The HIV-positive skin biopsy

Abstract

Dermatological disorders are a frequent presenting feature of HIV infection and/or AIDS. More than 90% of HIV-infected patients will suffer from one or more skin diseases during the course of their illness. This trend is reflected in the increasing number of skin biopsies from HIV-positive patients in those parts of the world where HIV infection/AIDS is highly prevalent. Histopathologists are therefore required to possess a working knowledge of the broad spectrum of cutaneous manifestations of HIV infection. These include the range of dermatoses that are specific to HIV infection, the more common dermatoses occurring with greater frequency (or modified by) HIV infection/AIDS, the spectrum of infectious diseases (often opportunistic) caused by viruses, bacteria, fungi, protozoa and even arthropods, and neoplastic conditions such as Kaposi sarcoma and B-cell non-Hodgkin lymphoma. The risk for adverse skin reactions to certain drugs is also greatly increased. Although the introduction of highly active antiretroviral therapy has resulted in a dramatic decrease in opportunistic infections, several of these drugs may result in adverse reactions in the skin. Skin biopsies play a vital diagnostic role when different diseases present with clinically similar skin lesions. Biopsy material should always be examined carefully to exclude dual pathology. The diagnosis may need to be confirmed with histochemical and immunohistochemical stains, and/or molecular studies. Where indicated, additional biopsies for microbiological culture should always be recommended. The examination of multiple serial sections often proves invaluable. A diagnostic approach is given based on the predominant histological reaction pattern, with an emphasis on clinicopathological correlation.

Recognition of Dual or Multiple Pathology in Skin Biopsies from Patients with HIV/AIDS

“…This spectrum encompasses dual noninfective dermatoses, dual or multiple infections, neoplasia (KS) in association with infection, neoplasia (KS) with an associated dermatosis, mixed infective and inflammatory dermatoses, dual neoplastic conditions, and multiple pathologies. Although this latter group is uncommon, a high index of suspicion should always be maintained [1]. In most cases, the detection of more than one pathological lesion in a single biopsy is fortuitous and unexpected.…”

“…On other occasions, however, a detailed history might reveal that the patient has clinical evidence of more than one type of skin lesion. Some dermatologists may therefore elect to intentionally sample overlapping lesions in a single biopsy [1]. …”

“…It is said that more than 90% of HIV+ patients will develop cutaneous complications during the course of their illness, and in a significant proportion of these individuals, skin lesions may be a presenting symptom or sign of previously undiagnosed HIV infection [1, 2]. The spectrum of HIV-related skin disease includes a wide range of noninfective dermatoses, infective conditions, adverse drug reactions, and neoplastic proliferations [1]. It is not uncommon for this group of patients to manifest with more than one concurrent integumentary condition.…”

“…Consequently, any given skin biopsy from an individual with cutaneous lesions in the presence of underlying HIV/AIDS could potentially reveal more than one pathological process. In severely immunosuppressed patients who have not received highly active antiretroviral therapy (HAART), subtle features of a coincidental potentially lethal opportunistic pathogen (e.g., cryptococcosis) can easily be overlooked in a specimen predominated by the primary pathological lesion (e.g., Kaposi sarcoma (KS)) [1, 3, 4]. Although dual or multiple pathological processes are seldom encountered in single skin biopsies in everyday practise, it is always wise to maintain a high index of suspicion when examining specimens from HIV/AIDS patients.…”

Gangrene Associated with Human Immunodeficiency Virus (HIV)

“…There are five patterns of vasculitis described in HIV i.e. lymphocytic vasculitis(LyV), leucocytoclastic vasculitis(LCV) of small dermal vessels, neutrophilic vasculitis with vascular thrombosis and intradermal suppuration, vasculitis with palisaded neutrophilic neutrophilic and granulomatous dermatitis and large vessel vasculitis affecting subcutaneous vessels (Grayson, 2008). The last three patterns usually infer systemic involvement.…”