Pruritic papular eruption in HIV-positive patients in Brazil

1576 AIDS 2020, Vol 34 No 10 Defect of immunity was regarded to be one potential susceptibility towards COVID-19 in patients with older age and malignancies [3,4]. However, the immunocompromised states of AIDS patients seemed to have no relevance with respect to COVID-19. One possible reason might be that protease inhibitors were used in some AIDS patients, which were reported to have an antiviral effect towards coronavirus [5,6]. Meanwhile, we speculated that AIDS patients were more likely to wear protective equipment because of concerns of opportunistic infections, and AIDS patients with mild or moderate symptoms might avoid going to see a doctor for personal reasons [7], which might lead to an extra transmission risk of SARSCoV-2. Even through, at the beginning of admission, this patient had persistent high fever with multifocal lesions on the chest CT, durations of symptoms and of lesion progression on the CT image were similar to other moderate COVID19 patients [8,9]. One explanation might be that impaired immunity of AIDS patients would attenuate the immune response towards coronavirus, which was supposed to cause more damage to the lungs [10]. Meanwhile, immune dysfunction was also regarded to delay the clearance of virus. However, paradoxically, the duration of positive RTPCR results of SARS-CoV-2 in this patient was shorter than the average level [8]. As LPV/r and arbidol were used after this patient was afebrile, it was hard to conclude from this patient that LPV/r and arbidol could benefit patients with respect to coronavirus clearance. Meanwhile, attention should be paid to irregularities in the administration of antibiotics in AIDS patients with fever during this period. More data are needed to better understand the pathogenesis and prognosis in patients with coinfection of SARS-CoV-2 and HIV. Acknowledgements We appreciate all of the clinical providers, nurses and scientific researchers for their efforts in fighting COVID-19. Sources of Funding: This work was supported by National Science and Technology Major Project (Dr Su; 2018ZX10715014-004-002). Conflicts of interest There are no conflicts of interest. and Jifang Sheng, Department of Infectious Diseases, State Key Laboratory for the Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for the Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, China. Correspondence to Jifang Sheng, MD, The First Affiliated Hospital, College of Medicine, Zhejiang University, 79th Qingchun Road, Hangzhou 310003, China. Tel: +86 571 87236491; fax: +86 571 87236491; e-mail: [email protected] Junwei Su and Xiaomin Shen contributed equally to this manuscript. Received: 27 March 2020; revised: 16 April 2020; accepted: 16 April 2020. References 1. Wong AT, Tsang OT, Wong MY, Lim WL, Zheng BJ, Lee SS, et al., PMH SARS Study Group. Coronavirus infection in an AIDS patient. AIDS 2004; 18:829–830. 2. Shalhoub S, AlZahrani A, Simhairi R, Mushtaq A. Successful recovery of MERS CoV pneumonia in a patient with acquired immunodeficiency syndrome: a case report. J Clin Virol 2015; 62:69–71. 3. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020; 395:497–506. 4. Liang W, Guan W, Chen R, Wang W, Li J, Xu K, et al. Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China. Lancet Oncol 2020; 21:335–337. 5. Cao B, Wang Y, Wen D, Liu W, Wang J, Fan G, et al. A trial of lopinavir-ritonavir in adults hospitalized with severe COVID19. N Engl J Med 2020; 382:1787–1799. 6. Yao TT, Qian JD, Zhu WY, Wang Y, Wang GQ. 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Junwei SuM, Xiaomin ShenM, Qin Ni, Hong Zhao, Jieru Cai, Biao Zhu, Wenrui Wu, Guanjing Lang, Kaijin Xu DOI:10.1097/QAD.0000000000002553 Pruritic papular eruption in HIV-positive patients in Brazil Pruritic papular eruption (PPE) is a mucocutaneous manifestation associated with HIV infection which was first described in the early years of the HIV epidemic [1]. PPE is characterized by erythematous papules or macules with symmetrical distribution mainly on the trunk and extremities in the absence of other causes of pruritus; Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. Correspondence Fig. 1. (a) CD4R cell count in HIV patients with (n U 45) and without (n U 159) pruritic papular eruption [each box indicates the median (horizontal line) and interquartile range, whiskers include data points within 1.5 interquartile range of nearer quartile]; (b) Log10 HIV viral load in HIV patients with (n U 40) and without (n U 133) pruritic papular eruption (each point represents a single measurement, horizontal lines indicate medians). Measurements at time of diagnosis were not available for all patients with pruritic papular eruption (n ¼ 65) and without pruritic papular eruption (n ¼ 305). Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. 1577 1578 AIDS 2020, Vol 34 No 10 intense itching is the most common symptom, leading to scratching, excoriation and postinflammatory hyperpigmentation [2]. PPE tends to be a chronic condition, but individual lesions will appear and disappear. Various aetiological factors have been explored in relation to PPE including immunological responses to insect bites, while infectious agents other than the primary HIV infection do not appear to be implicated [2]. Histopathological and haematological findings have been inconclusive and sometimes inconsistent, with most studies being small [2]. The salient feature of PPE is that it has been strongly and consistently associated with low CD4þ cell count, as described recently in paediatric and adult HIV patients [3,4]. Here, we report the associations that we found between PPE, CD4þ cell count and HIV viral load in HIV patients in Brazil who attended the Hospital Universitario Cassiano Antonio Moraes (HUCAM), Vit oria (Espı́rito Santo) between 2004 and 2010. Patients had a dermatological examination and 4-mm punch skin biopsy, with diagnosis of PPE based on clinical and histopathologic findings to exclude differential diagnosis as scabies, prurigo caused by insect bites, cutaneous drug reactions, lichen planus, acne, demodicosis, eosinophilic folliculitis and bacterial folliculitis [2]. CD4þ cell count and viral load measurements at the time of examination, if available, were obtained from medical records. Ethical permission for use of these data was obtained from HUCAM research ethics committee. Of 370 patients [190 (51.4%) male, 180 (48.7%) female], median age 39 (range 15–82), 17.6% (65/370) had PPE, with no difference in prevalence by age (Pt test ¼ 0.13) or sex (PChi-squared ¼ 0.23). PPE was generalized (more than one body area) in 60.0% (39/65) of cases and PPE manifested mostly [76.9% (50/65)] as papules. Median CD4þ cell count was lower in patients with PPE [266 (interquartile range (IQR) 114–524) cells/ml, n ¼ 45] than without PPE [400 (IQR 238–568) cells/ml, n ¼ 159] (PKruskal–Wallis ¼ 0.02) (Fig. 1a) and viral load was higher [1331 (IQR 5–171797, n ¼ 40) copies/ml compared with 5 (IQR 5–569) copies/ ml, n ¼ 133] (PKruskal–Wallis ¼ 0.001) (Fig. 1b); 32.5% (13/40) of patients with PPE had undetectable viral load (<10 copies/ml) compared with 51.9% (69/133) of patients without PPE (PChi-squared ¼ 0.03). Ten patients with PPE were not taking antiretroviral therapy (ART) (15.4%) compared with 56 patients (18.4%) without PPE (PChi-squared ¼ 0.57). The strong association that we found between low CD4þ cell count and PPE replicates findings in most, but not all [5], previous studies of HIV-related dermatoses. PPE in the early years of the HIV epidemic was considered pathognomonic of AIDS and is potentially prognostic of ART failure [6,7]. Given that the prevalence of PPE has remained relatively unchanged among HIV patients even in the era of ART and that countries such as Brazil continue to see large numbers of new HIV cases each year (44 000 in 2018 http://www.aids.gov.br/pt-br/pub/2019/boletim-epidemiologico-de-hivaids-2019), more consideration needs to be given to identifying effective treatments to relieve debilitating and stigmatizing symptoms of HIV-related dermatological conditions and to improve patient quality of life [2]. Acknowledgements We thank Professor Elton Lucas and Professor Tania Reuter from the Hospital Universitario Cassiano Antonio Moraes (HUCAM) for their advice. This study received no specific funding. Conflicts of interest The authors have no conflicts of interest to declare. Brunela Tozzia, Camila Gaviolia, Luciana Linharesa, Mayara Entringera, Monique Dalapı´colaa, Bruno Alves, Simon M. Collinb and Patrı´cia Depsa, aDepartment of Social Medicine, Federal University of Espı´rito Santo, Vit oria, Espı´rito Santo, Brazil, and bNational Infection Service, Public Health England, London, UK. Correspondence to Professor Patrı´cia Deps, Departamento de Medicina Social, Centro de Ciências da Saúde, Universidade Federal do Espı´rito Santo, Av. Marechal Campos, 1468, Maruı´pe, Vit oria CEP 29047105, ES, Brazil. Tel: +55 27 99999 6390; e-mail: [email protected] Received: 30 March 2020; revised: 22 April 2020; accepted: 28 April 2020. References 1. Colebunders R, Mann JM, Francis H, Bila K, Izaley L, Kakonde N, et al. Generalized papular pruritic eruption in African patients with human immunodeficiency virus infection. AIDS 1987; 1:117–121. 2. Eisman S. Pruritic papular eruption in HIV. Dermatol Clin 2006; 24:449–457vi. 3. Li YY, Yang SH, Wang RR, Tang JT, Wang HM, Kuang YQ. Effects of CD4R cell count and antiretroviral therapy on mucocutaneous manifestations among HIV/AIDS patients in Yunnan, China. Int J Dermatol 2020; 59:308–313. 4. Britto GR, Augustine M. Mucocutaneous manifestations of human immunodeficiency virus (HIV) infection in children in relation to the degree of immunosuppression. Int J Dermatol 2019; 58:1165–1171. 5. Chua SL, Amerson EH, Leslie KS, McCalmont TH, Leboit PE, Martin JN, et al. Factors associated with pruritic papular eruption of human immunodeficiency virus infection in the antiretroviral therapy era. Br J Dermatol 2014; 170:832–839. 6. Labhardt ND, Lejone T, Setoko M, Poka M, Ehmer J, Pfeiffer K, et al. A clinical prediction score in addition to WHO criteria for antiretroviral treatment failure in resource-limited settings – experience from Lesotho. PLoS One 2012; 7:e47937. 7. Castelnuovo B, Byakwaga H, Menten J, Schaefer P, Kamya M, Colebunders R. Can response of a pruritic papular eruption to antiretroviral therapy be used as a clinical parameter to monitor virological outcome? AIDS 2008; 22:269–273. DOI:10.1097/QAD.0000000000002575 Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.