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Prevalence of Dermatological Disorders in Hiv/Aids Patients and Correlation with Immunosuppression in Lagos, Nigeria

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Prevalence of Dermatological Disorders in Hiv/Aids Patients and Correlation with Immunosuppression in Lagos, Nigeria PREVALENCE OF DERMATOLOGICAL DISORDERS IN HIV/AIDS PATIENTS AND CORRELATION WITH IMMUNOSUPPRESSION IN LAGOS, NIGERIA BY NYOMUDIM EFFIONG ESSEN, MBBS (NIGERIA) A DISSERTATION SUBMITTED TO THE NATIONAL POSTGRADUATE MEDICAL COLLEGE OF NIGERIA IN PART FULFILMENT OF THE REQUIREMENTS FOR THE FELLOWSHIP OF THE COLLEGE IN INTERNAL MEDICINE (DERMATOLOGY/VENEREOLOGY) NOVEMBER, 2006. i DECLARATION It is hereby declared that this work is original unless otherwise acknowledged. The work has neither been presented to any other college for a fellowship nor submitted elsewhere for publication. …………………… DR N. E. ESSEN July 2006 ii CERTIFICATION The study reported in this dissertation was done by Dr Nyomudim Effiong Essen under our supervision. We have also supervised the writing of the dissertation to our satisfaction. Signature……………………………….. Prof Y M Olumide, MBBS (Ibadan), Dip Dermatol (Lond) FMCP, FWACP, MD (Ibadan), FAAD, FAS Consultant Physician/Dermatologist and Professor of Medicine, College of Medicine, University of Lagos, Lagos. Signature……………………………….. Dr G C Okudo MBBS, FMCP, FAAD Consultant Physician/Dermatologist, Police Medical Services, Lagos, and Associate Lecturer, College of Medicine, University of Lagos, Lagos. Signature……………………………….. Dr A S Akanmu, MBBS, FMCPath Consultant Haematologist and Senior Lecturer, Department of Pathology College of Medicine, University of Lagos, Lagos. iii HEAD OF DEPARTMENT’S CERTIFICATION I certify that this work was done by Dr N E Essen under the supervision of Prof. Y. M. Olumide Dr. G. C. Okudo and Dr. A. S. Akanmu Signature………………………………… Prof. M. A. Danesi, MBBS, MRCPI, FMCP, FWACP Head Department of Medicine Lagos University Teaching Hospital (LUTH) Lagos. iv TABLE OF CONTENTS Pages Title i Declaration ii Certification iii Table of Contents v Dedication vi Acknowledgement vii List of Abbreviations x List of Tables xi List of Figures xiii Summary xiv Chapter One: Introduction 1 Chapter Two: Literature Review 3 Chapter Three: Aims and Objectives 28 Chapter Four: Materials and Methods 29 Chapter Five: Results 39 Chapter Six: Discussion 81 Chapter Seven: Conclusion and Recommendations 98 References 100 Appendices 114 v DEDICATION To The memory of Hallel …………… a daughter who brought joy to me Effiong ……………. a dear father with vision, who strove to ensure I am what I am today Bassey ……………. a father-in-law who influenced my life. vi ACKNOWLEDGEMENT This study would not have been possible without the help of God who opened doors and granted me favour and speed. To Him I am eternally grateful. With all my love, I deeply appreciate my darling, Udy, and my wonderful daughters, Lala and Cutie, for their understanding and support. They sacrificed their comfort for this project to be accomplished. I am especially thankful to Professor Olumide, my supervisor and ‘Mama’ for being a true mother. She not only made provision for my stay in Lagos to be comfortable, but urged me on when I was wont to relax, provided unfettered access to her books and journals (both hard copies and electronic) and took special interest in making the home front restful for me to be focused. The God that is uncommon will give you an uncommon blessing. I am indeed indebted to my other supervisors. Dr. Okudo gave invaluable advice and was instrumental to getting approval for recruitment of patients from Nigeria Institute of Medical Research (NIMR), Lagos. Dr. Akanmu was always there, even late at night, to provide valuable suggestions. He also helped in assaying the CD4 count for some of the control population free of charge. I also appreciate my colleagues in the Dermatology unit; some of them have become consultants. They include Tahiru, Chinwe, Ngozi, Shola, Bolaji, Violet and Anaba. Anaba actually laid the foundation for this project before leaving for Europe. vii I thank the staff of NIMR, especially the Director-General, Dr Idigbe, for allowing this study, and Drs Ezechi, Akinbami, Njemanze, Somefun, Iloka and Gbajabiamila for their help with this study. I also thank Dr (Mrs) Banjo of Pathology department, LUTH, for help with histo- pathological analysis, and Messrs Linus, Ilori and Phillip of the Laboratory Department for their help with laboratory analysis of the samples. I thank the Head of Department of Medicine, LUTH, Prof Danesi, for the interest in this project, the Chairman MAC, Dr Oke, and other consultants for their help. Dr Okubadejo provided valuable suggestions and proof-read the book. I also thank Prof Ekanem of Department of Community Health, Unilag, for assistance with data analysis. I am grateful to the Head of Department of Internal Medicine, JUTH, Dr Ukoli, for her understanding and support, and to the management of JUTH for making my coming to Lagos possible. I also thank Prof Okehialam and Dr Agaba for proof- reading this work. I indeed bless God for my beloved mother, Arit, and my mother-in-law, Eno, for their understanding and support. My siblings have been wonderful: Mfon with his wife Ima, ID, Big, Ima, Ifure and Kuyik. I cannot forget my in-laws Etuk, Bassey, Gideon, Oborrt, Marie and Vicky for their prayers and support. I also thank God for positioning men like Bishop Oyedepo, Pastors Adeyinka, Agape and Haruna, Bro Joshua and Onuoha who have been of spiritual help to me. The Lord will multiply them and keep confirming the words of their mouths. viii To all other persons, who contributed in one way or the other, including all the doctors and nurses, medical students and other LUTH Staff, and the HIV/AIDS patients of LUTH and NIMR who were part of the study population, I am grateful. The good Lord shall bless you beyond measure. ix LIST OF ABBREVIATIONS ADC - AIDS dementia complex ARVs - Anti-retroviral drugs CDC - Centre for Disease Control and Prevention, Atlanta, USA CMV - Cytomegalovirus DM - Diabetes mellitus Eth - Ethambutol EV - Epidermodysplasia verruciformis FDE - Fixed drug eruption GUD - Genital ulcer disease HAART - Highly active anti-retroviral therapy IFN - Interferon IL - Interleukin IVDU - Intravenous drug use JUTH - Jos University Teaching Hospital KOH - Potassium hydroxide KS - Kaposi’s sarcoma LUTH - Lagos University Teaching Hospital MSM - Men having sex with men NIMR - Nigeria Institute of Medical Research PCP - Pneumocystis carinii pneumonia (now P. jiroveci) PPE - Pruritic papular eruption PZA - Pyrazinamide Rif - Rifampicin SD - Standard deviation SJS - Steven-Johnson’s syndrome STIs - Sexually transmitted infections TB - Tuberculosis TGF - Transforming growth factor TEN - Toxic epidermal necrolysis VDS - Vaginal discharge syndrome WB - Western blot x LIST OF TABLES Page Table 1: Age and Sex distribution of patients and controls…………… 40 Table 2: Educational status of patients and controls………………….. 43 Table 3: Social classes of patients and controls……………………….. 45 Table 4: Income brackets of the patients and controls………………… 46 Table 5: Marital status of the patients and controls…………………….. 48 Table 6: HIV risk factors in patients and controls………………………. 50 Table 7a: More frequent skin disorders in HIV/AIDS patients compared with controls.......................................................... 55 Table 7b: Less frequent skin disorders in HIV/AIDS patients compared with controls…………………………………………. 56 Table 8: Prevalence of skin diseases in different CDC stages of HIV/AIDS: ………………………………..…… 58 Table 9: Skin disease correlated with co-morbid illness in HIV/AIDS patients……………………………………..…… 59 Table 10: Skin disease in relation to educational levels in HIV/AIDS patients and controls………………………………60 Table 11: Skin disease in relation to income levels in HIV/AIDS patients and controls………………………………….61 Table 12: Skin disease frequency compared with CD4 counts levels…..65 Table 13: Pattern of skin disease in HIV/AIDS patients with CD4 counts <200 cells/µl……………………………………… 67 Table 14: Mean CD4 counts and viral loads in some dermatological disorders in HIV/AIDS patients……….………. 69 xi Table 15: Mean CD4 counts and viral loads in relation to the presence or absence of specific skin diseases………….…… 71 Table 16: Mean CD4 counts and viral loads in skin disease categories in HIV/AIDS patients……………………………… 73 xii LIST OF FIGURES Page Figure 1: Sex distribution of the patients and controls…………………. 41 Figure 2: Educational levels of patients and controls…………………. 44 Figure 3: Income levels of HIV/AIDS patients and controls…………… 47 Figure 4: Number of past sexual partners in HIV/AIDS patients and controls……………………………………………. 51 Figure 5: Symptoms of skin disease in HIV/AIDS patients and controls……………………………………………………… 53 Figure 6: CD4 levels in HIV/AIDS patients based on CDC Classification……………………………………………………. 63 Figure 7: Prevalence of skin diseases at each level of CD4 count (CDC categories)……………………………………. 66 Figure 8: Skin disorders with frequency of ≥3 in HIV patients with AIDS-defining CD4 counts (<200cells/µl)……………… 68 Figure 9: Clinical photograph of multi-dermatomal herpes zoster in an HIV/AIDS patient…………………………………. 74 Figure 10: Clinical photograph of ano-genital warts in an HIV/AIDS patient…………………………………………………. 75 Figure 11: Clinical photograph of another HIV/AIDS patient with ano-genital warts…………………….…………………… 76 Figure 12: Clinical photograph of pruritic papular eruption of HIV/AIDS……………………………………………………… 77 Figure 13: Clinical photograph of sub-cutaneous nodules in an HIV/AIDS patient with granuloma annulare…………….… 78 Figure 14: Clinical photograph of same patient with sub-cutaneous nodules on the legs…………………………… 78 Figure 15: Clinical photograph of an HIV/AIDS patient with tinea cruris and post-bleaching
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