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Fever and rash in HIV-infected patients

Fred A Lopez, MD
Charles V Sanders, MD
Section Editor
John G Bartlett, MD
Deputy Editor
Jennifer Mitty, MD, MPH


Dermatologic manifestations affect 80 to 90 percent of individuals infected with the human immunodeficiency virus (HIV) [1-4]. The frequency of cutaneous manifestations was illustrated in a review of 684 HIV-infected patients who were followed for almost three years; 540 patients (79 percent) were given one or more (average 3.7) dermatologic diagnoses [3,5]. Importantly, a higher number of mucocutaneous diseases in HIV-infected patients has been shown to correlate with poor prognosis and a shorter time to the development of AIDS [6,7].

Rash can occur as a manifestation of HIV infection, another infection, some neoplasms, and frequently as a reaction to a drug. The defect in cell-mediated immunity that results from HIV infection predisposes infected individuals to certain bacterial, fungal, mycobacterial, and viral infections, many of which have skin manifestations. In addition, many immune reconstitution inflammatory syndrome-associated events are dermatological and warrant consideration in the HIV-infected individual who has recently started highly active antiretroviral therapy [8,9].

Characteristic fever and rash syndromes in the HIV-infected patient will be reviewed here. The diagnosis and treatment of the individual diseases as well as the epidemiology, etiology, and diagnostic approach to fever and rash in HIV-uninfected immunocompromised hosts and in the normal host are discussed separately. (See "Fever and rash in immunocompromised patients without HIV infection" and "Fever and rash in the immunocompetent patient".)


Patients with HIV infection have an increased incidence of bacterial infections that is related to both deficiencies in T cell function and dysregulation of humoral immunity in advanced disease.

Staphylococcus aureus — Staphylococcus aureus is a common cause of skin infection and bacteremia in patients with the acquired immunodeficiency syndrome (AIDS). Risk factors for S. aureus bacteremia include nasal colonization with S. aureus, injection drug use (IDU), lymphedema due to Kaposi sarcoma (KS), neutropenia, and indwelling vascular catheters [10]. Colonization with S. aureus is increased in HIV-infected individuals and an increasing number of isolates are methicillin-resistant [11-15]. Risk factors for MRSA include the following: history of prior MRSA infection; recent systemic antibiotic use or hospitalization (ie, within last six months); lower CD4 count; recent sexually transmitted infection; and prior incarceration [16-20]. HIV infection also appears to increase the risk for community-associated MRSA skin and soft tissue infections [21]. In addition, HIV infection is an independent risk factor for recurrence of infection due to S. aureus in patients with a history of S. aureus bacteremia [22].


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