Context:A frequent cause of human im munodeficiency virus(HIV)-related morbidity in sub-Saharan Africa i s a commonly occurring,intensely prur itic skin rash.The re-sulting scars ar e disfiguring and stigmatizing.Desp...Context:A frequent cause of human im munodeficiency virus(HIV)-related morbidity in sub-Saharan Africa i s a commonly occurring,intensely prur itic skin rash.The re-sulting scars ar e disfiguring and stigmatizing.Despite the substantial prevalence of pruritic p apular eruption(PPE)among HIV-infected Africans,the cause has been elusive. Objective:To determine the etiolog y of PPE occurring in HIV-infected individu als.Design,Setting,and Patients:Cross-sectional study of HIV-infec ted pat ients with active PPE from clinics in Uganda conducted from May 19through June 6,2003.Enrollment occurred in the month preceding May 19.Each partici pant was clinically examined by 2dermatologists,had laboratory stu dies perfor med,was ad-ministered an epidemiologic questionnaire,and had a skin biopsy of a new lesion evaluated by a d ermatopathologist.Main Outcome Measures:Histolo gical characteristics of new pruritic lesions.Other assessm ents included CD4c ell count,eosinophil count,and physic ian-assessed rash severity.Results:Of 109patients meeting inclusion cri-teria,102(93.6%)-completed th e study.The CD4cell counts in this study population were generally low(median ,46/μL)and inversely related to increasing rash severity(median CD4cell counts:122for mild,41for moderate,and 9for severe;P<.001for trend ).Eighty-six patients(84%;95%confidence interval,77%-91%)had biopsy findings characteristic of arthropod bites.Patients with arthropod bite s on biopsy had signifi-cantly higher peripheral eosinophi l counts(median, 330vs180/μL;P=.02)and had a trend toward lower CD4cell counts(me dian,40vs 99/μL;P=.07)than those without histological evidence of a rthropod bites.Conclu-sions:Pruritic papular eruption oc curring in HIV-infe cted individuals may be a reaction to arth ropod bites.We hy-pothesize that th is condition refle cts an altered and exag-gerated immune response to arthropod antigens in a subset of susceptible HIV-infected patien ts.展开更多
A 15-year-old,unmarried female presented to our dermatology department for an intensely pruritic skin rash that had appeared abruptly 3 days earlier. She had a remarkable medical history for a case of allergic rhiniti...A 15-year-old,unmarried female presented to our dermatology department for an intensely pruritic skin rash that had appeared abruptly 3 days earlier. She had a remarkable medical history for a case of allergic rhinitis and several attacks of asthma in her early childhood. The condition waxed and waned initially but had improved in recent years. Physical examination revealed several erythematous plaques, papules studded with scattered pustules having diameters less than 0.3 mm. Conspicuous scratch marks had caused erythematous wheal- like indurations also studded with pustules in a linear distribution across the waist, forearms (Fig. 1), and back (Fig. 2). Discrete papulopustules were present on the face, nape and neck.The patient was otherwise healthy. There were no other symptoms such as fever, malaise, weakness, or lymphadenopathy Laboratory results were normal for hepatic and renal functions, serum electrolytes, glucose, protein, erythrocyte sedimentation rate (8 mm/h), and C- reactive protein (0.355 mg/l). A human immunodeficiency virus (HIV) antibody screen test was negative. Serum was positive for herpes simplex virus (HSV)- 1 and HSV- 2 IgG (in low titers), but negative for HSV- 1 and HSV2 IgM. White blood cell count revealed leukocytosis (11.2 × .103/l), with a differential count of 68% neutrophils, 27% lymphocytes, and 8% eosinophils. Serum IgA, IgG, and IgM were within normal limits, but the IgE level was elevated (677 mg/dl). Cultures from peripheral blood and pustules were negative. A Tzank smear performed on the pustules showed no multinucleated giant cells. Fungal testing of skin scrapings from the initial lesion site gave negative results. Routine stool tests, including common pathogen and parasite screens, were negative, and urinalysis results were unremarkable. A biopsy specimen obtained from a skin pustule showed subcorneal eosinophilic and neutrophilic pustules in the follicular infundibulum with marked spongiosis of the follicular epithelium. (Fig. 3). There was a moderately dense superficial and deep perivascular mixed inflammatory cell infiltrate comprising eosinophils, neutrophils and lymphocytes. Migration of eosinophils and neutrophils through the vessel wall with variable luminal intramural fibrin deposition, histologically indicative of vasculopathy, was seen. There was concomitant slight perivascular dermal necrosis. (Fig. 4) Based on the clinical presentation and light microscopic findings on biopsy, a diagnosis of eosinophilic pustular folliculitis with pathergy was made. Systemic prednisolone 30 mg in divided doses was given. After 1 week of systemic corticosteroid therapy, the patient’ s condition was significantly improved and the patient was subsequently discharged. Two months later she had a relapse, upon which corticosteroid therapy was commenced leading to lesional resolution. The foci of eosinophilic folliculitis healed with areas of hyperpigmentation with variable scarring.展开更多
A case report of cutaneous onchocercias acquired during travels to Africa is presented. The salient epidemiologic, clinical, diagnostic, and therapeutic aspects are reviewed. Clinical and laboratory differences betwee...A case report of cutaneous onchocercias acquired during travels to Africa is presented. The salient epidemiologic, clinical, diagnostic, and therapeutic aspects are reviewed. Clinical and laboratory differences between onchocerciasis patients who are inhabitants of endemic areas and those who are occasional visitors to such areas are discussed. Parasitic infections, including onchocerciasis, should be considered in the differential diagnosis of pruritic eruptions in patients with a history of foreign travel to Africa, Central and South America.展开更多
文摘Context:A frequent cause of human im munodeficiency virus(HIV)-related morbidity in sub-Saharan Africa i s a commonly occurring,intensely prur itic skin rash.The re-sulting scars ar e disfiguring and stigmatizing.Despite the substantial prevalence of pruritic p apular eruption(PPE)among HIV-infected Africans,the cause has been elusive. Objective:To determine the etiolog y of PPE occurring in HIV-infected individu als.Design,Setting,and Patients:Cross-sectional study of HIV-infec ted pat ients with active PPE from clinics in Uganda conducted from May 19through June 6,2003.Enrollment occurred in the month preceding May 19.Each partici pant was clinically examined by 2dermatologists,had laboratory stu dies perfor med,was ad-ministered an epidemiologic questionnaire,and had a skin biopsy of a new lesion evaluated by a d ermatopathologist.Main Outcome Measures:Histolo gical characteristics of new pruritic lesions.Other assessm ents included CD4c ell count,eosinophil count,and physic ian-assessed rash severity.Results:Of 109patients meeting inclusion cri-teria,102(93.6%)-completed th e study.The CD4cell counts in this study population were generally low(median ,46/μL)and inversely related to increasing rash severity(median CD4cell counts:122for mild,41for moderate,and 9for severe;P<.001for trend ).Eighty-six patients(84%;95%confidence interval,77%-91%)had biopsy findings characteristic of arthropod bites.Patients with arthropod bite s on biopsy had signifi-cantly higher peripheral eosinophi l counts(median, 330vs180/μL;P=.02)and had a trend toward lower CD4cell counts(me dian,40vs 99/μL;P=.07)than those without histological evidence of a rthropod bites.Conclu-sions:Pruritic papular eruption oc curring in HIV-infe cted individuals may be a reaction to arth ropod bites.We hy-pothesize that th is condition refle cts an altered and exag-gerated immune response to arthropod antigens in a subset of susceptible HIV-infected patien ts.
文摘A 15-year-old,unmarried female presented to our dermatology department for an intensely pruritic skin rash that had appeared abruptly 3 days earlier. She had a remarkable medical history for a case of allergic rhinitis and several attacks of asthma in her early childhood. The condition waxed and waned initially but had improved in recent years. Physical examination revealed several erythematous plaques, papules studded with scattered pustules having diameters less than 0.3 mm. Conspicuous scratch marks had caused erythematous wheal- like indurations also studded with pustules in a linear distribution across the waist, forearms (Fig. 1), and back (Fig. 2). Discrete papulopustules were present on the face, nape and neck.The patient was otherwise healthy. There were no other symptoms such as fever, malaise, weakness, or lymphadenopathy Laboratory results were normal for hepatic and renal functions, serum electrolytes, glucose, protein, erythrocyte sedimentation rate (8 mm/h), and C- reactive protein (0.355 mg/l). A human immunodeficiency virus (HIV) antibody screen test was negative. Serum was positive for herpes simplex virus (HSV)- 1 and HSV- 2 IgG (in low titers), but negative for HSV- 1 and HSV2 IgM. White blood cell count revealed leukocytosis (11.2 × .103/l), with a differential count of 68% neutrophils, 27% lymphocytes, and 8% eosinophils. Serum IgA, IgG, and IgM were within normal limits, but the IgE level was elevated (677 mg/dl). Cultures from peripheral blood and pustules were negative. A Tzank smear performed on the pustules showed no multinucleated giant cells. Fungal testing of skin scrapings from the initial lesion site gave negative results. Routine stool tests, including common pathogen and parasite screens, were negative, and urinalysis results were unremarkable. A biopsy specimen obtained from a skin pustule showed subcorneal eosinophilic and neutrophilic pustules in the follicular infundibulum with marked spongiosis of the follicular epithelium. (Fig. 3). There was a moderately dense superficial and deep perivascular mixed inflammatory cell infiltrate comprising eosinophils, neutrophils and lymphocytes. Migration of eosinophils and neutrophils through the vessel wall with variable luminal intramural fibrin deposition, histologically indicative of vasculopathy, was seen. There was concomitant slight perivascular dermal necrosis. (Fig. 4) Based on the clinical presentation and light microscopic findings on biopsy, a diagnosis of eosinophilic pustular folliculitis with pathergy was made. Systemic prednisolone 30 mg in divided doses was given. After 1 week of systemic corticosteroid therapy, the patient’ s condition was significantly improved and the patient was subsequently discharged. Two months later she had a relapse, upon which corticosteroid therapy was commenced leading to lesional resolution. The foci of eosinophilic folliculitis healed with areas of hyperpigmentation with variable scarring.
文摘A case report of cutaneous onchocercias acquired during travels to Africa is presented. The salient epidemiologic, clinical, diagnostic, and therapeutic aspects are reviewed. Clinical and laboratory differences between onchocerciasis patients who are inhabitants of endemic areas and those who are occasional visitors to such areas are discussed. Parasitic infections, including onchocerciasis, should be considered in the differential diagnosis of pruritic eruptions in patients with a history of foreign travel to Africa, Central and South America.
