American Journal of Clinical Dermatology

, Volume 8, Issue 4, pp 221–233 | Cite as

Dermatologic Adverse Effects of Antiretroviral Therapy

Recognition and Management
Review Article

Abstract

Despite the decrease in opportunistic infections associated with HIV in the highly active antiretroviral treatment (HAART) era, a significant number of patients still present with skin pathology, some of which can be attributed directly or indirectly to antiretroviral therapy. The non-nucleoside reverse transcriptase inhibitors exhibit a class effect with regard to skin adverse manifestations, and the spectrum of disease can vary from a mild morbilliform rash to Stevens-Johnson syndrome. Certain protease inhibitors are associated with rash, and indinavir causes retinoid-like manifestations such as paronychia, alopecia, ingrown toe-nails, and curling of straight hair. Abacavir, a nucleoside reverse transcriptase inhibitor, is notorious for causing a hypersensitivity reaction in select patients. The fusion inhibitor enfuvirtide causes injection-site reactions in the overwhelming majority of patients, although a new method of delivery has decreased the rate and severity of these reactions. A syndrome of lipoatrophy with or without lipohypertrophy, often termed lipodystrophy, has been described in patients receiving HAART. Potential management of lipoatrophy includes switching antiretrovirals and surgical treatment with facial fillers. Lastly, skin manifestations of the immune reconstitution inflammatory syndrome, including herpes zoster and warts, must be recognized and treated accordingly. In the evaluation of the individual HIV-infected patient receiving antiretroviral therapy who presents with a skin disorder, clinicians should consider the CD4 cell count as a marker of the degree of immunodeficiency, the specific antiretrovirals used, and the timing of the initiation of antiretroviral therapy in order to formulate a rational differential diagnosis. Management should be individualized based on the specific drug that is implicated and the severity of the reaction.

Keywords

Zidovudine Efavirenz Nevirapine Indinavir Abacavir 

Notes

Acknowledgments

This work was supported by National Institutes of Health grant R01-DK065515. Dr Glesby has received research support and served as an ad hoc consultant to Serono Laboratories and has received an honorarium for lecturing from Abbott Laboratories. Dr Luther has no conflicts of interest that are directly relevant to the content of this review. The authors thank Dr Toby Maurer for providing photographs and critically reviewing the manuscript.

References

  1. 1.
    Hengge UR, Franz B, Goos M. Decline of infectious skin manifestations in the era of highly active antiretroviral therapy. AIDS 2000; 14 (8): 1069–70PubMedCrossRefGoogle Scholar
  2. 2.
    Boehringer Ingelheim Pharmaceuticals, Inc. Viramune? prescribing information [package insert]. Ridgefield (CT): Boehringer Ingelheim Pharmaceuticals, Inc., 2007Google Scholar
  3. 3.
    Bristol-Myers Squibb Company. Sustiva? prescribing information [package insert]. Princetont (NJ): Bristol-Myers Squibb Company, 2007 JanGoogle Scholar
  4. 4.
    Pharmacia and Upjohn Company. Rescriptor? prescribing information [package insert]. Kalamazoo (MI): Pharmacia and Upjohn Company, 2006 FebGoogle Scholar
  5. 5.
    de Maat M, ter Heine R, Mulder JW, et al. Incidence and risk factors for nevirapine-associated rash. Eur J Clin Pharmacol 2003; 59: 457–62PubMedCrossRefGoogle Scholar
  6. 6.
    Bersoff-Matcha SJ, Miller WC, Aberg JA, et al. Sex differences in nevirapine rash. Clin Infect Dis 2001; 32: 124–9PubMedCrossRefGoogle Scholar
  7. 7.
    van Leth F, Andrews S, Grinsztejn B, et al. The effect of baseline CD4 cell count and HIV-1 viral load on the efficacy and safety of nevirapine or efavirenz based first-line HAART. AIDS 2005; 19: 463–71PubMedCrossRefGoogle Scholar
  8. 8.
    Hawkins T. Appearance related side-effects of HIV-1 treatment. AIDS Patient Care STDS 2006; 20: 6–18PubMedCrossRefGoogle Scholar
  9. 9.
    Knobel H, Miro JM, Mahillo B, et al. Failure of cetirizine to prevent nevirapine-associated rash. J Acquir Immune Defic Syndr 2004; 37: 1276–81PubMedCrossRefGoogle Scholar
  10. 10.
    Drugs for HIV infection: treatment guidelines. Med Lett 2006 Oct; 4 (50): 67–76Google Scholar
  11. 11.
    Wolff K, Johnson RA, Suurmond D. Miscellaneous inflammatory diseases. In: Fitzpatrick TB, Johnson RA, Wolff K, et al., editors. Fitzpatrick’s color atlas and synopsis of clinical dermatology. 5th ed. New York: The McGraw-Hill Companies, 2005: 118–57Google Scholar
  12. 12.
    Fagot JP, Mockenhaupt M, Bouwes-Bavinck JN, et al. Nevirapine and the risk of Stevens-Johnson syndrome or toxic epidermal necrolysis. AIDS 2001; 15: 1843–8PubMedCrossRefGoogle Scholar
  13. 13.
    Warren KJ, Boxwell DE, Drolet NY, et al. Nevirapine-associated Stevens-Johnson syndrome [letter]. Lancet 1998; 351: 567PubMedCrossRefGoogle Scholar
  14. 14.
    van Leth F, Phanuphak P, Ruxrungtham K, et al. Comparison of first-line antiretroviral therapy with regimens including nevirapine, efavirenz, or both drugs, plus stavudine and lamivudine: a randomised open-label trial, the 2NN Study. Lancet 2004; 363: 1253–63Google Scholar
  15. 15.
    Torralba M, Neira M, Rubio R, et al. Evaluation of cutaneous cross-toxicity between efavirenz and nevirapine-containing regimens in clinical practice [abstract no. 125]. Antivir Ther 2003; 8: L82Google Scholar
  16. 16.
    The TMC125-C223 Writing Group. Efficacy and safety of etravirine (TMC125) in patients with highly resistant HIV-1: primary 24-week analysis. AIDS 2007; 21: F1–10Google Scholar
  17. 17.
    Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents: developed by the DHHS panel on antiretroviral guidelines for adults and adolescents.A Working Group of the Office of AIDS Research Advisory Council; October 10th, 2006 [online].Available from URL: http://aidsinfo.nih.gov [Accessed 2007 May 8]
  18. 18.
    GlaxoSmithKline. Agerenase? prescribing information [package insert]. Research Triangle Park (NC): GlaxoSmithKline, 2005 MayGoogle Scholar
  19. 19.
    Kohli-Pamnani A, Huynh P, Lobo F. Amprenavir-induced maculopapular exanthem followed by desensitization in a patient with late-stage human immunodeficiency virus. Ann Allergy Asthma Immunol 2006; 96: 620–3PubMedCrossRefGoogle Scholar
  20. 20.
    Rodriguez-French A, Boghossian J, Gray GE, et al. The NEAT study: a 48-week open-label study to compare the antiviral efficacy and safety of GW433908 versus nelfinavir in antiretroviral therapy-naive HIV-1-infected patients. J Acquir Immune Defic Syndr 2004 Jan 1; 35 (1): 22–32PubMedCrossRefGoogle Scholar
  21. 21.
    GlaxoSmithKline. Lexiva? prescribing information [package insert]. Research Triangle Park (NC): GlaxoSmithKline, 2007 FebGoogle Scholar
  22. 22.
    Merck and Co., Inc. Crixivan? prescribing information [package insert].Whitehouse Station (NJ): Merck and Co., Inc., 2006 NovGoogle Scholar
  23. 23.
    Garcia-Silva J, Almagro M, Pena-Penabad C, et al. Indinavir-induced retinoid-like effects; incidence, clinical features and management. Drug Saf 2002; 25 (14): 993–1003PubMedCrossRefGoogle Scholar
  24. 24.
    Bouscarat F, Bouchard C, Bouhour D. Paronychia and pyogenic granuloma of the toes in patients treated with indinavir. N Engl J Med 1998; 338: 1776–7PubMedCrossRefGoogle Scholar
  25. 25.
    Carr A, Samaras K, Chisholm DJ, et al. Pathogenesis of HIV-1-protease inhibitor-associated peripheral lipodystrophy, hyperlipidaemia, and insulin resistance. Lancet 1998 Jun 20; 351 (9119): 1881–3PubMedCrossRefGoogle Scholar
  26. 26.
    Garcia-Silva J, Almagro M, Juega J, et al. Protease inhibitor-related paronychia, ingrown toenails, desquamative cheilits and cutaneous xerosis. AIDS 2000; 14 (9): 1289–91PubMedCrossRefGoogle Scholar
  27. 27.
    Ginarte M, Losada E, Prieto A. Generalized hair loss induced by indinavir plus ritonavir therapy. AIDS 2002; 16 (12): 1695–6PubMedCrossRefGoogle Scholar
  28. 28.
    JOLLC and Tibotech Therapeutics. Prezista? prescribing information [package insert]. Gurabo: JOLLC and Tibotech Therapeutics, 2006Google Scholar
  29. 29.
    Bristol-Myers Squibb Company. Reyataz? prescribing information [package insert]. Princeton (NJ): Bristol-Myers Squibb Company, 2007 MarGoogle Scholar
  30. 30.
    Boehringer Ingelheim Pharmaceuticals, Inc. Aptivus? prescribing information [package insert]. Ridgefield (CT): Boehringer Ingelheim Pharmaceuticals, Inc., 2006 JunGoogle Scholar
  31. 31.
    Abbott Laboratories. Kaletra? prescribing information [package insert]. North Chicago (IL): Abbott Laboratories, 2007 JanGoogle Scholar
  32. 32.
    Agouron Pharmaceuticals. Viracept? prescribing information [package insert]. La Jolla (CA): Agouron Pharmaceuticals, 2007 JanGoogle Scholar
  33. 33.
    Abbott Laboratories. Norvir? prescribing information [package insert]. North Chicago (IL): Abbott Laboratories, 2006 JanGoogle Scholar
  34. 34.
    Roche Pharmaceuticals. Invirase? product information [package insert]. Nutley (NJ): Roche Pharmaceuticals, 2005 SepGoogle Scholar
  35. 35.
    Hervey PS, Perry CM. Abacavir: a review of its clinical potential in patients with HIV infection. Drugs 2000; 60: 447–9PubMedCrossRefGoogle Scholar
  36. 36.
    Stekler J, Maenza J, Stevens C, et al. Abacavir hypersensitivity reaction in primary HIV infection. AIDS 2006; 20: 1269–74PubMedCrossRefGoogle Scholar
  37. 37.
    Mallal S, Nolan D, Witt C, et al. Association between presence of HLA-B*5701, HLA-DR7, and HLA-DQ3 and hypersensitivity to HIV-1 reverse-transcriptase inhibitor abacavir. Lancet 2002; 359 (9308): 727–3PubMedCrossRefGoogle Scholar
  38. 38.
    Rauch A, Nolan D, Martin AE, et al. Prospective genetic screening decreases the incidence of abacavir hypersensitivity reactions in the Western Australian HIV Cohort Study. Clin Infect Dis 2006; 43: 99–102PubMedCrossRefGoogle Scholar
  39. 39.
    GlaxoSmithKline. Retrovir? prescribing information [package insert]. Research Park (NC): GlaxoSmithKline, 2006 NovGoogle Scholar
  40. 40.
    Gilead. Viread? prescribing information [package insert]. Foster City (CA): Gile-ad, 2006 MarGoogle Scholar
  41. 41.
    Gallant JE, Dejesus E, Arribas JR, et al. Tenofovir DF, emtricitabine, and efavirenz vs. zidovudine, lamivudine, and efavirenz for HIV. N Engl J Med 2006 Jan 19; 354 (3): 251–60PubMedCrossRefGoogle Scholar
  42. 42.
    GlaxoSmithKline. Epivir? prescribing information [package insert]. Research Triangle Park (NC): GlaxoSmithKline, 2006 OctGoogle Scholar
  43. 43.
    Bristol-Myers Squibb Company. Zerit? product information [package insert]. Princeton (NJ): Bristol-Myers Squibb Company, 2006 AugGoogle Scholar
  44. 44.
    Hivid? product information [package insert]. Nutley (NJ): Roche Pharmaceuticals, 2002 SepGoogle Scholar
  45. 45.
    Jamjian MC, McNicholl IR. Enfuvirtide: first fusion inhibitor for treatment of HIV infection. Am J Health Syst Pharm 2004; 61: 1242–8PubMedGoogle Scholar
  46. 46.
    Gottlieb M, True A, Evans R, et al. Needle-free administration of enfuvirtide significantly reduces incidence of painful injection site reactions: results from a single blind, randomized, controlled study [abstract no. H-1905b]. 46th Inter- science Conference on Antimicrobial Agents and Chemotherapy; 2006 Sep 27-30; San Francisco (CA)Google Scholar
  47. 47.
    Roche Pharmaceuticals. Fuzeon? predscribing information [package insert]. Nutley (NJ): Roche Pharmaceuticals, 2007 JanGoogle Scholar
  48. 48.
    Harris M, Joy R, Larsen G, et al. Enfuvirtide plasma levels and injection site reactions using a needle-free gas-powered injections system (Biojector). AIDS 2006; 20 (5): 719–23PubMedCrossRefGoogle Scholar
  49. 49.
    Pfizer, Inc. Maraviroc tablets NDA 22-128 Antiviral Drugs Advisory Committee (ADVAC) briefing document, April 24, 2007Google Scholar
  50. 50.
    Bacchetti P, Gripshover B, Grunfeld C. Fat distribution in men with HIV infection; from the study of Fat Redistribution and Metabolic change in HIV infection (FRAM). J Acquir Immune Defic Syndr 2005; 40: 121–31PubMedCrossRefGoogle Scholar
  51. 51.
    Tien PC, Cole SR, Williams CM. Incidence of lipoatrophy and lipohypertrophy in the Women’s Interagency HIV Study. J Acquir Immune Defic Syndr 2003; 34: 461–6PubMedCrossRefGoogle Scholar
  52. 52.
    Wohl DA, McComsey P, Teba P, et al. Current concepts in the diagnosis and management of metabolic complications of HIV infection and its therapy. Clin Infect Dis 2006; 43: 645–53PubMedCrossRefGoogle Scholar
  53. 53.
    Engelhard P. Correction options for lipoatrophy in HIV-infected patients. AIDS Patient Care STDS 2006; 20: 151–60PubMedCrossRefGoogle Scholar
  54. 54.
    Koutkia P, Grinspoon S. HIV-associated lipodystrophy: pathogenesis, prognosis, treatment, and controversies. Annu Rev Med 2004; 55: 303–17PubMedCrossRefGoogle Scholar
  55. 55.
    Rodriguez de la Concepion ML, Domingo JC, Domingo P, et al. Uncoupling protein 1 gene expression implicates brown adipocytes in highly active antire-troviral therapy-associated lipomatosis. AIDS 2004; 18: 959–60CrossRefGoogle Scholar
  56. 56.
    Schurmann D, Rademaker J, Trottenberg T, et al. Spinal epidural lipomatosis: a manifestation of HAART-associated lipodystrophy. AIDS 2005; 19: 2052–4PubMedCrossRefGoogle Scholar
  57. 57.
    Oette M, Juretzko P, Kroidl A, et al. Lipodystrophy syndrome and self-assessment of well-being and physical appearance in HIV-positive patients. AIDS Patient Care STDS 2002; 16: 413–7PubMedCrossRefGoogle Scholar
  58. 58.
    Ammassari A, Antinor A, Cozzi-Lepri A, et al. Relationship between HAART adherence and adipose tissue alterations.J Acquir Immune Defic Syndr 2002; 31 Suppl. 3: S140–4CrossRefGoogle Scholar
  59. 59.
    Sutinen J. Interventions for managing antiretroviral therapy-associated lipoatrophy. Curr Opin Infect Dis 2005; 18: 25–33PubMedCrossRefGoogle Scholar
  60. 60.
    Brinkman K, Smeitink JA, Romijn JA, et al. Mitochondrial toxicity induced by nucleoside-analogue reverse-transcriptase inhibitors is a key factor in the pathogenesis of antiretroviral-therapy related lipodystrophy. Lancet 1999; 25: 1112–5CrossRefGoogle Scholar
  61. 61.
    Kakuda TN, Brundage RC, Anderson PL, et al. Nucleoside reverse transcriptase inhibitor-induced mitochondrial toxicity as an etiology for lipodystrophy [letter]. AIDS 1999; 13: 2311–2PubMedCrossRefGoogle Scholar
  62. 62.
    Nolan D, Hammond E, Martin A, et al. Mitochondrial DNA depletion and morphological changes in adipocytes associated with nucleoside reverse transcriptase inhibitor therapy. AIDS 2003; 17: 1329–38PubMedCrossRefGoogle Scholar
  63. 63.
    Boyd MA, Carr A, Ruxrungtham K, et al. Changes in body composition and mitochondrial nucleic acid content in patients switched from failed nucleoside analogue therapy to ritonavir-boosted indinavir and efavirenz. J Infect Dis 2006; 194: 642–50PubMedCrossRefGoogle Scholar
  64. 64.
    McComsey GA, Paulsen DM, Lonergan JT, et al. Improvements in lipoatrophy, mitochondrial DNA levels and fat apoptosis after replacing stavudine with abacavir or zidovudine. AIDS 2005; 19: 15–23PubMedCrossRefGoogle Scholar
  65. 65.
    Lichtenstein KA, Ward DJ, Moorman AC. Clinical assessment of HIV-associated lipodystrophy in an ambulatory population. AIDS 2001; 15: 1389–98PubMedCrossRefGoogle Scholar
  66. 66.
    Nolan D, Moore C, Castley A. Tumour necrosis factor-alpha gene: 238G/A promoter polymorphism associated with a more rapid onset of lipodystrophy. AIDS 2003; 17: 121–3PubMedCrossRefGoogle Scholar
  67. 67.
    Mallal SA, John M, Moore CB, et al. Contribution of nucleoside analogue reverse transcriptase inhibitors to subcutaneous fat wasting in patients with HIV infection. AIDS 2000; 14: 1309–16PubMedCrossRefGoogle Scholar
  68. 68.
    Lichtenstein KA, Ward DJ, Moorman AC, et al. Clinical assessment of HIV-associated lipodystrophy in an ambulatory population. AIDS 2001; 15: 1389–98PubMedCrossRefGoogle Scholar
  69. 69.
    Carr A, Workman C, Smith DE, et al. Abacavir substitution for nucleoside analogs in patients with HIV lipoatrophy: a randomized trial. JAMA 2002; 288: 207–15PubMedCrossRefGoogle Scholar
  70. 70.
    Martin A, Smith DE, Carr A, et al. Reversibility of lipoatrophy in HIV-infected patients 2 years after switching from a thymidine analog to abacavir: the MITOX Extension Study. AIDS 2004; 18: 1029–36PubMedCrossRefGoogle Scholar
  71. 71.
    Hadigan C, Yawetz S, Thomas A, et al. Metabolic effects of rosiglitazone in HIV lipodystrophy: a randomized, controlled trial. Ann Intern Med 2004; 140 (10): 786–94PubMedGoogle Scholar
  72. 72.
    Carr A, Workman C, Carey D, et al. No effect of rosiglitazone for the treatment of HIV-1 lipoatrophy: randomised double-blind, placebo-controlled trial. Lancet 2004; 363: 429–38PubMedCrossRefGoogle Scholar
  73. 73.
    Slama L, Lanoy E, Valentin MA, et al. Effect of pioglitazone on HIV-1 related lipoatrophy: a randomized double-bind placebo-controlled trial (ANRS 113) with 130 patients. 13th Conference on Retroviruses and Opportunistic Infections; 2006 Feb 5-8; Denver (CO)Google Scholar
  74. 74.
    Walker UA, Auclair M, Lebrecht D, et al. Uridine abrogates the adverse effects of antiretroviral pyrimidine analogues on adipose cell functions. Antivir Ther 2006; 11: 25–34PubMedGoogle Scholar
  75. 75.
    Sutinen J, Walker UA, Sevastianova K, et al. Uridine supplementation increases subcutaneous fat in patients with HAART associated lipodystrophy (HAL): a randomized, placebo-controlled trial [abstract no. 7]. Program and abstracts of the 7th International Workshop on Adverse Events and Lipodystrophy in HIV; 2006 Nov 13-16; DublinGoogle Scholar
  76. 76.
    Cofrancesco Jr J, Brown T, Martins CR. Management options for facial lipoatrophy. AIDS Read 2004; 14: 639–40PubMedGoogle Scholar
  77. 77.
    Humble G, Mest D. Soft tissue augmentation using Sculptra. Facial Plast Surg 2004; 20: 157–63PubMedCrossRefGoogle Scholar
  78. 78.
    Burgess CM, Quiroga RM. Assessment of the safety and efficacy of poly-L-lactic acid for the treatment of HIV-associated facial lipoatrophy. J Am Acad Dermatol 2005; 54: 233–9CrossRefGoogle Scholar
  79. 79.
    Valantin MA, Aubron-Olivier C, Ghosn J, et al. Polylactic acid implants (New-Fill) to correct facial lipoatrophy in HIV-infected patients: results of open label study VEGA. AIDS 2003; 17: 2471–7PubMedCrossRefGoogle Scholar
  80. 80.
    Dermik Laboratories. Sculptra? (injectable poly-L-lactic acid) product monograph [package insert]. Berwyn (PA): Dermik Laboratories, 2004Google Scholar
  81. 81.
    Jones D. Approaches to treatment of HIV facial lipoatrophy. Skin Therapy Lett 2005; 10 (9): 5–7PubMedGoogle Scholar
  82. 82.
    Silvers SL, Eviatar JA, Echavez MI, et al. Prospective, open-label, 18-month trial of calcium hydroxylapatite (Radiesse) for facial soft-tissue augmentation in patients with human immunodeficiency virus-associated lipoatrophy: one-year durability. Plast Reconstr Surg 2006; 118 Suppl.: 34S–45SGoogle Scholar
  83. 83.
    Guaraldi G, De Fazio D, Orlando G, et al. Facial lipohypertrophy in HIV-infected subjects who underwent fat tissue transplantation. Clin Infec Dis 2005; 40 (2): 13–5CrossRefGoogle Scholar
  84. 84.
    Shelburne SA, Visnegarwala F, Darcourt J, et al. Incidence and risk factors for immune reconstitution inflammatory syndrome during highly active antiretroviral therapy. AIDS 2005; 19: 399–406PubMedCrossRefGoogle Scholar
  85. 85.
    Crum-Cianflone NF. Immune reconstitution inflammatory syndromes: what’s new? AIDS Read 2006; 16: 199–206, 213-7PubMedGoogle Scholar
  86. 86.
    Autran B, Carcelain G, Li TS, et al. Positive effects of combined antiretroviral therapy on CD4+ T cell homeostasis and function in advanced HIV disease. Science 1997; 277: 122–6CrossRefGoogle Scholar
  87. 87.
    Shelburne SA, VMontes M, Hamil RJ. Immune reconstitution inflammatory syndrome: more answers, more questions. J Antimicrob Chemother 2005; 57: 167–70PubMedCrossRefGoogle Scholar
  88. 88.
    Ratnam I, Chiu C, Kandala NB, et al. Incidence and risk factors for immune reconstitution inflammatory syndrome in an ethnically diverse HIV type 1-infected cohort. Clin Infect Dis 2006; 42: 418–27PubMedCrossRefGoogle Scholar
  89. 89.
    Martinez E, Gatell J, Moran Y, et al. High incidence of herpes zoster in patients with AIDS soon after therapy with protease inhibitors. Clin Infect Dis 1998; 27 (6): 1510–3PubMedCrossRefGoogle Scholar
  90. 90.
    Domino P, Torres OH, Ris J, et al. Herpes zoster as an immune reconstitution disease after initiation of combination antiretroviral therapy in patients with human immunodeficiency virus type 1 infection. Am J Med 2001; 110 (8): 605–9CrossRefGoogle Scholar
  91. 91.
    Moussa R, Stephenson I, Fisk P, et al. Buschke-Loewenstein lesion: another possible manifestation of immune restoration inflammatory syndrome? AIDS 2004; 18: 1221–3PubMedCrossRefGoogle Scholar
  92. 92.
    Narita M, Ashkin D, Hollender ES, et al. Paradoxical worsening of tuberculosis following antiretroviral therapy in patients with AIDS. Am J Respir Crit Care Med 1998; 158: 157–61PubMedGoogle Scholar
  93. 93.
    Phillips P, Bonner S, Gataric N, et al. Nontuberculosis mycobacterial immune reconstitution syndrome in HIV-infected patients: spectrum of disease and long-term follow-up. Clin Infect Dis 2005; 41: 1483–97PubMedCrossRefGoogle Scholar
  94. 94.
    Shelburne SA, Visnegarwala F, Adams C, et al. Unusual manifestations of disseminated histoplasmosis in patients responding to antiretroviral therapy.Am J Med 2005; 118 (9): 1038–41PubMedCrossRefGoogle Scholar
  95. 95.
    Posada-Vergara MP, Lindoso JA, Tolezano JE, et al. Tegumentary leishmaniasis as a manifestation of immune reconstitution inflammatory syndrome in 2 patients with AIDS. J Infect Dis 2005; 192: 1819–22PubMedCrossRefGoogle Scholar
  96. 96.
    Ustianowski AP, Lawn SD, Lockwood DN, et al. Interactions between HIV infection and leprosy: a paradox. Lancet Infect Dis 2006 Jun; 6 (6): 350–60PubMedCrossRefGoogle Scholar
  97. 97.
    Stoll M, Schmidt RE. Immune restoration inflammatory syndromes: apparently paradoxical clinical events after the initiation of HAART. Curr HIV/AIDS Rep 2004; 1: 122–7PubMedCrossRefGoogle Scholar

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© Adis Data Information BV 2007

Authors and Affiliations

  1. 1.Upstate Medical SchoolState University of New YorkSyracuseUSA
  2. 2.Division of International Medicine and Infectious Diseases, Department of MedicineWeill Cornell Medical CollegeNew YorkUSA

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