determined. Results: SD

patients were found to be older than expected but were similar to other clinic pa tients with regard to race/ethnicity a nd

gender. CD4+ counts, viral loads were not related to SD. SD did not seem to be related to IRIS because few cases oc-

curred within the time frame associa ted with IRIS. SD frequ en tly appeared on the limb s alth ough the litera ture sug g ests

a more frequent appearance on the trunk and buttocks. Discussion: HIV clinicians may expect to see SD on occasion

and it may appear in unusual body sites and at any time during the course of the infection.

Keywords: Spongiotic Dermatitis, HIV Infection, Immune Reconstitution Inflammatory Syndrome

1. Introduction logic examination of tissue samples [6]. Immunocom-

promised patients are prone to the above risk factors for

SD and often suffer from multiple dermatological condi-

tions which may require a skin biopsy in order to make a

diagnosis [7]. So, one would expect that a linkage would

have b een made bet ween SD a nd HIV infec tion. Howe ver,

this has not been the case. No references to SD in HIV

patients could be found in the general medical literature or

in review articles of dermatologic conditions in HIV in-

fected persons [8-11].

Spongiotic dermatitis (SD), an intensely pruritic derma-

tologic condition, is diagnosed by biopsy [1]. Lesions of

this condition are typically found on the trunk or buttock s

but may appear on any part of the body. Early lesions are

erythematic and, with time, may darken to black. In the

absence of effective treatment, the skin may become

rough, ooze and cru st and constant scratching may lead to

scarring. The etiology of SD is not full y understood but SD

has been linked to contact dermatitis, food and drug aller-

gies, and reactions to insect bites, suggesting an immune

reaction [2]. SD also has been linked to infectious condi-

tions such as hepatitis C infection [3] and HTLV-1 infec-

tion [4]. A variant of SD is has been found in patients with

heavily pigmented skin [5]. Investigators have noted high

levels of proliferativ e activ ity of CD8 ( +) T ce l l s i n p a t ho -

Because of the lack of literature describing SD in the

HIV infected population and because skin lesions have

been found to occur as part of the immune reconstitution

syndrome (IRIS), [12] the authors report on a group of

HIV patients diagnosed with SD. Specifically, we de-

scribe the patient’s age, nadir CD4+ count, time since

initiation of antiretroviral therapy and viral load, all

characteristics that might be associated with IRIS.

*This study was supported by the Baylor-UT Houston Center for AIDS

Research (CFAR), a National Institutes of Health-funded program

(AI036211).

*The authors have no conflicts of interest with regard to this manu-

script. This study was approved by the Committee for the Protection o

Human Subjects at the University of Texas (The institutional review

board).

2. Methods

This study was conducted at the Thomas Street Health

Center of the Harris County Hospital District in Hous ton,

Characteristics of HIV Infected Patients with Biopsy Diagnosed Spongiotic Dermatitis147

Texas. This clinic has over 5000 active patients. The

clinic maintains a minor emergency and treatment room

with the capacity to collect skin samples for subsequent

examination by a pathologist.

The investigators reviewed the biopsy reports of 161

skin specimens that had been collected at the clinic be-

tween 2005 and 2009. Twenty six of these specimens

were classified as spongiotic dermatitis by a pathologist.

The electronic medical record was examined for each

patient with this diagnosis. Demographic data were ex-

tracted from the record. In an attempt to determine if the

condition could be linked to Immune Reconstitution

Syndrome (IRIS), CD4+ t lymphocyte data were also

collected. IRIS is described as occurring within 60 - 90

days after a patient’s CD4+ count begins to rise follow-

ing initiation of antiretroviral therapy (ART) [12,13].

Therefore, the patient’s nadir CD4+ count was collected

and the date that the assay was done. The date that the

skin biopsy was performed was also recorded and the

CD4+ count closest to the date of the biopsy was also

recorded. If spongiotic dermatitis was associated with

IRIS, it should have occurred shortly after the nadir

CD4+ count. Therefore the time from the nadir to the

biopsy was calculated. The increase of the CD4+ count

between the nadir and the time of SD was also recorded

because IRIS has been linked to rapid and large increases

in CD4+ counts [13]. The location of th e lesion was also

recorded to determine if SD in HIV infected persons’

lesions followed the usual pattern of SD being found on

the trunk and buttocks.

3. Results

Twenty six patients had been diagnosed with SD at the

time of this investigation. Eighteen or 70% of the diag-

nosed SD patients were African-American while the re-

maining eight were evenly split between White and His-

panic. Twenty (77%) of the subjects were male and six

(23%) were female. These demographics are similar to

the clinic’s population. Approximately 20% of the pa-

tient population at the clinic, however, is less than 30

years of age while all of the patients diagnosed with SD

were 30 years of age or greater. As can be seen from Ta-

ble 1, the CD4+ counts nearest to the time of the occur-

rence of SD exhibited a wide range of CD4+ counts from

31 to 1226. Similarly, the viral load at the time that SD

occurred ranged <400 to >750,000 copies of HIV viral

RNA. All of the CD4+ counts and viral loads were per-

formed within two months of the skin biopsy. Also, a

broad range of nadir CD4+ counts was represented in the

SD patients with a range from as low as 5 cells to as high

as 389. When the time from the nadir CD4+ count until

the occurrence of SD was examined, the range of times

was from 8 months before the nadir to 76 months after its

Table 1. Immunological characteristics of HIV-infected pa-

tients with spongiatic dermatitis (N = 26).

Clinical

Character Istics Number Percentage

CD 4 Count at time of SD

<100 10 38%

101 - 200 2 8%

200 - 500 5 19%

>500 9 35%

Nadir CD 4 Count

<50 13 50%

50 - 99 2 8%

100 - 199 6 23%

200 - 500 5 19%

Viral Load at Time of SD

<400 14 54%

401 - 10,000 3 11%

10,001- 100,000 3 11%

>100,001 - 500,000 2 8%

>500,000 4 15%

Increase In CD 4 Count from

NADIR to SD Diagnosis

<50 10 38%

51 - 100 2 8%

101 - 200 2 8%

201 - 500 7 27%

>500 5 19%

Time from Nadir to SD

Diagnosis

SD before Nadir 1 4%

<1 Months 4 15%

1 Month - 1 Year 4 15%

1 - 3 Years 7 27%

3+ Years 10 38%

Location of the lesion

Trunk 2 8%

Head and neck 3 12%

Upper extremity 10 38%

Lower extremity 10 38%

Unknown 1 4%

Characteristics of HIV Infected Patients with Biopsy Diagnosed Spongiotic Dermatitis

148

occurrence. The lesions tended to be located on the arms

and legs and only five patients had lesions that were lo-

cated on the trunk or the head and neck.

4. Discussion

This is the first paper that describes SD in HIV infected

persons. It seems that the lesion is not related to the im-

munological state of these patients nor does the level of

virus seem to be factor in its occurrence. Attempts to

relate SD to the time frame that is associated with IRIS

were not successful. Of note, SD in these HIV-infected

patients tended to be located on the extremities, not on

the trunk and buttocks as in non-HIV infected persons.

So, those who are treating HIV infected persons may

expect to see SD on occasion and it may appear in un-

usual body sites and at any time during the course of the

infection.

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