Erythema elevatum diutinum as a first clinical manifestation for diagnosing HIV infection: case history

ABSTRACT CONTEXT: Erythema elevatum diutinum is a chronic and rare dermatosis that is considered to be a variant of leukocytoclastic vasculitis. It is probably mediated by immune complexes. It is generally associated with autoimmune, neoplastic and infectious processes. Recently, it has been added to the group of specific dermatoses that are associated with HIV. CASE REPORT: We report on the case of a patient who had erythema elevatum diutinumas the first clinical evidence for diagnosing HIV infection. Dapsone was used in the treatment of this patient, and partial regression of the lesions was achieved within 15 days, even before antiretroviral therapy was prescribed. CONCLUSION: When there is a diagnosis of erythema elevatum diutinum, HIV infection should be investigated, especially in atypical and exacerbated clinical manifestations.


Erythema elevatum diutinum as a first clinical manifestation for diagnosing HIV infection: case history
Dermatology Department, Hospital Universitário Celso Pierro (HMCP), Pontifícia Universidade Católica de Campinas (PUC-Campinas), Campinas, São Paulo, Brazil CONTEXT: Erythema elevatum diutinum is a chronic and rare dermatosis that is considered to be a variant of leukocytoclastic vasculitis.It is probably mediated by immune complexes.It is generally associated with autoimmune, neoplastic and infectious processes.Recently, it has been added to the group of specific dermatoses that are associated with HIV.

CASE REPORT:
We report on the case of a patient who had erythema elevatum diutinum as the first clinical evidence for diagnosing HIV infection.Dapsone was used in the treatment of this patient, and partial regression of the lesions was achieved within 15 days, even before antiretroviral therapy was prescribed.

CONCLUSION:
When there is a diagnosis of erythema elevatum diutinum, HIV infection should be investigated, especially in atypical and exacerbated clinical manifestations.electrophoresis presented no abnormalities.The blood test was negative for hepatitis B and C, and positive for HIV.
The histopathological examination revealed blood vessels with rather thickened walls that were dissociated by fibrin, with neutrophils that were often fragmented, i.e. necrotizing leukocytoclastic vasculitis (Figure 2).
Dapsone at a dose of 100 mg/day was prescribed.Fifteen days later, partial regression of the lesions was achieved, without any antiretroviral therapy yet prescribed.One month after diagnosing HIV infection, the patient presented a neurological  Neurotoxoplasmosis of the central nervous system was diagnosed by means of computed tomography of the head, and the patient was hospitalized for 15 days for treatment.On this occasion, antiretroviral therapy was begun.The patient was no longer using dapsone and dermatological examination showed only residual lesions.Today, one-and-a-half years after the HIVpositive blood test and the beginning of antiretroviral therapy, the patient has not had any recurrence of the skin lesions.

DISCUSSION
There is still controversy about the etiology of EED.Nevertheless, the most widely accepted theory is that previous and repeated exposure to bacterial infections, particularly streptococcal ones, may trigger an immunological reaction that culminates in an outbreak of skin lesions. 9,10It is believed that the immune complex is deposited in vessel walls and subsequently phagocytized by the neutrophils. 13][24][25] Among young males, exacerbated clinical states with nodular lesions seem to be correlated with HIV infection, in contrast with the clinical picture observed for the general population. 24,25he EED skin lesions of this patient allowed the detection of HIV infection through laboratory investigation.There was no history of streptococcal infection, hematological disorders or autoimmune disease.Reports of an association between EED and HIV have only sporadically been published.Over the last few years, eleven EED cases have been described in patients who already knew they were HIV-positive.It is believed that such an association results from the HIV antigen-antibody interaction, which causes direct damage to vessel walls.It is also supposed that the immunosuppression caused by HIV predisposes towards infection by other agents that trigger an antigenic stimulus for the development of EED. 8 Consequently, even though the association of EED with HIV infection is infrequent, laboratory investigation for this virus should be requested in conventional cases, and especially in cases of atypical and exacerbated clinical manifestations.In addition, antiretroviral therapy should be introduced in these cases, in association with dapsone, which is the drug of choice for the treatment of EED. 25,26 KEY WORDS: Skin diseases.HIV.Vasculitis.Streptococcal infections.Dapsone.

Figure 1 .
Figure 1.Violet-colored confluent erythematous papules on the feet and ankles of a man with HIV infection.

Figure. 2 .
Figure. 2. Dense infiltrate of neutrophils with fibrin deposition and nuclear fragments within superficial and deep blood vessel walls (hematoxylin and eosin; original magnification 400 X; inset 25 X), in a case of erythema elevatum diutinum in a man with HIV infection.