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Disseminated papular lesions in an HIV infected patient

BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g6110 (Published 13 October 2014) Cite this as: BMJ 2014;349:g6110
  1. Cheng-Yin Tseng, doctor1,
  2. Shey-Chiang Su, vice president1,
  3. Nan-Chang Chiu, assistant professor2,
  4. Chien-Yu Lin, doctor1
  1. 1Department of Infectious Disease, Hsinchu Mackay Memorial Hospital, Hsinchu City, Taiwan
  2. 2Department of Infectious Disease, Mackay Memorial Hospital, Taipei City, Taiwan
  1. Correspondence to: C-Y Lin, Department of Pediatrics and Infectious Disease, Hsinchu Mackay Memorial Hospital, Hsinchu City 30071, Taiwan mmhped.lin{at}gmail.com

A 31 year old man living in northern Taiwan presented to the emergency department with fever of three days’ duration, diffuse skin lesions and nausea for the past two weeks, and weight loss of 9 kg over 10 months. His vital signs were stable except for fever. Physical examination showed hepatosplenomegaly, generalised lymphadenopathy, and diffuse nodular and molluscum contagiosum-like papular lesions mainly on his face (fig 1) and arms (fig 2), some of which were umbilicated.

Blood tests showed pancytopenia and mildly raised liver enzymes (haemoglobin 86 g/L (reference range 130-180), haematocrit 26.2% (40-54%), white blood cells 3.2×109/L (4-10), platelets 73×109/L (140-450), aspartate transaminase 70 U/L (15-41), and alanine transaminase 35 U/L (14-40). A chest radiograph was unremarkable. He was found to be infected with HIV and his CD4 cell count was 0.7×106 cells/L (428-1481). A skin biopsy was obtained and cultured. He was started on highly active antiretroviral therapy (HAART) with efavirenz 600 mg daily and Kivexa (abacavir 600 mg and lamivudine 300 mg) once a day along with antibiotics.

Questions

  • 1. What is the differential diagnosis of the skin lesions?

  • 2. What is the most likely diagnosis?

  • 3. How can we confirm the diagnosis?

  • 4. How is this condition treated?

Answers

1. What is the differential diagnosis of the skin lesions?

Short answer

The differential diagnosis of disseminated papular skin lesions in an HIV positive patient with a low CD4 count includes disseminated viral, bacterial, and fungal infections; neoplastic disorders; and drug reactions.

Long answer

The differential diagnosis of …

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