European Journal of Cardiovascular Medicine

Mucocutaneous manifestations are among the most common and earliest clinical features of Human Immunodeficiency Virus (HIV) infection in children, often appearing before systemic symptoms become evident and serving as important diagnostic clues to the underlying immunodeficiency [1]. These manifestations are particularly significant in pediatric patients, as they not only indicate immune suppression but can also help predict disease progression and treatment response [2]. The skin and mucous membranes, being primary protective barriers, are especially vulnerable to opportunistic infections and inflammatory changes resulting from the immune dysregulation caused by HIV [3].

The prevalence of mucocutaneous disorders among HIV-infected children varies globally, ranging from 40% to 90%, influenced by factors such as access to antiretroviral therapy (ART), regional pathogen burden, socioeconomic conditions, and nutritional status [4]. In resource-limited settings, these conditions tend to be more severe and atypical due to delayed diagnosis and inadequate treatment coverage [5]. In India, where pediatric HIV remains a substantial public health concern, studies have documented skin disorders in 30% to 80% of affected children, with patterns differing according to the degree of immunosuppression and ART status [6].

The pathogenesis of HIV-associated mucocutaneous disorders is multifactorial, primarily driven by progressive depletion of CD4+ T lymphocytes and impaired cell-mediated immunity [7]. This immune dysfunction predisposes children to infectious dermatoses such as oral candidiasis, herpes simplex virus infection, molluscum contagiosum, varicella-zoster virus reactivation, and extensive human papillomavirus–related warts [8]. Fungal infections, particularly dermatophytosis, are also common, often presenting in widespread or recalcitrant forms [9]. Bacterial skin infections, including impetigo, folliculitis, and ecthyma, may occur more frequently and with greater severity in immunocompromised children [10].

From a psychosocial standpoint, visible skin lesions may contribute to stigma, discrimination, and emotional distress, particularly among school-aged children and adolescents. These factors can negatively affect adherence to ART and engagement with healthcare services. Therefore, addressing both the medical and psychological aspects of mucocutaneous disorders is essential in pediatric HIV management. In conclusion, mucocutaneous manifestations remain highly prevalent in HIV-infected children despite advances in ART. They are important diagnostic and prognostic indicators, reflecting immune status, disease progression, and treatment efficacy. Continuous research, early recognition, and integrated dermatologic care are vital for improving the quality of life and clinical outcomes in this vulnerable population.

Study design: Prospective Study.

Place of study: Calcutta school of tropical medicine.

Period of study: 1 Year.

Study Variables:

• Age
• Gender
• BMI
• Endocrine Disorder
• Thyroid disorders
• Adrenal disorders
• Pituitary disorders
• PCOS
• Skin Manifestation
• Skin Feature

Sample size: 60 Patients with Human Immunodeficiency Virus (HIV) infection presenting with mucocutaneous manifestations.

Inclusion Criteria:

• Children aged 0–18 years diagnosed with HIV infection.
• Patients presenting with mucocutaneous manifestations.
• Both ART-naïve and ART-experienced children.
• Willingness of parent/guardian to provide informed consent.

 Exclusion Criteria:

• Children with skin disorders unrelated to HIV.
• Patients with incomplete clinical records.
• Children receiving systemic immunosuppressive therapy for other illnesses.
• Refusal of consent by parent/guardian.

Statistical Analysis: The collected data were compiled and analyzed using Statistical Package for the Social Sciences (SPSS) version XX. Descriptive statistics were used to summarize demographic and clinical variables, with continuous data expressed as mean ± standard deviation (SD) and categorical data presented as frequencies and percentages. The Chi-square test or Fisher’s exact test was applied to compare categorical variables, while Student’s t-test or Mann–Whitney U test was used for continuous variables, depending on the normality of distribution assessed by the Shapiro–Wilk test. A p-value < 0.05 was considered statistically significant for all analyses

Table 1: Demographic Profile of Study Participants

Table 2: ART Status and Duration in Study Participants

Table 3: Types of Mucocutaneous Manifestations

Table 4: Association of CD4 Count with Mucocutaneous Manifestations

Table 5. Association of ART Duration with Prevalence of Lesions

Figure 1: Types of Mucocutaneous Manifestations

Figure 2: Association of ART Duration with Prevalence of Lesions

In the present study of 60 children with HIV infection, the majority were aged between 6–10 years (36.7%), followed by 0–5 years (30%), 11–15 years (23.3%), and 16–18 years (10%). The age distribution difference was not statistically significant (p = 0.214). Males constituted 56.7% of the study population, while females accounted for 43.3%, with no statistically significant difference in gender distribution (p = 0.562).

Regarding antiretroviral therapy (ART) status, 70% of the children were on ART, while 30% were ART-naïve, with a statistically significant difference between the groups (p = 0.031). Among those receiving ART, the duration of therapy was less than 1 year in 33.3% of patients, between 1–3 years in 42.9%, and more than 3 years in 23.8%, showing a statistically significant distribution (p = 0.047).

Oral candidiasis was the most common mucocutaneous manifestation, observed in 46.7% of the children, followed by seborrheic dermatitis (23.3%), bacterial skin infections (13.3%), molluscum contagiosum (10%), and herpes zoster (6.7%). The distribution of lesion types showed a statistically significant difference (p = 0.002).

A significant association was found between CD4 count and the occurrence of oral candidiasis (p = 0.001). Among children with CD4 counts <200 cells/mm³, 57.1% had oral candidiasis compared to 21.4% with other lesions. In the 200–499 cells/mm³ group, 35.7% had oral candidiasis and 42.9% had other lesions. In those with CD4 counts ≥500 cells/mm³, oral candidiasis was present in only 7.1%, while 35.7% had other lesions.

The occurrence of mucocutaneous lesions was significantly associated with the duration of ART (p = 0.004). Lesions were present in 85.7% of children on ART for less than 1 year, compared to 55.6% in those on ART for 1–3 years, and 40% in those on ART for more than 3 years.

In our study of 60 HIV-infected children, oral candidiasis was the most frequent mucocutaneous lesion (46.7%) and showed a strong inverse relationship with CD4 count, being most common in children with CD4 <200 cells/mm³; this proportion is higher than pooled pediatric estimates but is comparable to several single-center reports from resource-limited settings, suggesting local factors and ART coverage strongly influence prevalence [1]. Several authors have similarly documented a higher frequency of oral and other fungal infections among children with advanced immune suppression, and meta-analyses estimate variable pediatric oral candidiasis prevalence depending on study setting and ART access [2], [3]. The predominance of seborrheic dermatitis and pruritic/inflammatory lesions in our cohort mirrors findings from hospital-based series where inflammatory dermatoses remain common even in the ART era, likely reflecting chronic immune dysregulation and environmental cofactors [4], [5]. Molluscum contagiosum in our study (10%) aligns with published pediatric HIV cohorts where prevalence typically ranges from low single digits up to the teens and is well known to be more extensive and treatment-refractory in immunocompromised children [6].

The clear association we observed between low CD4 counts and oral candidiasis is supported by multiple reports that link lower CD4 strata with opportunistic mucocutaneous infections; comparable studies have shown both increased frequency and greater severity of candidiasis and viral skin infections as CD4 falls, underscoring CD4 count as an important prognostic marker for cutaneous morbidity [7], [8]. Importantly, our finding that shorter duration on ART (<1 year) correlated with higher lesion prevalence (85.7%) is consistent with the documented protective effect of sustained ART—several contemporary series report declining rates of opportunistic and infective skin disease with prolonged viral suppression and immune recovery, although immune reconstitution inflammatory syndrome (IRIS) can transiently increase certain dermatologic presentations shortly after ART initiation [9]. Finally, while prevalence proportions vary across reports (owing to differences in geography, nutrition, coinfections, ART regimens, and case definitions), the overall pattern in our cohort—higher infectious lesions with advanced immunosuppression and reduced lesion burden with longer ART exposure—closely matches findings from other recent pediatric and mixed-age studies in low- and middle-income settings [10]. These comparisons emphasize the need for early diagnosis, prompt ART initiation, and routine dermatologic screening in pediatric HIV programs to reduce cutaneous morbidity and its psychosocial impact

In conclusion, this study highlights the high prevalence of mucocutaneous manifestations among HIV-infected children, with oral candidiasis being the most common, followed by seborrheic dermatitis, bacterial skin infections, molluscum contagiosum, and herpes zoster. A statistically significant association was observed between the occurrence of these lesions and factors such as ART status, duration on ART, and CD4 count, indicating that immune status and treatment duration play crucial roles in determining the risk and pattern of skin and mucosal involvement. Children with lower CD4 counts and shorter ART duration were more likely to present with lesions, underscoring the importance of early initiation and sustained adherence to ART for reducing dermatological morbidity.

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