Pustular psoriasis and arthropathy in a patient with HIV infection. Clinical case

Valery V. Dubensky; Дубенский Валерий Викторович; Elizaveta G. Nekrasova; Некрасова Елизавета Георгиевна; Vladislav V. Dubensky; Дубенский Владислав Валерьевич; Olga A. Alexandrova; Александрова Ольга Александровна; Ekaterina S. Muraveva; Муравьева Екатерина Сергеевна

doi:10.17816/dv63949

Pustular psoriasis and arthropathy in a patient with HIV infection. Clinical case

作者: Dubensky V.V.¹, Nekrasova E.G.¹, Dubensky V.V.¹, Alexandrova O.A.¹, Muraveva E.S.¹
隶属关系:
1. Tver State Medical University
期: 卷 24, 编号 2 (2021)
页面: 151-160
栏目: DERMATOLOGY
##submission.dateSubmitted##: 22.03.2021
##submission.dateAccepted##: 20.05.2021
##submission.datePublished##: 15.04.2021
URL: https://rjsvd.com/1560-9588/article/view/63949
DOI: https://doi.org/10.17816/dv63949
ID: 63949

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The article presents a clinical case of pustular psoriasis and arthropathy in a patient with HIV infection. The diagnosis of psoriasis was confirmed by morphological examination. Signs of arthropathy were confirmed by X-Ray: presence of oligoarthritis of the distal interphalangeal joints of the fingers and feet was seen. Dactylitis severity ― 2–3 points, the Ritchie index ― 2, DLQI ― 28. The clinical course of psoriasis and its treatment in HIV-infected patients was considered after taking into account the data from literature and the patients current condition and observation. The above observation of a combination of several clinical forms of psoriasis (vulgar, pustular and arthropathy) in patients with HIV infection is an illustration of the features of the course and comorbidity of chronic dermatosis and AIDS, due to the influence of the infectious process, immunosuppression and ART. The development of pustular form and arthropathy creates the additional challenge of prescribing basic systemic treatment for severe and complicated psoriasis in an HIV-infected patient due to the presence of contraindications due to comorbidity. The glucocorticosteriod selected by the committee was effective on the skin and joint pathological processes, without having any negative impact on the course and treatment of the HIV infection. Such cases require further study and development of methods for the treatment of patients with comorbidity and their inclusion in an additional section in the clinical recommendations for the diagnosis and treatment of psoriasis.

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psoriasis, HIV infection, pustular psoriasis, psoriatic arthropathy, comorbidity, clinical features, immunosuppression, treatment

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The high incidence of HIV infection in the world and in Russia makes it an urgent medical and social problem of our time [1-5]. Currently, there are more than 800 thousand HIV-infected people in the Russian Federation, the monthly increase in the number of patients is 85 thousand. At the same time, 75% of patients are detected in the early stages of the disease, and 55.6% are receiving antiretroviral therapy (ART) [6]. Skin lesions in HIV infection are possible in all clinical forms of the disease, often outstripping the manifestations of the most viral and immunodeficient state, have a high diagnostic and prognostic value [5, 7-10]. In HIV-infected patients, the most common skin diseases that develop against the background of immunodeficiency: neoplastic (Kaposi's sarcoma), infectious (bacterial, viral, fungal) and other dermatoses with unexplained pathogenesis (psoriasis, seborrheic dermatitis, toxicoderma, etc.) [2, 3, 5, 7-9, 11-13]. The course of psoriasis in people with HIV infection can be mild or severe. Often in one patient, a combination of several clinical forms of psoriasis is possible, incl. pustular and erythroderma, as well as resistance to therapy [2, 3, 5, 14-18]. Psoriasis refers to dermatoses prone to comorbidity, both "systemic" (metabolic syndrome, endocrine diseases, diseases of the cardiovascular system), and with skin diseases (vitiligo, chronic lupus erythematosus, scleroderma, pemphigus vulgaris, ichthyosis, fungal skin infections, nails and mucous membranes, malignant neoplasms of the skin, etc.) [19-28]. Psoriasis usually occurs in the early stages and may be the first comorbid condition in HIV-infected patients [5, 14]. In psoriasis that arose before infection, the severity of the course may be due to the development of an immunodeficiency state and ART [2, 5, 14, 29-31]. In patients with HIV infection, psoriasis is recorded more often (up to 6%) than in the population [2, 4, 5, 14, 18]. However, there is no clear justification for what is the cause of these indicators (acquired immunosuppression, systemic treatment of viral infection with drugs based on interferons and cytokines, or a more thorough examination of patients when establishing a diagnosis) and requires further study. The mechanisms of the etiopathogenesis of psoriasis and HIV infection are paradoxical to a certain extent. Thus, there are indications that in some patients with psoriasis, an exacerbation of the disease develops, despite a decrease in the number of CD4 lymphocytes in the peripheral blood during HIV infection. Perhaps this is due to an increase in the number and hyperreactivity of CD8-lymphocytes, against the background of inhibition of CD4-lymphocytes, as well as increased activity of opportunistic (fungal, bacterial, viral) infections, incl. on the skin and mucous membranes during the development of AIDS [2, 3, 5, 7, 8, 29-36]. To illustrate the clinical features of psoriasis in a patient with HIV infection and approaches to the treatment of a comorbid state, we present a clinical observation.

Description of the case. Patient I, 44 years old, who was admitted for inpatient treatment of psoriasis to the dermatological department of the Center for Specialized Types of Medical Aid named after V.I. V.P. Avayev ”(Center named after V.P. Avayev). The main diagnosis: vulgar psoriasis, widespread with lesions of the skin and nail plates. Psoriatic arthropathy. Concomitant diagnosis: HIV infection, stage IV, with antiretroviral therapy. HIV infection was established in November 2013, for which the patient was observed at the Tver AIDS Center with a diagnosis of HIV infection, stage III (subclinical), without antiretroviral therapy. In October 2019, the patient's general condition changed: “weakness and increasing fatigue” appeared. During immunological study, the number of DM 4-cells sharply decreased to 378 cells / μl (with an age norm of 470-1298 cells / μl), the viral load was 11000 (RT-PCR method). Diagnosed with HIV infection, stage IV, and prescribed antiretroviral therapy: tenofovir, lamivudine, efavirenz. Rashes on the scalp appeared in January 2014, the patient associates their appearance with stress after the establishment of HIV infection. For several years, the patient independently and without effect took antihistamines in courses and externally used emollients. Further, the rash spread to the skin of the palms and soles, which was accompanied by significant subjective sensations - itching and pain in the area of cracks. The nail plates of the hands and feet have changed. In January 2019, she turned to a dermatologist (private clinic in Moscow), where she was diagnosed with acrodermatitis Allopo and prescribed external treatment with topical steroids and antimycotics. The treatment effect was not significant, with temporary clinical improvement. During the summer of 2019, the patient noted a deterioration in the skin process: pustular elements appeared, the skin of the palms and soles thickened, painful cracks formed, the function of flexion of the hands and feet was somewhat disturbed (due to skin tension). Infiltration, swelling and redness formed on the distal phalanges of the fingers and toes. External changes were accompanied by pain during movement. The patient turned to an appointment with a dermatologist of the polyclinic "Center. V.P. Avayeva ”and was hospitalized in the dermatological department. Dermatological status. The mucous membrane of the oral cavity is pale pink with cyanotic areas in the area of the hard palate, the inner surface of the upper and lower lips and the transitional fold. The tongue is enlarged, red in color, with a whitish coating on the back and lateral surfaces. The plaque is located in the form of islets of a whitish-gray color, it is difficult to remove. The pathological process is localized on the skin of the scalp, hands, feet and nail plates. The prevalence of the process is diffusely disseminated. The process is acutely inflammatory. On the scalp, there are bright pink plaques, flat in shape, irregular in shape, prone to peripheral growth and fusion, on the surface of the plaques, small and medium lamellar scales of a whitish color. The Kebner phenomenon and the "psoriatic triad" are positive. On the skin of the palms in the area of the tenor and hypotenor against the background of stagnant red infiltration, there are superficial non-follicular pustular elements and scaly crusts (Fig. 1, a); on the feet in the area of the arch - massive horny layers with a yellowish tinge and deep cracks; on the distal phalanges of the fingers and feet - erythematous-squamous eruptions, with pronounced infiltration of the periungual ridges (Fig. 1, b, c). The nail plates of the hands and feet are thickened due to pronounced subungual hyperkeratosis, brown-yellow, dry and crumbling from the free edge, with signs of onycholysis (Fig. 1, b, c).

Pic. 1. Patient I., 44 years old. Pustular psoriasis and arthropathy before treatment.

a-pustular psoriasis on the skin of the palms. In the area of the tenor and hypotenor – non-follicular pustules on the background of infiltration and hyperkeratosis, scaly-crusts.

b-psoriatic rashes on the distal parts of the fingers of the hands; pronounced hyperkeratosis in combination with onycholysis of the nail plates. Signs of acute dactylitis of the I, II, V fingers and" radish-like " defiguration of the I – IV fingers.

с-psoriatic rashes on the distal parts of the toes; pronounced hyperkeratosis in combination with onycholysis of the nail plates. Acute dactylitis of the I, IV, and V toes.

Results of physical, laboratory and instrumental research. The dermatological index of quality of life (DLQI) was 28. There is a high degree of peripheral arthritis: inflammation of the interphalangeal joints of the fingers with a "radish" deflection. Separate fingers of the hands (I, II, V) and feet (I, IV, V) show signs of acute dactylitis with the formation of a “sausage-like” deformity (Fig. 1b); the severity of dactylitis is 2-3 points (moderate to severe); Richie index (IR) - 2 [4.37-39]. The results of laboratory tests (09/19/19): Clinical blood test: hemoglobin 127 g / l, erythrocytes 3.92 × 1012 / l, platelets 210 × 109 / l, leukocytes 3.81 × 109 / l, neutrophils 41.9%, lymphocytes 42.3%, monocytes 9.2%, basophils 0.8%, eosinophils 5.8%. Biochemical blood test: total bilirubin 11.2 μmol / L, ALT 28.5 U / L, AST 27.4 U / L, cholesterol 4.99 μmol / L, creatinine 89 μmol / L, urea 3.27 mmol / L , glucose 6.19 μmol / l, CRP 4.1 mg / l. General urine analysis: yellow color, light turbidity, specific gravity 1014, pH 5.0, blood, ketones, glucose - not detected. HbsAg, anti-HCV were not detected. Cultural research: Candida albicans fungi were found in plaque from the mucous membrane of the tongue; when examining the nail plates of the hands and feet - Trrubrum; from the skin of the palms and soles - no growth. Sowing the contents of the pustules did not result in the growth of microorganisms. X-ray: revealed the presence of oligoarthritis of the distal interphalangeal joints of the fingers and toes with signs of periarticular osteoporosis, narrowing of the joint spaces, osteophytes and cystic enlightenment of bone tissue. Rheumatologist's conclusion: psoriatic arthropathy of fingers and toes (peripheral arthritis, acute dactylitis). A diagnostic morphological study of a piece of palm skin was carried out. Staining with hemotoxylin and eosin. Increase of 100. In the preparation, the spongioform pustule of Kagoya is determined subcorneally. Against the background of acanthosis, there are separate granulocytic neutrophilic infiltrates. The morphological picture corresponds to Barber's pustular psoriasis (Fig. 2).

Pic. 2. The same patient. Histological picture of Barber's pustular psoriasis.

The preparation subcorneally determines the spongioform pustule of Kagoi. Against the background of acanthosis, there are separate granulocytic neutrophil infiltrates. Stained with hematoxylin-eosin ×100.

Diagnosed with psoriasis vulgaris with damage to the scalp and nail plates (onychodystrophy with hyperkeratosis and onycholysis). Pustular psoriasis of the palms and soles (Barbera). Psoriatic arthritis of fingers and toes (peripheral arthritis, acute dactylitis). Concomitant diagnosis: HIV infection, stage IV (receiving ART). Candidal glossitis. Onychomycosis of the hands and feet. Treatment. Considering the comorbidity, the general condition of the patient and the results of the studies, treatment was prescribed: prednisolone tablets 30 mg per day, in 2 doses, fluconazole 150 mg once every 5 days No. 5, omeprazole tablets 20 mg per day, Panangin 1 t. 3 times a day ; outwardly: 0.05% clobetasol propianate ointment and 2% salicylic ointment (once a day). Exodus. Against the background of the treatment, subjective sensations (itching and pain) disappeared, the rash turned pale and flattened with a pronounced decrease in infiltration and swelling of the periungual ridges; “Pustular” elements involved with the formation of crusts and pigmentation. Nail plates: unclear with striation and a decrease in the phenomena of hyperkeratosis. The DLQI after treatment was 9. Infiltration decreased and the color of the skin in the interphalangeal joints faded (Fig. 3, a, b, c).

Pic. 3. The same patient after treatment.

a-rashes and infiltration on the skin of the palms resolved with residual hyperpigmentation.

b-psoriatic rashes on the skin of the hands were resolved. Onychia with hyperkeratosis and onycholysis. Mild defiguration of the fingers of the hands.

с-psoriatic rashes on the skin of the feet have resolved. Onychia with hyperkeratosis and onycholysis. Mild defiguration of the toes.

The severity of dactylitis decreased from 2-3 points to 1, peripheral arthritis - to a low degree, IR - from 2 to 0. The manifestations of candidal glossitis resolved on the 4th day from the start of antimycotic therapy. Upon reaching a pronounced clinical effect, a gradual decrease in prednisolone to 20 mg per day was started. An immunological study showed an increase in CD4 to 523 / cell. μl. (21%); viral load was <150 cells. Continues ARVT.

Discussion. The presence of comorbidity justifies the interaction of several specialists: a dermatologist, a rheumatologist, an infectious disease specialist, for the effective treatment of psoriasis and psoriatic arthropathy, without damage and deterioration of the condition caused by HIV infection. The selection of drugs is regulated by the "Clinical guidelines for the diagnosis and treatment of psoriasis" [4]. It was determined that systemic therapy for moderate forms of psoriasis, as well as for its complications - erythroderma and arthropathy, is carried out with methotrexate, retinoids, cyclosporine. At the same time, methotrexate is a "basic" drug in the treatment of psoriatic arthropathy, together with genetically engineered biological drugs (GIBP) [4]. However, the main contraindications for the appointment of methotrexate are infectious diseases (including viral and fungal), as well as immunodeficiency states. In the indications for the appointment of acitretin and cyclosporin, there is no psoriatic arthropathy, at the same time, contraindications to the use of cyclosporine are infectious, incl. viral diseases [2-4, 38, 39]. Direct contraindications to the appointment of GIBP are infections, incl. HIV. Intra-articular administration of glucocorticosteroid drugs is provided for in the treatment of psoriatic arthropathy [2-4]. In the literature [3, 4, 36-38] there are indications that psoriasis is “corticosteroid-sensitive dermatosis”. This is due to the main spectrum of action of systemic glucocorticosteroids (GCS): anti-inflammatory, antiproliferative, vasoconstrictor. This is indicated by the effect of topical steroids, which have been successfully used for many decades in psoriasis. The use of systemic corticosteroids can also be shown in the severe course of atopic dermatitis and its resistance to other methods of treatment. In this case, the main problem seems to be a possible relapse after a short course of treatment [4, 36]. The high efficacy of GCS in severe forms of psoriasis and erythroderma has been proven, in which treatment with pills in short courses is carried out (as a prevention of the onset of withdrawal syndrome). Recommendations for intra-articular administration of corticosteroids are combined with indications of the lack of data on their effectiveness when administered systemically. However, randomized clinical trials of the effectiveness of systemic and intra-articular administration of GCS have not been conducted [4]. Conclusion. The presented observation of a combination of several clinical forms of psoriasis (vulgar, pustular and arthropathy) in a patient with HIV infection is an illustration of the peculiarities of the course and comorbidity of chronic dermatosis and AIDS, caused by the influence of the infectious process, immunosuppression and ARVT. The development of pustular form and arthropathy creates an additional problem of prescribing basic systemic treatment for severe and complicated psoriasis in an HIV-infected patient, due to the presence of contraindications due to comorbidity. The selected corticosteroids were found to be effective in relation to the skin and articular processes without negatively affecting the course and therapy of HIV infection. Such situations require further study and development of methods for treating patients with comorbidity and their inclusion in the form of an additional section "Clinical guidelines for the diagnosis and treatment of psoriasis."

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