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Pityriasis rubra pilaris: an unusual cutaneous complication of AIDS
R A Bonomo1, N Korman, L Nagashima-Whalen
1Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA. rab14@po.cwru.edu
Abstract:
Pityriasis rubra pilaris is an uncommon hyperkeratotic, papulosquamous disorder that has been reported in patients infected by HIV. We recount a case of pityriasis rubra pilaris in an HIV-seropositive man. A 36-year-old man with a history of ulcerative colitis and recurrent otitis externa had diffuse psoriaform erythroderma. He was treated initially with methotrexate and isoretinoin without clinical improvement. Skin examination showed large, erythematous, orange, scaly patches on the upper extremities and thickening of the nail beds. The palms and soles were hyperkeratotic. Skin biopsy revealed changes that were consistent with pityriasis rubra pilaris. Six months before the onset of symptoms, results of an enzyme-linked immunosorbent assay (ELISA) and Western Blot assay for HIV were negative. Six months after symptoms, results of repeat enzyme-linked immunosorbent assay and Western blots for HIV were positive (CD4+ T-cell count = 200 cells/ mm3). Clinical course had been complicated by episodes of Staphylococcus aureus bacteremia, mucocutaneous candidiasis, and development of localized squamous cell carcinoma of the skin. The increased severity of pityriasis rubra pilaris should prompt clinicians to consider coinfection with HIV in patients who have disease that is refractory to treatment. Clinicians also should remain vigilant for the development of squamous cell carcinoma.
Insights
Pityriasis rubra pilaris (PRP) can manifest in individuals with Human Immunodeficiency Virus (HIV). This case highlights PRP progression in an HIV-positive patient, emphasizing the need for HIV testing in refractory cases.
Area of Science:
- Dermatology
- Immunology
- Infectious Diseases
Background:
- Pityriasis rubra pilaris (PRP) is a rare hyperkeratotic disorder.
- PRP has been documented in patients with Human Immunodeficiency Virus (HIV) infection.
Observation:
- A 36-year-old male with ulcerative colitis and otitis externa presented with diffuse psoriaform erythroderma.
- Skin biopsy confirmed PRP; however, HIV testing was initially negative, becoming positive six months later (CD4+ T-cell count = 200 cells/mm³).
- The patient experienced Staphylococcus aureus bacteremia, mucocutaneous candidiasis, and squamous cell carcinoma.
Findings:
- The patient's PRP was refractory to methotrexate and isoretinoin.
- The clinical course was complicated by opportunistic infections and skin cancer.
- Delayed HIV diagnosis complicated the management of PRP.
Implications:
- Clinicians should consider HIV coinfection in patients with severe or treatment-refractory PRP.
- Vigilance for squamous cell carcinoma is crucial in HIV-positive individuals with dermatological conditions.
- Early HIV diagnosis and management are essential for patients presenting with atypical dermatoses.