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. 1995 Jul;8(3):440–450. doi: 10.1128/cmr.8.3.440

Cutaneous manifestations of opportunistic infections in patients infected with human immunodeficiency virus.

J W Tappero 1, B A Perkins 1, J D Wenger 1, T G Berger 1
PMCID: PMC174635  PMID: 7553576

Abstract

Bacillary angiomatosis (BA) presents most commonly as a cutaneous disease and is caused by two organisms. Bartonella (Rochalimaea) henselae and Bartonella (Rochalimaea) quintana. Biopsy confirmation of cutaneous BA is essential because lesions can mimic nodular Kaposi's sarcoma in appearance. Although the vast majority of human immunodeficiency virus (HIV)-infected patients with BA have CD4 lymphocyte counts of less than 100 cells per mm3, the disease responds well to antimicrobial therapy. Staphylococcus aureus is the most common bacterial skin pathogen affecting HIV-infected patients. The prevalence of skin disease due to S. aureus may be explained by high nasal carriage rates for the organism ( > or = 50%) and altered immune function in conjunction with an impaired cutaneous barrier. Herpes simplex virus causes mucocutaneous disease early in the course HIV infection and ulcerative lesions at any site in advanced HIV infection. Herpes zoster is common early in the course of HIV infection; recurrent and disseminated herpes zoster infections are characteristic of patients with advanced HIV disease. Acyclovir resistance is usually seen in patients with large, untreated, ulcerative lesions of herpes simplex virus and in patients with chronic, verrucous lesions of varicella-zoster virus. Cutaneous cryptococcosis, histoplasmosis, and coccidiomycosis are markers of disseminated disease and require biopsy confirmation. Scabies is easily diagnosed but may be atypical in presentation and difficult to eradicate in advanced HIV disease.

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Selected References

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  1. Anderson B., Kelly C., Threlkel R., Edwards K. Detection of Rochalimaea henselae in cat-scratch disease skin test antigens. J Infect Dis. 1993 Oct;168(4):1034–1036. doi: 10.1093/infdis/168.4.1034. [DOI] [PubMed] [Google Scholar]
  2. Bagdades E. K., Pillay D., Squire S. B., O'Neil C., Johnson M. A., Griffiths P. D. Relationship between herpes simplex virus ulceration and CD4+ cell counts in patients with HIV infection. AIDS. 1992 Nov;6(11):1317–1320. doi: 10.1097/00002030-199211000-00012. [DOI] [PubMed] [Google Scholar]
  3. Becker B. A., Frieden I. J., Odom R. B., Berger T. G. Atypical plaquelike staphylococcal folliculitis in human immunodeficiency virus-infected persons. J Am Acad Dermatol. 1989 Nov;21(5 Pt 1):1024–1026. doi: 10.1016/s0190-9622(89)80379-2. [DOI] [PubMed] [Google Scholar]
  4. Berger T. G., Greene I. Bacterial, viral, fungal, and parasitic infections in HIV disease and AIDS. Dermatol Clin. 1991 Jul;9(3):465–492. [PubMed] [Google Scholar]
  5. Berger T. G., Tappero J. W., Kaymen A., LeBoit P. E. Bacillary (epithelioid) angiomatosis and concurrent Kaposi's sarcoma in acquired immunodeficiency syndrome. Arch Dermatol. 1989 Nov;125(11):1543–1547. [PubMed] [Google Scholar]
  6. Birch C. J., Tyssen D. P., Tachedjian G., Doherty R., Hayes K., Mijch A., Lucas C. R. Clinical effects and in vitro studies of trifluorothymidine combined with interferon-alpha for treatment of drug-resistant and -sensitive herpes simplex virus infections. J Infect Dis. 1992 Jul;166(1):108–112. doi: 10.1093/infdis/166.1.108. [DOI] [PubMed] [Google Scholar]
  7. Brenner D. J., O'Connor S. P., Winkler H. H., Steigerwalt A. G. Proposals to unify the genera Bartonella and Rochalimaea, with descriptions of Bartonella quintana comb. nov., Bartonella vinsonii comb. nov., Bartonella henselae comb. nov., and Bartonella elizabethae comb. nov., and to remove the family Bartonellaceae from the order Rickettsiales. Int J Syst Bacteriol. 1993 Oct;43(4):777–786. doi: 10.1099/00207713-43-4-777. [DOI] [PubMed] [Google Scholar]
  8. Buchbinder S. P., Katz M. H., Hessol N. A., Liu J. Y., O'Malley P. M., Underwood R., Holmberg S. D. Herpes zoster and human immunodeficiency virus infection. J Infect Dis. 1992 Nov;166(5):1153–1156. doi: 10.1093/infdis/166.5.1153. [DOI] [PubMed] [Google Scholar]
  9. Chatis P. A., Miller C. H., Schrager L. E., Crumpacker C. S. Successful treatment with foscarnet of an acyclovir-resistant mucocutaneous infection with herpes simplex virus in a patient with acquired immunodeficiency syndrome. N Engl J Med. 1989 Feb 2;320(5):297–300. doi: 10.1056/NEJM198902023200507. [DOI] [PubMed] [Google Scholar]
  10. Cohen P. R., Grossman M. E. Clinical features of human immunodeficiency virus-associated disseminated herpes zoster virus infection--a review of the literature. Clin Exp Dermatol. 1989 Jul;14(4):273–276. doi: 10.1111/j.1365-2230.1989.tb01978.x. [DOI] [PubMed] [Google Scholar]
  11. Colebunders R., Mann J. M., Francis H., Bila K., Izaley L., Ilwaya M., Kakonde N., Quinn T. C., Curran J. W., Piot P. Herpes zoster in African patients: a clinical predictor of human immunodeficiency virus infection. J Infect Dis. 1988 Feb;157(2):314–318. doi: 10.1093/infdis/157.2.314. [DOI] [PubMed] [Google Scholar]
  12. Coopman S. A., Johnson R. A., Platt R., Stern R. S. Cutaneous disease and drug reactions in HIV infection. N Engl J Med. 1993 Jun 10;328(23):1670–1674. doi: 10.1056/NEJM199306103282304. [DOI] [PubMed] [Google Scholar]
  13. Crowe S. M. Unusual features of herpes simplex or zoster infection that suggest HIV infection. Med J Aust. 1993 Feb 1;158(3):186–187. doi: 10.5694/j.1326-5377.1993.tb121701.x. [DOI] [PubMed] [Google Scholar]
  14. Dolan M. J., Wong M. T., Regnery R. L., Jorgensen J. H., Garcia M., Peters J., Drehner D. Syndrome of Rochalimaea henselae adenitis suggesting cat scratch disease. Ann Intern Med. 1993 Mar 1;118(5):331–336. doi: 10.7326/0003-4819-118-5-199303010-00002. [DOI] [PubMed] [Google Scholar]
  15. Duvic M. Staphylococcal infections and the pruritus of AIDS-related complex. Arch Dermatol. 1987 Dec;123(12):1599–1599. [PubMed] [Google Scholar]
  16. Ellis M., Gupta S., Galant S., Hakim S., VandeVen C., Toy C., Cairo M. S. Impaired neutrophil function in patients with AIDS or AIDS-related complex: a comprehensive evaluation. J Infect Dis. 1988 Dec;158(6):1268–1276. doi: 10.1093/infdis/158.6.1268. [DOI] [PubMed] [Google Scholar]
  17. Engel J. P., Englund J. A., Fletcher C. V., Hill E. L. Treatment of resistant herpes simplex virus with continuous-infusion acyclovir. JAMA. 1990 Mar 23;263(12):1662–1664. [PubMed] [Google Scholar]
  18. Erlich K. S., Jacobson M. A., Koehler J. E., Follansbee S. E., Drennan D. P., Gooze L., Safrin S., Mills J. Foscarnet therapy for severe acyclovir-resistant herpes simplex virus type-2 infections in patients with the acquired immunodeficiency syndrome (AIDS). An uncontrolled trial. Ann Intern Med. 1989 May 1;110(9):710–713. doi: 10.7326/0003-4819-110-9-710. [DOI] [PubMed] [Google Scholar]
  19. Erlich K. S., Mills J., Chatis P., Mertz G. J., Busch D. F., Follansbee S. E., Grant R. M., Crumpacker C. S. Acyclovir-resistant herpes simplex virus infections in patients with the acquired immunodeficiency syndrome. N Engl J Med. 1989 Feb 2;320(5):293–296. doi: 10.1056/NEJM198902023200506. [DOI] [PubMed] [Google Scholar]
  20. Eyster M. E., Rabkin C. S., Hilgartner M. W., Aledort L. M., Ragni M. V., Sprandio J., White G. C., Eichinger S., de Moerloose P., Andes W. A. Human immunodeficiency virus-related conditions in children and adults with hemophilia: rates, relationship to CD4 counts, and predictive value. Blood. 1993 Feb 1;81(3):828–834. [PubMed] [Google Scholar]
  21. Funkhouser M. E., Omohundro C., Ross A., Berger T. G. Management of scabies in patients with human immunodeficiency virus disease. Arch Dermatol. 1993 Jul;129(7):911–913. [PubMed] [Google Scholar]
  22. Ganesh R., Castle D., McGibbon D., Phillips I., Bradbeer C. Staphylococcal carriage and HIV infection. Lancet. 1989 Sep 2;2(8662):558–558. doi: 10.1016/s0140-6736(89)90675-2. [DOI] [PubMed] [Google Scholar]
  23. Gaut P., Wong P. K., Meyer R. D. Pyomyositis in a patient with the acquired immunodeficiency syndrome. Arch Intern Med. 1988 Jul;148(7):1608–1610. [PubMed] [Google Scholar]
  24. Gilson I. H., Barnett J. H., Conant M. A., Laskin O. L., Williams J., Jones P. G. Disseminated ecthymatous herpes varicella-zoster virus infection in patients with acquired immunodeficiency syndrome. J Am Acad Dermatol. 1989 Apr;20(4):637–642. doi: 10.1016/s0190-9622(89)70076-1. [DOI] [PubMed] [Google Scholar]
  25. Hardy W. D. Foscarnet treatment of acyclovir-resistant herpes simplex virus infection in patients with acquired immunodeficiency syndrome: preliminary results of a controlled, randomized, regimen-comparative trial. Am J Med. 1992 Feb 14;92(2A):30S–35S. doi: 10.1016/0002-9343(92)90335-9. [DOI] [PubMed] [Google Scholar]
  26. Heinic G. S., Northfelt D. W., Greenspan J. S., MacPhail L. A., Greenspan D. Concurrent oral cytomegalovirus and herpes simplex virus infection in association with HIV infection. A case report. Oral Surg Oral Med Oral Pathol. 1993 Apr;75(4):488–494. doi: 10.1016/0030-4220(93)90176-5. [DOI] [PubMed] [Google Scholar]
  27. Hirsch M. S., Schooley R. T. Resistance to antiviral drugs: the end of innocence. N Engl J Med. 1989 Feb 2;320(5):313–314. doi: 10.1056/NEJM198902023200510. [DOI] [PubMed] [Google Scholar]
  28. Horn T. D., Hood A. F. Cytomegalovirus is predictably present in perineal ulcers from immunosuppressed patients. Arch Dermatol. 1990 May;126(5):642–644. [PubMed] [Google Scholar]
  29. Jacobson M. A., Berger T. G., Fikrig S., Becherer P., Moohr J. W., Stanat S. C., Biron K. K. Acyclovir-resistant varicella zoster virus infection after chronic oral acyclovir therapy in patients with the acquired immunodeficiency syndrome (AIDS). Ann Intern Med. 1990 Feb 1;112(3):187–191. doi: 10.7326/0003-4819-112-3-187. [DOI] [PubMed] [Google Scholar]
  30. Jacobson M. A., Gellermann H., Chambers H. Staphylococcus aureus bacteremia and recurrent staphylococcal infection in patients with acquired immunodeficiency syndrome and AIDS-related complex. Am J Med. 1988 Aug;85(2):172–176. doi: 10.1016/s0002-9343(88)80337-1. [DOI] [PubMed] [Google Scholar]
  31. Jura E., Chadwick E. G., Josephs S. H., Steinberg S. P., Yogev R., Gershon A. A., Krasinski K. M., Borkowsky W. Varicella-zoster virus infections in children infected with human immunodeficiency virus. Pediatr Infect Dis J. 1989 Sep;8(9):586–590. doi: 10.1097/00006454-198909000-00003. [DOI] [PubMed] [Google Scholar]
  32. Koehler J. E., Glaser C. A., Tappero J. W. Rochalimaea henselae infection. A new zoonosis with the domestic cat as reservoir. JAMA. 1994 Feb 16;271(7):531–535. doi: 10.1001/jama.271.7.531. [DOI] [PubMed] [Google Scholar]
  33. Koehler J. E., Quinn F. D., Berger T. G., LeBoit P. E., Tappero J. W. Isolation of Rochalimaea species from cutaneous and osseous lesions of bacillary angiomatosis. N Engl J Med. 1992 Dec 3;327(23):1625–1631. doi: 10.1056/NEJM199212033272303. [DOI] [PubMed] [Google Scholar]
  34. Koehler J. E., Tappero J. W. Bacillary angiomatosis and bacillary peliosis in patients infected with human immunodeficiency virus. Clin Infect Dis. 1993 Oct;17(4):612–624. doi: 10.1093/clinids/17.4.612. [DOI] [PubMed] [Google Scholar]
  35. Kory W. P., Rico M. J., Gould E., Penneys N. S. Dermatopathologic findings in patients with acquired immunodeficiency syndrome. South Med J. 1987 Dec;80(12):1529–1532. doi: 10.1097/00007611-198712000-00011. [DOI] [PubMed] [Google Scholar]
  36. LeBoit P. E., Berger T. G., Egbert B. M., Beckstead J. H., Yen T. S., Stoler M. H. Bacillary angiomatosis. The histopathology and differential diagnosis of a pseudoneoplastic infection in patients with human immunodeficiency virus disease. Am J Surg Pathol. 1989 Nov;13(11):909–920. [PubMed] [Google Scholar]
  37. Melbye M., Grossman R. J., Goedert J. J., Eyster M. E., Biggar R. J. Risk of AIDS after herpes zoster. Lancet. 1987 Mar 28;1(8535):728–731. doi: 10.1016/s0140-6736(87)90365-5. [DOI] [PubMed] [Google Scholar]
  38. Pahwa S., Biron K., Lim W., Swenson P., Kaplan M. H., Sadick N., Pahwa R. Continuous varicella-zoster infection associated with acyclovir resistance in a child with AIDS. JAMA. 1988 Nov 18;260(19):2879–2882. [PubMed] [Google Scholar]
  39. Patterson L. E., Butler K. M., Edwards M. S. Clinical herpes zoster shortly following primary varicella in two HIV-infected children. Clin Pediatr (Phila) 1989 Aug;28(8):354–354. [PubMed] [Google Scholar]
  40. Perkins B. A., Swaminathan B., Jackson L. A., Brenner D. J., Wenger J. D., Regnery R. L., Wear D. J. Case 22-1992--pathogenesis of cat scratch disease. N Engl J Med. 1992 Nov 26;327(22):1599–1601. doi: 10.1056/NEJM199211263272215. [DOI] [PubMed] [Google Scholar]
  41. Perronne C., Lazanas M., Leport C., Simon F., Salmon D., Dallot A., Vildé J. L. Varicella in patients infected with the human immunodeficiency virus. Arch Dermatol. 1990 Aug;126(8):1033–1036. [PubMed] [Google Scholar]
  42. Picon L., Vaillant L., Duong T., Lorette G., Bacq Y., Besnier J. M., Choutet P. Cutaneous cryptococcosis resembling molluscum contagiosum: a first manifestation of AIDS. Acta Derm Venereol. 1989;69(4):365–367. [PubMed] [Google Scholar]
  43. Raphael S. A., Wolfson B. J., Parker P., Lischner H. W., Faerber E. N. Pyomyositis in a child with acquired immunodeficiency syndrome. Patient report and brief review. Am J Dis Child. 1989 Jul;143(7):779–781. doi: 10.1001/archpedi.1989.02150190029014. [DOI] [PubMed] [Google Scholar]
  44. Reed J. A., Brigati D. J., Flynn S. D., McNutt N. S., Min K. W., Welch D. F., Slater L. N. Immunocytochemical identification of Rochalimaea henselae in bacillary (epithelioid) angiomatosis, parenchymal bacillary peliosis, and persistent fever with bacteremia. Am J Surg Pathol. 1992 Jul;16(7):650–657. doi: 10.1097/00000478-199207000-00003. [DOI] [PubMed] [Google Scholar]
  45. Regnery R. L., Anderson B. E., Clarridge J. E., 3rd, Rodriguez-Barradas M. C., Jones D. C., Carr J. H. Characterization of a novel Rochalimaea species, R. henselae sp. nov., isolated from blood of a febrile, human immunodeficiency virus-positive patient. J Clin Microbiol. 1992 Feb;30(2):265–274. doi: 10.1128/jcm.30.2.265-274.1992. [DOI] [PMC free article] [PubMed] [Google Scholar]
  46. Regnery R. L., Olson J. G., Perkins B. A., Bibb W. Serological response to "Rochalimaea henselae" antigen in suspected cat-scratch disease. Lancet. 1992 Jun 13;339(8807):1443–1445. doi: 10.1016/0140-6736(92)92032-b. [DOI] [PubMed] [Google Scholar]
  47. Relman D. A., Loutit J. S., Schmidt T. M., Falkow S., Tompkins L. S. The agent of bacillary angiomatosis. An approach to the identification of uncultured pathogens. N Engl J Med. 1990 Dec 6;323(23):1573–1580. doi: 10.1056/NEJM199012063232301. [DOI] [PubMed] [Google Scholar]
  48. Rolston K. V., Uribe-Botero G., Mansell P. W. Bacterial infections in adult patients with the acquired immune deficiency syndrome (AIDS) and AIDS-related complex. Am J Med. 1987 Sep;83(3):604–605. doi: 10.1016/0002-9343(87)90789-3. [DOI] [PubMed] [Google Scholar]
  49. Safrin S., Berger T. G., Gilson I., Wolfe P. R., Wofsy C. B., Mills J., Biron K. K. Foscarnet therapy in five patients with AIDS and acyclovir-resistant varicella-zoster virus infection. Ann Intern Med. 1991 Jul 1;115(1):19–21. doi: 10.7326/0003-4819-115-1-19. [DOI] [PubMed] [Google Scholar]
  50. Safrin S., Crumpacker C., Chatis P., Davis R., Hafner R., Rush J., Kessler H. A., Landry B., Mills J. A controlled trial comparing foscarnet with vidarabine for acyclovir-resistant mucocutaneous herpes simplex in the acquired immunodeficiency syndrome. The AIDS Clinical Trials Group. N Engl J Med. 1991 Aug 22;325(8):551–555. doi: 10.1056/NEJM199108223250805. [DOI] [PubMed] [Google Scholar]
  51. Safrin S., Kemmerly S., Plotkin B., Smith T., Weissbach N., De Veranez D., Phan L. D., Cohn D. Foscarnet-resistant herpes simplex virus infection in patients with AIDS. J Infect Dis. 1994 Jan;169(1):193–196. doi: 10.1093/infdis/169.1.193. [DOI] [PubMed] [Google Scholar]
  52. Schwartz J. J., Myskowski P. L. Molluscum contagiosum in patients with human immunodeficiency virus infection. A review of twenty-seven patients. J Am Acad Dermatol. 1992 Oct;27(4):583–588. doi: 10.1016/0190-9622(92)70226-6. [DOI] [PubMed] [Google Scholar]
  53. Slater L. N., Welch D. F., Hensel D., Coody D. W. A newly recognized fastidious gram-negative pathogen as a cause of fever and bacteremia. N Engl J Med. 1990 Dec 6;323(23):1587–1593. doi: 10.1056/NEJM199012063232303. [DOI] [PubMed] [Google Scholar]
  54. Snoeck R., Andrei G., Gérard M., Silverman A., Hedderman A., Balzarini J., Sadzot-Delvaux C., Tricot G., Clumeck N., De Clercq E. Successful treatment of progressive mucocutaneous infection due to acyclovir- and foscarnet-resistant herpes simplex virus with (S)-1-(3-hydroxy-2-phosphonylmethoxypropyl)cytosine (HPMPC). Clin Infect Dis. 1994 Apr;18(4):570–578. doi: 10.1093/clinids/18.4.570. [DOI] [PubMed] [Google Scholar]
  55. Stockman L., Clark K. A., Hunt J. M., Roberts G. D. Evaluation of commercially available acridinium ester-labeled chemiluminescent DNA probes for culture identification of Blastomyces dermatitidis, Coccidioides immitis, Cryptococcus neoformans, and Histoplasma capsulatum. J Clin Microbiol. 1993 Apr;31(4):845–850. doi: 10.1128/jcm.31.4.845-850.1993. [DOI] [PMC free article] [PubMed] [Google Scholar]
  56. Stoler M. H., Bonfiglio T. A., Steigbigel R. T., Pereira M. An atypical subcutaneous infection associated with acquired immune deficiency syndrome. Am J Clin Pathol. 1983 Nov;80(5):714–718. doi: 10.1093/ajcp/80.5.714. [DOI] [PubMed] [Google Scholar]
  57. Tappero J. W., Koehler J. E., Berger T. G., Cockerell C. J., Lee T. H., Busch M. P., Stites D. P., Mohle-Boetani J., Reingold A. L., LeBoit P. E. Bacillary angiomatosis and bacillary splenitis in immunocompetent adults. Ann Intern Med. 1993 Mar 1;118(5):363–365. doi: 10.7326/0003-4819-118-5-199303010-00007. [DOI] [PubMed] [Google Scholar]
  58. Tappero J. W., Mohle-Boetani J., Koehler J. E., Swaminathan B., Berger T. G., LeBoit P. E., Smith L. L., Wenger J. D., Pinner R. W., Kemper C. A. The epidemiology of bacillary angiomatosis and bacillary peliosis. JAMA. 1993 Feb 10;269(6):770–775. [PubMed] [Google Scholar]
  59. Toth I. R., Kazal H. L. Botryomycosis in acquired immunodeficiency syndrome. Arch Pathol Lab Med. 1987 Mar;111(3):246–249. [PubMed] [Google Scholar]
  60. Zangwill K. M., Hamilton D. H., Perkins B. A., Regnery R. L., Plikaytis B. D., Hadler J. L., Cartter M. L., Wenger J. D. Cat scratch disease in Connecticut. Epidemiology, risk factors, and evaluation of a new diagnostic test. N Engl J Med. 1993 Jul 1;329(1):8–13. doi: 10.1056/NEJM199307013290102. [DOI] [PubMed] [Google Scholar]

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