Clinical variations in dermatophytosis in HIV infected patients

Introduction

Dermatophyte infections are common in HIV infected patients and can occur at some point during their illness.[1],[2] It has been estimated that these infections may not occur anymore frequently in HIV patients than in control groups.[3]

The severity and variability of presentation are more common in HIV/AIDS.[4],[5],[6] Goodman et all observed that the prevalence of dermatophytosis was four times higher amongst HIV infected population and it followed a normal pattern, but atypical form or extensive in HIV infected individuals.[6]

Various studies show increasing incidence of dermatophytosis in HIV infected patients even at their early stage of infection and hence it becomes imperative for a dermatologist to have a good knowledge of cutaneous manifestations of fungal infections in those infected with HIV.[7],[8],[9] The present study was to note the prevalence and clinical variations in dermatophytosis in HIV infected patients.

Materials and Methods

It was a descriptive study in which all HIV seropositive patients (by double ELISA methods) who attended the Dermatology and STD Out Patient Department or admitted in Infectious Disease ward were screened for cutaneous fungal infections and those with dermatophytosis were recruited for this study. The study was conducted from September 1998 to June 2000 at JIPMER, Pondicherry. A detailed history including marital and sexual history was taken and the patients were subjected to a thorough physical examination, with particular reference to duration of the disease, site of involvement and morphology of the lesions. The clinical diagnosis was supplemented with laboratory procedures like microscopic examination (KOH preparation) and Gram staining.

Routine hematological, biochemical and radiological investigations were performed to rule out systemic involvement wherever felt necessary. The patients were staged according to the Center for Disease Control (CDC) classification system for HIV infection (1986).[10] The cutaneous changes were recorded and correlated with various clinical parameters. Results were tabulated and analyzed.

Results

Out of 185 patients, the diagnosis of dermatophytosis was made in 41 cases. The prevalence of dermatophytosis was 22.2%. Male to female ratio was 3:1. Fifty percent of our patients were in the age group of 21-30 years. The mean age of our patients was 30.7 years. The occupations of our patients in decreasing order of frequency were laborers (43.9%), drivers (29.3%) and rest were housewives, commercial sex workers etc. All the drivers were promiscuous.

Heterosexual route was the most common mode of acquisition of HIV infection and was observed in 33 cases, 3 had homosexual and 5 had bisexual mode. None of our patients in the study group gave the history of condom use.

Tinea corporis was the commonest dermatophyte infection [Figure - 1] and was seen in 22 (53.7%) cases, followed by tinea cruris [Figure - 2] 18 (49.9%), tinea pedis in 7 (17.1 %), tinea faciei in 6 (14.7%) and one patient had tinea manuum infection [Table - 1] Tinea unguium was recorded in 11 cases.

Out of the 22 patients with tinea corporis, 19 were in the HIV Group IV. Ten of them presented with multiple, larger sharply marginated areas of hyperkeratosis (rather than sharply marginated scaly patches with raised inflammatory edge with papules and vesicles) resembling dry scaly skin. Amongst the tinea cruris (18 cases), fourteen were in HIV Group IV and they had extensive involvement which extended beyond the groin onto the thighs, gluteal region and lower abdomen, and three patients of tinea cruris had scrotal involvement. Tinea pedis occurred in 7 cases in HIV Group IV, three of them presented with intertrigo and diffuse hyperkeratosis of the soles whereas four of them had only hyperkeratotic type of tinea pedis. Tinea faciei, which was seen in six cases, four of these cases were in HIV Group IV and one of these cases had extensive lesions over the face and scalp mimicking seborrheic dermatitis.

A total number of fifty-four dermafophytic infections were diagnosed from the skin and nail of 41 patients and most of the patients had more than one type of dermatophytosis. An average number of 1.3 dermatophyte infections per patient were observed. Among these, 44 (81.5%) dermatophyte infections were seen in the Group IV of HIV infection.

The duration of dermatophyte infections at the time of presentation was less than one month in 13 cases, between 1-2 month in 18 and more than 2 months in 10 cases. The mean duration at presentation of the dermatophyte infection was 1.5 months. Eight (22.8%) cases had extensive dermatophyte infections of the skin and nail.

A total number of 11 patients had dermatophytosis of the nails. Of which distal subungual onychomycosis (DLSO) was seen in 3 cases and proximal white subungual onychomycosis (PWSO) was seen in 3 cases, nail dystrophy in 4 cases, and only one patient had superficial white onychomycosis.

Nail dystrophy was seen in 4 patients, which was characterized by total nail destruction. Fingernails were involved in 6 cases; toenails in 4 and both finger and toenails were involved 1 of the case. Tinea pedis was associated with onychomycosis in 5 patients.

Discussion

Dermatophyte infections are common in HIV infected patients. However these skin diseases may not occur any more frequently in HIV positive patients than in comparable group.[3] Studies have been few and their results are contrary. In one survey for example, the prevalence of dermatophytosis was not significantly higher in a group of HIV infected patients (37%) than in a paired population of HIV homosexual males (32%). These investigators noted that superficial fungal infections were more common in both groups of homosexual males than in the general population.[5] In another study, however, the prevalence of dermatophytosis was four times higher amongst HIV-infected persons.[7]

Kumarasamy et al[11] in their study from south India, found 8.0 percent of HIV infected patients having dermatophytosis. Its frequency was 22.2% in the present study. Majority of our cases (70.7%) were seen in Group IV HIV infection and 29.3% were seen in the early stages of HIV, which is much higher than of Rosatelli et al[12] (17.5%) and Singh et al[3] (32.9%). This could be partially explained by the fact that our cases were selected from Infectious Disease ward where mostly Group IV patients are admitted.

Tinea corporis in the setting of HIV disease, virtually always is tinea cruris that has extended beyond the groin into the trunk.[13] Fourteen such cases were recorded in our series of 41 cases of dermatophytosis in HIV infected patients. This extensive form of tinea occurs in hot, humid climates and may be seen at all levels of immunosuppression.[13] In severely immunosuppressed patients with AIDS, lesions have little inflammation and often lack the elevated border and central clearing typical of tinea (anergic tinea). They are recognized as sharply marginated areas of hyperkeratosis resembling dry skin. We came across similar 10 cases with extensive tinea corporis. In contrast, Torssander et al[5] found dermatophytosis in 37% of HIV seropositive patients, but no patient had extensive dermatophytosis. No difference in clinical presentations in those infected with HIV as compared to general population were recorded in a study from south India.[14]

Among the patients with dermatophytosis, tinea corporis was observed in 53.7% of cases, tinea cruris in 49.9%, tinea pedis in 17.1% and tinea faciei in 14.6%. This is in contrast with that of Goodman et all and Torssander et al[5] where tinea pedis was the commonest dermatophytosis and was seen in 25% - 40% of cases. Extensive dermatophyte infections were observed in 19.9% of our cases.

Goodman et al[17] observed several cases of tinea capitis with significant hair loss but no such cases were observed in our study. Grossman et al[9] reported invasive Trichophyton rubrum infections like Majocchi′s granuloma, papules, nodules and abscesses in immunocompromised patients, but no such cases were seen in our study. Torssander et al[5] found T. rubrum being the predominant species involved in the causation of dermatophytosis in their HIV seropositive patients.

The onychomycosis caused by T rubrum. may either present independently or in association with palmoplantar hyperkeratosis but characteristically paronychium is more involved in HIV infected patients, which is usually spared in others. Onychomycosis in HIV infection commonly involves the toe nails.[2],[15] Proximal subungual onychomycosis and superficial white onychomycosis are commonly observed in HIV patients. In contrast, distal subungual onychomycosis (DLSO) was observed in 3 of our cases, proximal white subungual onychomycosis (PWSO) in 3, nail dystrophy in 4 cases, and one case had superficial white onychomycosis. These findings are in discordance with Goodman et al.[7] in which proximal subungual onychomycosis was the most common form of onychomycosis. HIV infected patients more frequently acquire proximal white subungual onychomycosis, a dermatophyte infection of the nails that is rare in individuals with intact immune system.[16] It is nearly pathognomonic of HIV infection.[6],[15],[16],[17]

Though, the presentation of dermatophytosis was very much similar to non-HIV patients, there were ten patients with finea corporis who presented with extensive, atypical, anergic form of dermatophyfosis and fourteen cases with finea cruis had extensive form of tinea.