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JAMA Clinical Challenge
January 20, 2015

A Crusted Rash in a Patient With AIDS

Author Affiliations
  • 1Perelman School of Medicine, University of Pennsylvania, Philadelphia
  • 2Department of Dermatology, University of Pennsylvania
  • 3Department of Medicine, University of Pennsylvania, Philadelphia
JAMA. 2015;313(3):298-299. doi:10.1001/jama.2014.16051

A 39-year-old man with a recent diagnosis of AIDS (CD4 cell count, 13 cells/μL) was admitted to the hospital for diarrhea and dehydration and was noted to have an intensely pruritic rash with diffuse crust and scale. Dolutegravir and emtricitabine/tenofovir were continued, and diphenhydramine was prescribed for pruritus. On day 3 of hospitalization, the dermatology service was consulted.

The patient had a history of mild psoriasis, which significantly worsened 1 year prior to presentation, necessitating treatment with systemic agents and ultimately leading to a diagnosis of human immunodeficiency virus (HIV) infection. Physical examination was remarkable for severe cachexia and diffuse plaques of thick, tan scale (Figure 1). Hyperkeratotic areas were verrucous and fissured over bony prominences, including the elbows, knees, ribs, and clavicles. Linear excoriations were noted diffusely. Unroofed crust revealed a smooth, red, moist undersurface.

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