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Nabiyeva D.D., Abdullaev M.I., Rakhmankulova S.A.
Objective of the study.
To develop approaches
to the management of HIV-associated dermatoses in
children depending on the clinical stage of HIV and to
evaluate their effectiveness.
Materials and methods of the study.
46
patients with HIV-associated dermatoses, including 25
males (54.3%) and 21 females (45.7%) aged from 4 to
18 years were under our observation. Non-specific
markers of inflammatory process - C-reactive protein,
seromucoid; indicators of lipid metabolism, indicators
of immune status were determined in the study.
Results.
The positive influence of inclusion of
metabolic agents and detoxification therapy in the
complex treatment of all patients, depending on the
stage of infection and prescription of standard ARV
therapy was revealed. It was noted that in the persons
receiving ARV therapy in two compared groups,
regardless of the type of dermatosis, the treatment
results were better than in the persons receiving only
dermatologic therapy.
Relevance.
Preventing the spread of HIV
infection occupies a special place among public health
problems due to the global growth of HIV infection,
significant socioeconomic consequences of the
epidemic, lack of means of reliable specific prophylaxis
and significant costs of treatment [1, 4]. In the modern
world, ongoing global processes are strongly increasing
the spread of HIV [3, 10, 11].
In Uzbekistan, the current situation on HIV
infection/AIDS cannot be analyzed separately from the
situation in the whole world. According to official
statistics, 28,250 persons with HIV infection are
registered in the Republic of Uzbekistan (as of
01.01.2014). The share of parenteral transmission was
40.6%, sexual transmission 41.8%, and vertical
transmission 3.4%. In recent years, there has been an
annual increase in the number of cases of infection
through unprotected sexual contacts and the spread of
HIV from HIV-infected mother to child (National
Report on the implementation of the Declaration of
Commitment on HIV/AIDS of the UN Special Session
of the Republic of Uzbekistan). This shows that the
HIV/AIDS epidemic in Uzbekistan is beginning to
affect not only high-risk groups, but also other segments
of the population.
According to the World Health Organization
recommendations, before starting antiretroviral (ARV)
therapy, treatment of patients with clinical
manifestations of HIV infection should begin with the
treatment of existing opportunistic infections [2, 3]. The
prerequisite for the development of skin lesions is the
violation of its protective and barrier properties in HIV-
positive individuals for the development of pathogenic
and/or opportunistic flora, layering and aggravating the
course of dermatoses against the background of
immunodeficiency. [4,6,7,8] Early detection and timely
therapy of HIV-associated dermatoses in children
allows the immune system to function effectively
enough for a longer period of time and increase the
effectiveness of antiretroviral therapy, thus preserving
the quality of life of patients at a high level. However,
there are no unified standards for the treatment of
infectious and non-infectious dermatoses in HIV-
positive children and no criteria for prescribing ARV
therapy taking into account the existing dermatoses,
there are no algorithms for the management of persons
with dermatoses against the background of different
clinical stages of HIV infection. [2, 5, 9]
The aim of the study is to develop approaches
to the management of HIV-associated dermatoses in
children depending on the clinical stage of HIV and to
evaluate their effectiveness.
Materials and methods of the study
There were 46 patients with HIV-associated
dermatoses under our observation, including 25 males
(54.3%) and 21 females (45.7%) aged from 4 to 18
years. HIV status and confirmation of the clinical stage
of HIV infection were performed by specialists from the
Tashkent Oblast AIDS Center in accordance with the
clinical classification of the stages of HIV infection in
children and adults.
The study included determination of bilirubin
and its fractions; alanine aminotransferase; aspartate
aminotransferase; creatinine; urea; total protein and
albumin; and blood glucose, which were performed in
accordance with generally accepted methods.
On indications we determined: non-specific
markers of inflammatory process - C-reactive protein,
seromucoid; lipid metabolism indicators, total
APPROACHES TO THE MANAGEMENT OF HIV-ASSOCIATED DERMATOSES AT DIFFERENT
CLINICAL STAGES OF HIV INFECTION
Tashkent Pediatric Medical Institute
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ПЕДИАТРИЯ
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cholesterol, triglycerides, high, low and very low
density lipoproteins.
Mycological studies with microscopic and
culture diagnostics were performed in skin scales,
mucous membrane scrapings, from under the nail plates.
If indicated, a study for scabies mite, germ mite, yeast
was carried out. Ultrasound examination of abdominal
cavity and pelvic organs, thyroid gland, lymph nodes
was performed, if indicated. If necessary, they consulted
a therapist, neurologist, endocrinologist, gynecologist
and others. Serologic status in HIV infection, in
accordance with generally accepted recommendations,
was performed by enzyme-linked immunosorbent assay
(ELISA) tests using domestic test systems. Positive
result of serologic test in ELISA was confirmed by
immunoblot test. To establish the degree of
immunodeficiency, the absolute and relative number of
CD4 and CD8 lymphocytes in peripheral blood, the
ratio of CD4/CD8 lymphocytes were determined
according to the generally accepted methods. Statistical
processing of the material was performed with the help
of a personal computer IBN PC/AT using the licensed
package Statistica 6.
Results
According to the results of the data obtained
from the examined patients with HIV-associated
dermatoses, it was noted that 73% of patients had two
or more types of dermatoses. Among all skin lesions
infectious dermatoses prevailed - in 94 % of patients;
among infectious dermatoses mycotic dermatoses
prevailed - in 90 % of patients, in 63 % of patients,
dermatoses of viral etiology were revealed: herpes
simplex - in 10,3 % of patients; - common warts - in
43,2 %; - molluscum contagiosum - in 8 %; - papillomas
- in 10,7 %. Pyodermas were detected in 18.1 % of
patients, including: - vulgar impetigo - in 6.3 %; -
furunculosis - in 2.6 %; - ecthyma - in 3.7 Seborrheic
dermatitis was detected in 79% of patients. It was found
that 89% of patients had combined infectious skin
lesions, a variety of clinical forms in one and the same
patient, lesions of several topographic regions: - lesions
of two or more topographic regions in mycotic and viral
infections were observed in 94% of patients, regardless
of the clinical stage of HIV and the level of
immunologic changes; - combination of two and more
clinical varieties of mycotic and viral pathology was
detected in 88% of patients, somewhat more often - at
the 2nd and 3rd clinical stage; - mycoses were
accompanied by the development of mycotic eczema -
in 28% of patients, mainly at the 1-2 clinical stage, with
a decrease in CD4 content below 350 cells /1 ml of
blood; - combination of herpes simplex vesicular
(genital and labial) with oral mucosa candidiasis - in
83% of patients, mainly at the 2nd clinical stage, with
CD4 level decreasing to 200 cells/1 ml of blood.
Allergic and toxic-allergic dermatoses (chronic eczema,
urticaria, erythema multiforme, etc.) prevailed among
non-infectious dermatoses - in 60% of patients;
-
lichenoid dermatoses (psoriasis, red squamous
lichen) - in 34%. Kaposi's sarcoma was not diagnosed
in the observed children. When analyzing the clinical
features of non-infectious dermatoses, the prevalence of
lesions drew attention: in 68% of patients, the area of
psoriatic and/or allergic lesions exceeded 20% of the
div area. At the 2
nd
clinical stage there was a frequent
accession of infectious component to the course of
dermatosis and with decreased CD4 level. Frequent
recurrence of the process (eczema, psoriasis, etc.) and a
wide range of concomitant somatic pathology, among
which digestive disorders (hepatitis, intestinal
dysbacteriosis,
colitis,
gastroduodenitis)
were
predominant. Allergic dermatoses and toxiderma
occurred in 15.1% of patients on ARV therapy.
Correlation analysis of clinical features of HIV-
associated dermatoses, immunologic changes and
biochemical parameters revealed a significantly
pronounced dependence of clinical manifestations of
dermatosis on the clinical stage of HIV infection, the
degree of severity of metabolic and immunologic
disorders. The revealed changes served as a justification
for the inclusion of metabolic agents and detoxification
therapy in the complex treatment of all patients,
depending on the stage of infection and prescription of
ARV therapy. To correct metabolic disorders we used:
- levocarnitine - 1 tsp. 3 times a day for a month and/or
- intravenous injection of carnitine solution, daily, for a
course of 10 injections. For the purpose of basic long-
term detoxification were prescribed: - sorbent -
polyisorb - 3 times a day for 3 months in combination
with lacto- and bifidobacteria; courses of intravenous
administration of rheosorbilakt
-
200.0 ml intravenously, drip, every other day, for a
course of N5). Conventional therapy included: -
antihistamines and hyposensitizing agents; - vitamin
therapy; as indicated: - antiviral drugs (acyclovir,
valacyclovir); - antimycotic drugs (terbinafine); -
antibacterial drugs (amoxicillin or azithromycin.); -
external treatment (when indicated - topical
corticosteroids in the form of combined preparations).
All patients under observation were divided into three
groups depending on the approach to therapy: group 1
included 12 patients who received traditional therapy
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in combination with metabolic drugs (levocarnitine);
group 2 included patients (12 children) treated with
traditional therapy in combination with detoxification
therapy; group 3 (12 patients) - traditional therapy in
combination with metabolic and detoxification therapy;
group 4 (comparison) - 10 patients treated traditionally.
All groups were representative of the main comparable
indicators. The analysis of immediate and distant results
of treatment showed high efficiency of the proposed
method. Thus, regression of clinical manifestations of
dermatoses came on average on 12-18 days of treatment
in the study group and on 23-28 days - in the comparison
group. At the same time in patients of group 3, whose
complex therapy included detoxification and metabolic
drugs, regression of clinical manifestations of
dermatoses came on average 2-4 days earlier than in
groups 1 and 2. The use of detoxification and metabolic
drugs in the complex treatment of patients increased the
effectiveness of
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treatment of HIV-associated dermatoses, increased the
duration of remission by 2-2.5 times and reduced the
number of relapses by 35%.
It was noted that in persons receiving ARV
therapy in the two compared groups, irrespective of the
type of dermatosis, the treatment results were better
than in those receiving only dermatologic therapy.
Conclusions
1.
These studies demonstrate the significance
of skin lesions at all clinical stages of the course of HIV
infection.
2.
The proposed approach to the treatment of
HIV-associated dermatoses using metabolic agents and
detoxification therapy allows to achieve better clinical
results and preserve the quality of life of HIV-positive
patients.
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