Etiology of Pruritic Papular Eruption With HIV Infection in Uganda
2004
ContextA frequent cause of human immunodeficiency virus (HIV)–related
morbidity in sub-Saharan Africa is a commonly occurring, intensely pruritic
skin rash. The resulting scars are disfiguring and stigmatizing. Despite the
substantial prevalence of pruritic papular eruption (PPE) among HIV-infected
Africans, the cause has been elusive.ObjectiveTo determine the etiology of PPE occurring in HIV-infected individuals.Design, Setting, and PatientsCross-sectional study of HIV-infected patients with active PPE from
clinics in Uganda conducted from May 19 through June 6, 2003. Enrollment occurred
in the month preceding May 19. Each participant was clinically examined by
2 dermatologists, had laboratory studies performed, was administered an epidemiologic
questionnaire, and had a skin biopsy of a new lesion evaluated by a dermatopathologist.Main Outcome MeasuresHistological characteristics of new pruritic lesions. Other assessments
included CD4 cell count, eosinophil count, and physician-assessed rash severity.ResultsOf 109 patients meeting inclusion criteria, 102 (93.6%) completed the
study. The CD4 cell counts in this study population were generally low (median,
46/μL) and inversely related to increasing rash severity (median CD4 cell
counts: 122 for mild, 41 for moderate, and 9 for severe; P<.001 for trend). Eighty-six patients (84%; 95% confidence interval,
77%-91%) had biopsy findings characteristic of arthropod bites. Patients with
arthropod bites on biopsy had significantly higher peripheral eosinophil counts
(median, 330 vs 180/μL; P = .02) and
had a trend toward lower CD4 cell counts (median, 40 vs 99/μL; P = .07) than those without histological evidence of arthropod
bites.ConclusionsPruritic papular eruption occurring in HIV-infected individuals may
be a reaction to arthropod bites. We hypothesize that this condition reflects
an altered and exaggerated immune response to arthropod antigens in a subset
of susceptible HIV-infected patients.
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