stopped ART long back. Investigations revealed CD4 + counts 12 cells/mL, reactive Toxoplasma-IgM ELISA, haemoglobulin 8 g% and ESR 95 mm in first hour. He could not afford viral load studies. With reinstitution of triple ART and prophylaxis for opportunistic infections, he was free of all skin/scrotal lesions within a week.
DiscussionHIV-associated psoriasis usually develops in non-terminal stages of AIDS and is frequently severe, recalcitrant to therapy and has associated arthritis six times more often. 4 The clinical appearance is rather uniform with facial seborrhea, scalp, flexural and acral involvement, palmoplantar pustulosis and asymptomatic arthritis. 5 A considerable clinical overlap occurs between psoriasis, psoriatic arthropathy and Reiter's syndrome that correlates with the presence of HLA-B27, suggesting that HIV-associated psoriasis and Reiter's syndrome perhaps constitutes a continuum of similarly expressed cutaneous disease in genetically predisposed individuals manifesting with a psoriatic spectrum having Reiter's dsyndrome as its severest manifestation. 2,4 Although his past immune status was uncertain, he had similar manifestations at that time and a diagnostic/therapeutic dilemma of Reiter's syndrome for years.HIV infection shares many immunologic features with psoriasis including increased production of cytokines relevant to pathogenesis of psoriasis. 6,7 There is evidence that HIV plays a direct role in the pathogenesis of HIV-related psoriasis in genetically predisposed patients. 3,8,9 However, degree of immunosuppression and the type or severity of HIV-related psoriasis show no correlation. Paradoxically, it worsens with immunosuppression unlike classical psoriasis. Falling CD4 + cell counts (as observed in our patient) or ART resistance precipitates psoriasis relapses while clinical improvement occurs in the absence of viral replication implying that efficacy of ART in HIV-related psoriasis is attributable to improved cytokine imbalance/ immunosuppression following reduction of HIV load rather than to CD4 + cells. 3,10 Excellent response to triple ART in our patient substantiates foregoing observations. As the therapeutic effect seems only suppressive, ART irrespective of CD4 + cell counts would greatly improve survival and quality of life in these patients.
VK Mahajan, NL
References1 Buccheri L, Katchen BR, Karte AJ, Cohen SR. Acitretin therapy is effective for psoriasis associated with Human Immunodeficiency virus infection. Arch Dermatol 1997; 133: 711-715. 2 Breuer-McHam J, Marshall G, Adu-Oppong A et al. Alterations in HIV expression with psoriasis or pruritus treated with phototherapy. J Am Acad Dermatol 1999; 40: 48 -60. 3 Duvic M, Crane MM, Conant M, Mahoney SE, Reveille JD, Lehrman SN. Zidovudine improves psoriasis in human immunodeficiency virus-positive males. Arch Dermatol 1994; 130: 447-451. 4 Reveille JD, Conant MA, Duvic M. Human immunodeficiency virus-associated psoriasis, psoriatic arthritis and Reiter's syndrome: a disease continuum. Arthritis Rheum 1990; 33: 1574-157...
