Photogallery. Fungal lesions of skin and nails infections in HIV-associated immunodeficiency

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Abstract

Against the background of any immunodeficiency, including that caused by HIV infection, the risk of developing superficial and invasive fungal diseases increases. Among people living with HIV, the most common fungal skin lesions are candidiasis, rubromycosis, and pityriasis versicolor. As immunosuppression worsens in HIV-positive patients not on antiretroviral therapy, the frequency and severity of mycoses increases. Thus, rubromycosis can spread beyond the feet, covering large areas of skin; sometimes the smooth skin of the hands, large folds, and areas of long hair growth are affected. In this case, the peripheral inflammatory ridge along the edge of the lesions, characteristic of rubromycosis, is sometimes absent.

According to some reports, over half of patients in the secondary disease stage of HIV infection suffer from onychomycosis. The progression of the disease often occurs in a short time. In addition to the nail plates of the feet, the nails on the hands are often affected. In patients with HIV infection who do not receive antiretroviral therapy, difficult-to-treat onychomycosis occurs.

Cryptococcosis is an opportunistic mycosis caused by yeast-like fungi Cryptococcus spp. It usually develops in HIV-positive individuals with a CD4+ T-lymphocyte level of less than 100 cells/μl. Skin lesions are usually secondary and indicate cryptococcal dissemination. Dermatological manifestations of cryptococcosis are varied. These may include papules and nodules surrounded by erythema and prone to ulceration, vesicular, pustular, herpetiform, acne-like rashes, ulcerative-necrotic lesions.

We present to your attention a photogallery of cases of fungal skin lesions that developed against the background of HIV-associated immunosuppression.

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About the authors

Sergey V. Prozherin

Sverdlovsk Regional Center for Prevention and Control of AIDS

Author for correspondence.
Email: rjdv@eco-vector.com
ORCID iD: 0000-0001-9956-4700
Russian Federation, Ekaterinburg

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2. Fig. 1. Patient A., 37 years old. Mycosis of the smooth skin of the trunk, buttocks, thighs (a, b), nail plates (c) and skin of the foot (d). During the cultural study, Trichophyton rubrum was isolated from all the presented loci. In this case, there is a combination of erythematous-squamous and follicular-nodular forms of smooth skin lesions, squamous-hyperkeratotic form of mycosis of the feet and hypertrophic type of onychomycosis. The spread of the process in the patient was facilitated by severe immunodeficiency (the number of CD4+ T-lymphocytes was 26 cells/μl).

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3. Fig. 2. Patient G., 48 years old. Mycosis, onychomycosis of the right hand (a), feet (b, c), caused by Tr. rubrum. The clinical picture corresponds to the so-called syndrome “Two feet ― one hand”, in which the fungus simultaneously affects both feet and one hand. In this syndrome, dermatophytes of the genus Trichophyton are most often detected.

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4. Fig. 3. Patient Z., 39 years old. Proximal subungual onychomycosis. The proximal part of the nail plates is milky-white. Proximal subungual and superficial white forms of onychomycosis usually occur in immunodeficiency states, including HIV infection. In this case, the level of CD4+ T-lymphocytes is 42 cells/μl.

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5. Fig. 4. Patient N., 30 years old. Squamous form of mycosis of the feet. Superficial white and distal-lateral clinical forms of onychomycosis. The number of CD4+ T-lymphocytes is 159 cells/μl.

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6. Fig. 5. Patient K., 43 years old. Inguinal epidermophytosis. On the skin of the inguinal-femoral-scrotal folds with the transition to the pubis and the inner surface of the thighs, there is a pink-red lesion with a raised continuous inflammatory ridge along the periphery. There is no glow in the Wood’s lamp. A culture study revealed Epidermophyton floccosum.

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7. Fig. 6. Patient S., 32 years old. Rubromycosis of the skin of the thighs. On the inner surface of the thighs there are pink-red spots merging into “scalloped” foci with a bright hyperemic raised peripheral ridge and lighter colour in the central part. A cultural study revealed Trichophyton rubrum.

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8. Fig. 7. Patient L., 31 years old. Candidiasis of the inguinal folds. Candidal vulvitis. Erythema and swelling of the vulva, perigenital area, skin of the inguinal folds, focal white plaque are noted.

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9. Fig. 8. Patient E., 40 years old. Candidal balanoposthitis. Redness of the skin of the glans penis and the inner layer of the foreskin. Cracks have formed at the transition point of the outer layer of the foreskin to the inner layer.

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10. Fig. 9. Patient S., 40 years old. Microsporia of the smooth skin of the trunk caused by Microsporum canis. On the anterior surface of the trunk there are over twenty erythematous rounded lesions with clear borders, covered with small grayish scales. The multifocal process developed with low CD4+ T-lymphocyte counts (74 cells/μl).

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11. Fig. 10. Patient K., 46 years old. Disseminated cryptococcosis with skin lesions. On the face there are rounded pink-red papules up to 1 cm in diameter with a rim of erythema. The largest lesions are ulcerated in the central part. The skin of the left wing of the nose is deep pink, infiltrated, with single milium-like efflorescences visible on the surface. In a biopsy of the lesions on the skin, clusters of cryptococci were detected during pathomorphological examination; in the blood serum, the Cryptococcus neoformans antigen was detected by latex agglutination. At the time of diagnosis, the number of CD4+ T-lymphocytes was 2 cells/μl.

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