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April 2001
Discussion
This 12 year old boy with HIV wasting and encephalopathy came to clinic with a two week history of increasing erythema, pruritis, and skin lesions on his right hand. The erythema began distally on the fourth finger and slowly spread proximally on the volar and dorsal surfaces of the hand with progressive scaling and blistering. A potassium iodide (KOH) preparation of a skin scraping showed budding yeast, most consistent with candida species.
The differential diagnosis of this cutaneous disease includes fungal diseases, especially candidiasis, herpetic whitlow, and staphylococcal or streptococcal scalded skin syndrome. Herpetic whitlow is usually localized to the distal phalynx and rarely spreads to the hand. It can effect several digits and may be associated with a history of mucocutaneous herpes, usually HSV-2. Scalded skin syndrome is a toxin-mediated, and usually fulminant, process due to disseminated Staphylococcus aureus or Streptococcus pyogenes (Group A Streptococcus). It can be ruled out clinically in this patient who has no systemic symptoms (fever, malaise, hypotension, anorexia). This patient should be considered at high risk for bacterial superinfection by these same pathogens.
Cutaneous candidiasis is not uncommon in patients with advanced AIDS. It usually occurs in skin folds and moist areas and can be very difficult to control. This patient with HIV-related encephalopathy has a history of oral candidiasis and sucking on his fingers, two factors which undoubtedly contributed to the process. Microscopic examination of a KOH preparation from skin scrapings is often diagnostic, as it was in this child. Fungal culture, if available, may also be of use for susceptibility testing if there is a prolonged history of failed treatment. The treatment of severe candidiasis requires a combination of local and systemic therapy. Topical anti-fungal therapy (nystatin) may help relieve local erythema and pruritis, but is unlikely to cure the disease. Systemic therapy with fluconazole or ketoconazole should be continued until there is near complete resolution of the local symptoms, including oral disease.
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