De Dipankar, Dogra Sunil, Narang Tarun, Radotra Bishan Dass, Kanwar Amrinder Jit
Department of Dermatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
Skinmed. 2008 Jan-Feb;7(1):47-50. doi: 10.1111/j.1540-9740.2007.07167.x.
A 45-year-old previously healthy man presented with minimally itchy spiny papular lesions of 3 years' duration and discharging nodular cystic lesions for the past 2 years. Initially, lesions appeared on his ears, followed by the gradual appearance of similar lesions over his face, back, and extremities. The lesions were not associated with photosensitivity. Over the years, the patient continued to have similar lesions without any significant response to various topical medications and oral antibiotics. There was no history of fever or any other systemic complaints and the patient denied any other significant medical problems in the past. Cutaneous examination revealed multiple, grouped, spiny papular lesions coalescing to form plaques at places over the ears, extremities, and trunk (Figure 1). Elongated, horny, follicular spires were noted on the top of the papular lesions. Multiple discharging nodular lesions with crusting were seen predominantly over the chest, abdomen, and back (Figure 2), and closed comedonal lesions were noted on the face and trunk. Multiple orange-brown scaly plaques were seen over the extensor aspect of the patient's thighs (Figure 1, inset). A few nails showed wedge-shaped thickening without subungual hyperkeratosis or other nail changes. Palms, soles, and oral mucosa were normal. Considering the atypical cutaneous findings, the clinical possibility of pityriasis rubra pilaris (human immunodeficiency virus [HIV]-associated type 6 PRP) was considered. Hematoxylin and eosin stain of skin biopsy specimens taken from the spiny papular and plaque lesions revealed marked hyperkeratosis with alternating orthokeratosis and parakeratosis with follicular keratotic plugging (Figure 3; Figure 3, inset). Irregular broad acanthosis was also detected in the epidermis. Dermis showed moderate perivascular lymphomononuclear inflammatory infiltrate. Thus, the skin biopsy was consistent with PRP. HIV serology by enzyme-linked immunosorbent assay (ELISA) with 3 different kits was found to be positive for HIV-1. The patient denied any risk factors associated with acquiring HIV infection, and laboratory values for complete blood cell count, routine serum biochemical profile, and lipid profile were normal. The patient was prescribed oral isotretinoin and asked to come for follow-up for CD4 T-cell count, but did not return.
一名45岁既往健康的男性，出现轻度瘙痒的棘状丘疹性皮损3年，过去2年有结节性囊肿性皮损并有分泌物排出。最初，皮损出现在耳部，随后面部、背部和四肢逐渐出现类似皮损。这些皮损与光敏性无关。多年来，患者持续出现类似皮损，对各种外用药物和口服抗生素均无明显反应。无发热史或其他全身不适，患者否认既往有任何其他重大疾病史。皮肤检查发现耳部、四肢和躯干多处有多个成簇的棘状丘疹性皮损，部分融合形成斑块（图1）。丘疹性皮损顶部可见细长的角质化毛囊尖。胸部、腹部和背部可见多个有结痂的有分泌物排出的结节性皮损（图2），面部和躯干可见闭合性粉刺样皮损。患者大腿伸侧可见多个橙褐色鳞屑性斑块（图1，插图）。少数指甲呈楔形增厚，无甲下角化过度或其他指甲改变。手掌、足底和口腔黏膜正常。考虑到非典型的皮肤表现，考虑了红皮病型毛发红糠疹（人类免疫缺陷病毒[HIV]相关的6型PRP）的临床可能性。取自棘状丘疹和斑块性皮损的皮肤活检标本苏木精-伊红染色显示明显的角化过度，伴有正角化和不全角化交替，并有毛囊角化性栓塞（图3；图3，插图）。表皮还检测到不规则的广泛棘层肥厚。真皮显示中度血管周围淋巴细胞单核细胞炎性浸润。因此，皮肤活检符合PRP。采用3种不同试剂盒的酶联免疫吸附测定（ELISA）检测HIV血清学，结果显示HIV-1阳性。患者否认有任何与感染HIV相关的危险因素，全血细胞计数、常规血清生化指标和血脂指标的实验室检查值均正常。患者被处方口服异维A酸，并被要求前来随访CD4 T细胞计数，但未复诊。
