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HIV-related skin diseases
THE LANCET
Letters to the Editor
Pressure-sore care and cure SIK-10 years ago my wife suffered a stroke at the age of 77, leaving her completely immobile and speechless. After months in hospital, I cared for her at home. T h e Health Services provided a ripple mattress for the bed and rubberised cushion for the chair. Within a year, pressure sores had appeared over her trochanters, ischial tuberosities, and sacrum. We were unaware of the danger of erosion of flesh beneath the skin until the sacral sore suddenly broke down leaving a huge and horrifying cavity, 12 cm across and 8 cm deep, looking like putrid meat. We called in a consultant, who in seven visits cut away necrotic tissue and cleared the slough with streptokinase (Varidase). Subsequent treatment was carried out by a nurse. The main question then was how to support my wife to relieve the pressure o n the various wounds. A former colleague in research projects for the Army who had become a leading physician discussed our dilemma with the Nursing Unit of Surrey University. I noted their use of a gauge in research o n pressure sores. Patients have differing characteristics and it seemed t o me the absence of measurement on individual patients was a major gap in procedure. The gauge is an inflatable disc with pressure sensors, and is put under pressure spots. Th e disc is inflated until the sensor pressure equals the applied pressure. It was also suggested that for the cushioning we should try soft foam 10-1 5 cm thick and cut small hollows where the pressure was too high. I purchased a gauge and soft foam. Unfortunately, the foam proved subject to permanent compression. Changing to stiffer foam caused new sores. Eventually a pliable foam which recovered shape became available, and I put 10 cm depth overlay on the bed and a 15 cm cushion o n her chair. Now all sores are cured. It seems a miracle that after 7 years the huge sacral sore has filled and healed. Now she is comfortable and motionless, 10 hours a day on the chair and 14 hours in bed. Curing the wounds has taken 3000 hours of nursing time and a cost of about UKE30 000 (US845 000). Th e national outlay for the treatment of pressure sores in hospitals is around UKE100 (US8150) million per year. Tackled effectively, the scourge of pressure sores could be reduced by the routine use of pressure gauges. Stanley Hey 4 Shortlands Close, Eastbourne. East Sussex EN22 OJE, UK
HIV-related skin diseases SIR-I was surprised by an important omission in Tschachler and colleagues’ review (Sept 7, p 659).’ They failed to comment o n mucocutaneous candidosis. For those who do not know, four patients with mucocutaneous candidosis were the first cases of AIDS that were reported to the Centers for Disease Control. Michael Gottlieb admitted these four cases to the U C I A Center for the Health Sciences to treat them with ketoconazole, a new antifungal agent. Having been the house oficer for two of these cases, I and my colleagues were struck by the extent of the skin lesions and how rapidly they responded to the antifungal agent. We were then shocked when the first case returned a few weeks later in respiratory
-
Vol348 November 30, 1996
distress and died of a Pneumocystis curinii pneumonia. Although mucosal candidal infections and candidal infections of the vulvovaginal area are more common than mucocutaneous candidosis, the latter should have at least been mentioned as a manifestation of HIV-1 infection, especially in the later stages of the illness. Jerome B Zeldis 157 Christopher Drive. Princeton, NJ 08540.USA
1
Tschachler E, Bergstresser PR, Stingl G. HIV-related skin diseases. Lancer 1996; 348: 659-63.
SIR-Seborrhoeic dermatitis and dandruff, its minor manifestation, have been shown to be caused by pityrosporum ovale’ not pityrosporum orbiculare, as Tschachler and colleagues state.’ The latter organism causes pityriasis versicolor, a totally different disorder. Sam Shuster Department of Dermatology, University of Newcastle upon Tyne, Newcastle upon Tyne NE2 4BW, UK
Shuster S.The aetiology of dandruff and mode of action of therapeutic agents. BrJDemazol 1984; 111: 2 3 5 4 2 . 2 Tschachler E, Bergstresser PR, Stingl G. HIV-related skin diseases. Lancet 1996; 348: 659-63. 1
Author’s reply SIR-I am pleased to receive the thoughtful comments of Zeldis and Shuster. The term chronic mucocutaneous candidosis to which Zeldis is probably referring, is a distinct syndrome, which, besides the presence of oral thrush, presents with chronic candidal infection of the skin and nails that is often resistant to therapy. This disorder, which may be familial as well as sporadic in nature, has been found in association with various immunological defects including, but not exclusively, those associated with cell-mediated immunity.’ We have never recorded candida infection of the skin resembling chronic mucocutaneous candidosis in adult patients with HIV disease, not even when overt immunodeficiency and oral thrush or candida oesophagitis were present. Furthermore, screening MEDLINE databases for articles on candidosis in AIDS we could not find any report describing conditions fitting the definition of chronic mucocutaneous candidosis in patients with AIDS. All the four AIDS cases reported by Gottlieb and co-workers’ in 1981 had oral thrush and one was described as having mucocutaneous candidosis.’ This patient presented with “moist superficial gluteal erosions” and “fungating lesion on the distal index fingers”. Cundidu albicuns was cultured from these lesions, but so was herpes simplex virus, and the lesions healed after therapy with both ketoconazole and acyclovir. The description of the skin lesions given in this report is certainly not sufficient for the diagnosis of chronic mucocutaneous candidosis. T h e absence of chronic mucocutaneous candidosis in HIV disease is somewhat surprising and suggests that immune defence mechanisms against candida organisms differ profoundly in skin and mucous membranes. As Shuster points out, Fityrosporum ovale and P orbiculare have been associated with seborrhoeic dermatitiddandruff
1511
THE LANCET
and pityriasis versicolor, respectively, in the past. T h e differentiation of the lipophilic yeasts was based on the cellular morphology, which has been shown to be unstable in lesions as well as in culture.’ Analysis of the G+C composition of several independent isolates and D N A reassociation studies revealed that both P ovule and P orbiculare are indeed synonymous and represent a single species-Malassezia furfur.4 Therefore, the correct designation of the agent implied in the pathogenesis of seborrhoeic dermatitis in patients with AIDS would have been M furjur at the time the review was written. In the meantime more extended typing has established a total of seven species within the genus Malassezia. Some of the strains belonging to two of these species-ie, M globosa and M sloof/iae-were isolated from seborrhoeic dermatitis in patients with AIDS.’ Erwin Tschachler, Paul R Bergstresser, Georg Sting/ Division of Immunology. Allergy and Infectious Diseases, Department of
Dermatology. University of Vienna Medical School. A 1090 Vienna, Austria Martin AG, Kobayashi GS. Yeast infections: candidiasis, pityriasis (Tinea) versicolor. In: Fitzpatrick TB, Eisen AZ, Wolff K, Freedberg IM, Austen KF, eds. Dermatology in general medicine. New York McGraw Hill, 1993: 2452-67. Gottlieb MS, Schroff R, Schanker HM, et al. heumocystis carinii pneumonia and mucosal canididiasis in previously healthy homosexual men: evidence of a new acquired cellular immunodeficiency. NEngljrMed 1981; 305: 1425-31. Randjandiche M. Le genre Pityrosporum Sabouraud 1904. Special Med Vet Faculte de Medecine Vetkinaire, University of Liege: PhD thesis, 1979. Gueho E, Meyer SA. A reevaluation of the genus Malassezia by means of genome comparison. Antonie wan Leeuwenhoek 1989; 55: 245-5 1. Gueho E, Midgley G , Guillot J. The genus Malassezia with description of four new species. Antonie wan Leeuwenhoek 1996; 69: 337-55.
Risk of HIV-1 infection after human bites SIR-The first documented seroconversion of HIV- 1 following a human bite’ raises an important concern regarding occupational transmission of HIV from patient to health care workers. T h e HIV- 1 seroconversion described suggests that for HIV-1 transmission to occur, there must be blood in the mouth of the source patient and a break in the integrity of the skin of the health-care worker. 74 hospitals in the USA participating in the Exposure Prevention Information Network (EPINet) report their employees’ occupational percutaneous injuries and exposures to blood or body fluids to researchers at the University of Virginia. A review of EPINet data from 1993 to 1995 was conducted to determine the rate of bite exposures in health-care workers and the frequency of associated risk factors that might increase occupational infection risk. There were no occupational HIV-1 seroconversions in participating hospitals, and 50170 (7 1%) hospitals reported that overall 1.7% of exposures involved an HIV-1-positive source patient. 50 of 10 125 incidents involved a health-care worker who was bitten by a patient; an annual rate of 0.12 reported bites per 100 occupied hospital beds. O n the basis of 518 400 Body part*
Frequency
Job category
Freauencv
Hand Arm
Nurse Attendant
Chest Head Leg
24 23 5 2 1
Other Physician
25 9 7 7 2
Total
55
Total
50
Therapist/counsellor/teacher
*Some health-care workers were bitten on more than one body part. Table: Characteristics of reported bites 1993-95
1512
occupied U S hospital beds, this yields an estimated annual total of 622 reported bite exposures in US hospitals. The job categories and locations of bites are shown in the table. 19 of the 50 bites (38%) involved non-intact skin or a percutaneous injury to the health-care worker. Information concerning presence of blood in the source patient’s mouth was available for 36 of the 50 cases. Of these, blood was noted in three cases of exposure to intact skin and in none of the cases in which there was a break in the integrity of the skin. In contrast to the case reported,’ of the 28 incidents in which descriptions of the bites were available, none involved an involuntary bite as might occur during a seizure. In the 28 cases, 14 source patients were combative, ten were children, three were psychiatric patients, and one involved the removal of an orthodontic appliance. These data show that occupational bites are fairly infrequent. Nevertheless, because 86% of bites were to the hand and arms of health care workers, the frequency of these exposures can be minimised by consistent glove use and arm protection when health-care workers are in close contact with paediatric, psychiatric, or combative patients. *Patti M Tereskerz, Melanie Bentley, Janine Jagger International Health Care Worker Safety Center, UnlverSity of Virginia Health Sciences Center, Charlottesville. Virginia, USA. 1 Vidmar L, Poljak M, Tornazic J, Seme K, Lavs I. Transmission of HIV-1 by human bite. Lancet 1996; 347: 1762-63.
Tuberculosis skin tests SIR-Maderazo (Sept 21, p 832)I addresses the question of tissue response to cutaneous tuberculin testing in patients with suspected Mycobactenum tuberculosis disease. We contest the clinical relevance in this setting. The ideal method of reading the test can be debated, but it is more important to define the test’s true value in diagnosis. Several workers have found tuberculin testing to be neither sensitive nor specific. Holden and colleagues‘ reported false negative rates of 48.7%, 33.9%, and 17.4% for commercial purified protein derivative (PPD), standard PPD, and stabilised PPD, respectively, among 115 simultaneously skintested proven M tuberculosis patients. This work highlights the inadaquacy of the test for diagnosing the condition and, furthermore, illustrates the variable responses to the different preparations of PPD. Subgroup analysis of these 115 cases showed that the test was less reliable in both the elderly and the sicker patients, adding credence to the previously reported occurrence of anergic states. Odelwo’ found similar shortcomings of the tuberculin test among 37 proven cases and 75 controls. In this study Mantoux responses of 9.9 mm represented a sensitivity of 86.5% and a specificity of only 28%, and there was no significant difference between the number of cases compared with controls for those showing reactions of 9 mm. By contrast, Rose and colleagues* cite more optimistic data for the tuberculin skin test. They retrospectively examined data for 643 694 naval recruits and a population of 3826 confirmed cases of tuberculosis. The results showed a range of sensitivities: from 0.59 to 1.0 depending on the cutpoint for skin response size. The specificity ranged from 0.95-1.0. Rose and colleagues suggest that the test compares favourably to other screening and diagnostic methods. The diagnosis of M tuberculosis is not easy, and involves consideration of the patient’s ethnic and social background, age, and nutritional and general health status. Traditional clinical assessments-including chest radiographs and
Vol348 November 30, 1996
Letters to the Editor
Pressure-sore care and cure SIK-10 years ago my wife suffered a stroke at the age of 77, leaving her completely immobile and speechless. After months in hospital, I cared for her at home. T h e Health Services provided a ripple mattress for the bed and rubberised cushion for the chair. Within a year, pressure sores had appeared over her trochanters, ischial tuberosities, and sacrum. We were unaware of the danger of erosion of flesh beneath the skin until the sacral sore suddenly broke down leaving a huge and horrifying cavity, 12 cm across and 8 cm deep, looking like putrid meat. We called in a consultant, who in seven visits cut away necrotic tissue and cleared the slough with streptokinase (Varidase). Subsequent treatment was carried out by a nurse. The main question then was how to support my wife to relieve the pressure o n the various wounds. A former colleague in research projects for the Army who had become a leading physician discussed our dilemma with the Nursing Unit of Surrey University. I noted their use of a gauge in research o n pressure sores. Patients have differing characteristics and it seemed t o me the absence of measurement on individual patients was a major gap in procedure. The gauge is an inflatable disc with pressure sensors, and is put under pressure spots. Th e disc is inflated until the sensor pressure equals the applied pressure. It was also suggested that for the cushioning we should try soft foam 10-1 5 cm thick and cut small hollows where the pressure was too high. I purchased a gauge and soft foam. Unfortunately, the foam proved subject to permanent compression. Changing to stiffer foam caused new sores. Eventually a pliable foam which recovered shape became available, and I put 10 cm depth overlay on the bed and a 15 cm cushion o n her chair. Now all sores are cured. It seems a miracle that after 7 years the huge sacral sore has filled and healed. Now she is comfortable and motionless, 10 hours a day on the chair and 14 hours in bed. Curing the wounds has taken 3000 hours of nursing time and a cost of about UKE30 000 (US845 000). Th e national outlay for the treatment of pressure sores in hospitals is around UKE100 (US8150) million per year. Tackled effectively, the scourge of pressure sores could be reduced by the routine use of pressure gauges. Stanley Hey 4 Shortlands Close, Eastbourne. East Sussex EN22 OJE, UK
HIV-related skin diseases SIR-I was surprised by an important omission in Tschachler and colleagues’ review (Sept 7, p 659).’ They failed to comment o n mucocutaneous candidosis. For those who do not know, four patients with mucocutaneous candidosis were the first cases of AIDS that were reported to the Centers for Disease Control. Michael Gottlieb admitted these four cases to the U C I A Center for the Health Sciences to treat them with ketoconazole, a new antifungal agent. Having been the house oficer for two of these cases, I and my colleagues were struck by the extent of the skin lesions and how rapidly they responded to the antifungal agent. We were then shocked when the first case returned a few weeks later in respiratory
-
Vol348 November 30, 1996
distress and died of a Pneumocystis curinii pneumonia. Although mucosal candidal infections and candidal infections of the vulvovaginal area are more common than mucocutaneous candidosis, the latter should have at least been mentioned as a manifestation of HIV-1 infection, especially in the later stages of the illness. Jerome B Zeldis 157 Christopher Drive. Princeton, NJ 08540.USA
1
Tschachler E, Bergstresser PR, Stingl G. HIV-related skin diseases. Lancer 1996; 348: 659-63.
SIR-Seborrhoeic dermatitis and dandruff, its minor manifestation, have been shown to be caused by pityrosporum ovale’ not pityrosporum orbiculare, as Tschachler and colleagues state.’ The latter organism causes pityriasis versicolor, a totally different disorder. Sam Shuster Department of Dermatology, University of Newcastle upon Tyne, Newcastle upon Tyne NE2 4BW, UK
Shuster S.The aetiology of dandruff and mode of action of therapeutic agents. BrJDemazol 1984; 111: 2 3 5 4 2 . 2 Tschachler E, Bergstresser PR, Stingl G. HIV-related skin diseases. Lancet 1996; 348: 659-63. 1
Author’s reply SIR-I am pleased to receive the thoughtful comments of Zeldis and Shuster. The term chronic mucocutaneous candidosis to which Zeldis is probably referring, is a distinct syndrome, which, besides the presence of oral thrush, presents with chronic candidal infection of the skin and nails that is often resistant to therapy. This disorder, which may be familial as well as sporadic in nature, has been found in association with various immunological defects including, but not exclusively, those associated with cell-mediated immunity.’ We have never recorded candida infection of the skin resembling chronic mucocutaneous candidosis in adult patients with HIV disease, not even when overt immunodeficiency and oral thrush or candida oesophagitis were present. Furthermore, screening MEDLINE databases for articles on candidosis in AIDS we could not find any report describing conditions fitting the definition of chronic mucocutaneous candidosis in patients with AIDS. All the four AIDS cases reported by Gottlieb and co-workers’ in 1981 had oral thrush and one was described as having mucocutaneous candidosis.’ This patient presented with “moist superficial gluteal erosions” and “fungating lesion on the distal index fingers”. Cundidu albicuns was cultured from these lesions, but so was herpes simplex virus, and the lesions healed after therapy with both ketoconazole and acyclovir. The description of the skin lesions given in this report is certainly not sufficient for the diagnosis of chronic mucocutaneous candidosis. T h e absence of chronic mucocutaneous candidosis in HIV disease is somewhat surprising and suggests that immune defence mechanisms against candida organisms differ profoundly in skin and mucous membranes. As Shuster points out, Fityrosporum ovale and P orbiculare have been associated with seborrhoeic dermatitiddandruff
1511
THE LANCET
and pityriasis versicolor, respectively, in the past. T h e differentiation of the lipophilic yeasts was based on the cellular morphology, which has been shown to be unstable in lesions as well as in culture.’ Analysis of the G+C composition of several independent isolates and D N A reassociation studies revealed that both P ovule and P orbiculare are indeed synonymous and represent a single species-Malassezia furfur.4 Therefore, the correct designation of the agent implied in the pathogenesis of seborrhoeic dermatitis in patients with AIDS would have been M furjur at the time the review was written. In the meantime more extended typing has established a total of seven species within the genus Malassezia. Some of the strains belonging to two of these species-ie, M globosa and M sloof/iae-were isolated from seborrhoeic dermatitis in patients with AIDS.’ Erwin Tschachler, Paul R Bergstresser, Georg Sting/ Division of Immunology. Allergy and Infectious Diseases, Department of
Dermatology. University of Vienna Medical School. A 1090 Vienna, Austria Martin AG, Kobayashi GS. Yeast infections: candidiasis, pityriasis (Tinea) versicolor. In: Fitzpatrick TB, Eisen AZ, Wolff K, Freedberg IM, Austen KF, eds. Dermatology in general medicine. New York McGraw Hill, 1993: 2452-67. Gottlieb MS, Schroff R, Schanker HM, et al. heumocystis carinii pneumonia and mucosal canididiasis in previously healthy homosexual men: evidence of a new acquired cellular immunodeficiency. NEngljrMed 1981; 305: 1425-31. Randjandiche M. Le genre Pityrosporum Sabouraud 1904. Special Med Vet Faculte de Medecine Vetkinaire, University of Liege: PhD thesis, 1979. Gueho E, Meyer SA. A reevaluation of the genus Malassezia by means of genome comparison. Antonie wan Leeuwenhoek 1989; 55: 245-5 1. Gueho E, Midgley G , Guillot J. The genus Malassezia with description of four new species. Antonie wan Leeuwenhoek 1996; 69: 337-55.
Risk of HIV-1 infection after human bites SIR-The first documented seroconversion of HIV- 1 following a human bite’ raises an important concern regarding occupational transmission of HIV from patient to health care workers. T h e HIV- 1 seroconversion described suggests that for HIV-1 transmission to occur, there must be blood in the mouth of the source patient and a break in the integrity of the skin of the health-care worker. 74 hospitals in the USA participating in the Exposure Prevention Information Network (EPINet) report their employees’ occupational percutaneous injuries and exposures to blood or body fluids to researchers at the University of Virginia. A review of EPINet data from 1993 to 1995 was conducted to determine the rate of bite exposures in health-care workers and the frequency of associated risk factors that might increase occupational infection risk. There were no occupational HIV-1 seroconversions in participating hospitals, and 50170 (7 1%) hospitals reported that overall 1.7% of exposures involved an HIV-1-positive source patient. 50 of 10 125 incidents involved a health-care worker who was bitten by a patient; an annual rate of 0.12 reported bites per 100 occupied hospital beds. O n the basis of 518 400 Body part*
Frequency
Job category
Freauencv
Hand Arm
Nurse Attendant
Chest Head Leg
24 23 5 2 1
Other Physician
25 9 7 7 2
Total
55
Total
50
Therapist/counsellor/teacher
*Some health-care workers were bitten on more than one body part. Table: Characteristics of reported bites 1993-95
1512
occupied U S hospital beds, this yields an estimated annual total of 622 reported bite exposures in US hospitals. The job categories and locations of bites are shown in the table. 19 of the 50 bites (38%) involved non-intact skin or a percutaneous injury to the health-care worker. Information concerning presence of blood in the source patient’s mouth was available for 36 of the 50 cases. Of these, blood was noted in three cases of exposure to intact skin and in none of the cases in which there was a break in the integrity of the skin. In contrast to the case reported,’ of the 28 incidents in which descriptions of the bites were available, none involved an involuntary bite as might occur during a seizure. In the 28 cases, 14 source patients were combative, ten were children, three were psychiatric patients, and one involved the removal of an orthodontic appliance. These data show that occupational bites are fairly infrequent. Nevertheless, because 86% of bites were to the hand and arms of health care workers, the frequency of these exposures can be minimised by consistent glove use and arm protection when health-care workers are in close contact with paediatric, psychiatric, or combative patients. *Patti M Tereskerz, Melanie Bentley, Janine Jagger International Health Care Worker Safety Center, UnlverSity of Virginia Health Sciences Center, Charlottesville. Virginia, USA. 1 Vidmar L, Poljak M, Tornazic J, Seme K, Lavs I. Transmission of HIV-1 by human bite. Lancet 1996; 347: 1762-63.
Tuberculosis skin tests SIR-Maderazo (Sept 21, p 832)I addresses the question of tissue response to cutaneous tuberculin testing in patients with suspected Mycobactenum tuberculosis disease. We contest the clinical relevance in this setting. The ideal method of reading the test can be debated, but it is more important to define the test’s true value in diagnosis. Several workers have found tuberculin testing to be neither sensitive nor specific. Holden and colleagues‘ reported false negative rates of 48.7%, 33.9%, and 17.4% for commercial purified protein derivative (PPD), standard PPD, and stabilised PPD, respectively, among 115 simultaneously skintested proven M tuberculosis patients. This work highlights the inadaquacy of the test for diagnosing the condition and, furthermore, illustrates the variable responses to the different preparations of PPD. Subgroup analysis of these 115 cases showed that the test was less reliable in both the elderly and the sicker patients, adding credence to the previously reported occurrence of anergic states. Odelwo’ found similar shortcomings of the tuberculin test among 37 proven cases and 75 controls. In this study Mantoux responses of 9.9 mm represented a sensitivity of 86.5% and a specificity of only 28%, and there was no significant difference between the number of cases compared with controls for those showing reactions of 9 mm. By contrast, Rose and colleagues* cite more optimistic data for the tuberculin skin test. They retrospectively examined data for 643 694 naval recruits and a population of 3826 confirmed cases of tuberculosis. The results showed a range of sensitivities: from 0.59 to 1.0 depending on the cutpoint for skin response size. The specificity ranged from 0.95-1.0. Rose and colleagues suggest that the test compares favourably to other screening and diagnostic methods. The diagnosis of M tuberculosis is not easy, and involves consideration of the patient’s ethnic and social background, age, and nutritional and general health status. Traditional clinical assessments-including chest radiographs and
Vol348 November 30, 1996