Mucocutaneous Manifestations in HIV-Infected Patients: A  Clinicopathological Study and Correlation with CD4 Cell Counts

Milan, M; V, Kaviya

doi:10.65188/nurexus.1096

Milan M et al | DOI: 10.65188/nurexus.1096

Page 1

Journal of MedVerse Research & Practice

ISSN: 3107-4278

Mucocutaneous Manifestations in HIV-Infected Patients: A

Clinicopathological Study and Correlation with CD4 Cell Counts

M Milan

1

, V Kaviya

2

Postgraduate, Professor

Department of Pathology, Fudan University Shanghai Medical College , China

Email ID: milanmazug@gmail.Com

Submission Date: 05.07.2026

Accepted Date:12.08.2026

Published Date: 31.08.2026

DOI: 10.65188/nurexus.1096

article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits unrestricted

use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.

Abstract

Background: Human immunodeficiency virus (HIV) infection is frequently associated with a wide spectrum of

mucocutaneous manifestations that serve as important clinical indicators of immune dysfunction and disease

progression. The occurrence and severity of these lesions are closely related to the degree of immunosuppression,

particularly CD4 lymphocyte count. Early recognition of these manifestations facilitates prompt diagnosis, timely

treatment, and improved clinical outcomes.

Objectives: To study the clinicopathological spectrum of mucocutaneous manifestations in HIV-infected patients

and to correlate these manifestations with CD4 count and viral load.

Materials and Methods: A hospital-based cross-sectional observational study was conducted among HIV-infected

patients attending a tertiary care centre. Detailed demographic, clinical, and dermatological examinations were

performed, and relevant histopathological evaluation was carried out whenever indicated. CD4 lymphocyte count

and plasma HIV viral load were recorded for all participants. Mucocutaneous lesions were categorized into infectious

and non-infectious groups. Statistical analysis was performed using appropriate descriptive and inferential tests. A

p-value of <0.05 was considered statistically significant.

Results: Non-infectious mucocutaneous manifestations were more common, accounting for 57.9% of cases, while

infectious lesions constituted 42.1%. Papulopruritic eruption was the most frequent non-infectious lesion, whereas

dermatophytosis and candidiasis were the predominant infectious manifestations. A significant association was

observed between the type of mucocutaneous manifestation and CD4 count (χ² = 11.81, p = 0.0027). Patients with

infectious lesions had a significantly lower mean CD4 count (334.75 ± 140.42 cells/mm³) than those with non-

infectious lesions (487.27 ± 243.43 cells/mm³) (p = 0.001). However, no statistically significant difference in viral

load was observed between the two groups (p = 0.695).

Conclusion: Mucocutaneous manifestations remain valuable clinical markers of immune status in HIV infection.

Infectious lesions are significantly associated with lower CD4 counts, whereas viral load showed no significant

correlation with the pattern of mucocutaneous manifestations. Comprehensive dermatological examination combined

with regular CD4 monitoring should be incorporated into routine HIV care for early diagnosis, assessment of disease

progression, and timely management.

Keywords: Human immunodeficiency virus; Mucocutaneous manifestations; CD4 count; Viral load; Dermatological

manifestations; Clinicopathological correlation; Opportunistic infections.

Introduction

Human immunodeficiency virus (HIV) infection continues to be a major global public health concern

despite remarkable advances in antiretroviral therapy (ART). According to recent global estimates, millions

of individuals are living with HIV, with the greatest burden occurring in low- and middle-income countries.

HIV progressively destroys CD4+ T lymphocytes, leading to impaired cell-mediated immunity and

increased susceptibility to opportunistic infections, malignancies, and a wide variety of mucocutaneous

disorders. These manifestations contribute substantially to morbidity and significantly affect patients'

ORIGINAL ARTICLE

Milan M et al | DOI: 10.65188/nurexus.1096

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quality of life. Early recognition and appropriate management of these lesions are therefore essential

components of comprehensive HIV care.[1,2]

Mucocutaneous manifestations are among the earliest and most frequent clinical features of HIV infection,

occurring in nearly 90% of infected individuals during the course of the disease, while oral manifestations

are reported in approximately 30%–80% of patients.[2,3] Dermatological manifestations may be the first

clinical indication of underlying HIV infection or may reflect progression of immunosuppression. Although

many of these disorders also occur in immunocompetent individuals, they frequently present with atypical

morphology, extensive distribution, recurrent episodes, greater severity, poor therapeutic response, and

unusual histopathological features in HIV-infected patients. Consequently, skin and mucosal lesions often

serve as valuable clinical markers for diagnosing HIV infection and assessing disease progression.[3,4]

The spectrum of mucocutaneous manifestations associated with HIV is diverse and includes infectious,

inflammatory, drug-induced, and neoplastic conditions. Common infectious lesions include oral

candidiasis, herpes simplex, herpes zoster, dermatophytosis, molluscum contagiosum, human

papillomavirus infections, bacterial folliculitis, and cutaneous tuberculosis. Inflammatory dermatoses such

as seborrheic dermatitis, psoriasis, xerosis, eosinophilic folliculitis, and pruritic papular eruptions are also

frequently encountered. In advanced stages of HIV infection, neoplastic conditions such as Kaposi sarcoma

and non-Hodgkin lymphoma may develop. The frequency and severity of these manifestations generally

increase with progressive immunosuppression, making them useful indicators of immune status.[4,5]

CD4+ T-lymphocyte count remains the most reliable laboratory marker for evaluating immune function in

HIV-infected patients. Progressive depletion of CD4 cells is closely associated with increased viral

replication, declining host immunity, and a greater risk of opportunistic infections and mucocutaneous

disorders. Numerous studies have demonstrated that specific dermatological manifestations are associated

with particular CD4 count ranges. Oral candidiasis, chronic herpes zoster, extensive dermatophytosis, oral

hairy leukoplakia, and Kaposi sarcoma are more frequently observed in patients with lower CD4 counts,

whereas milder inflammatory dermatoses may occur during earlier stages of infection. Thus, the presence

and pattern of mucocutaneous lesions may provide valuable clinical information regarding the degree of

immunosuppression and disease progression.[5,6]

Histopathological examination plays an important role in confirming the diagnosis of atypical skin lesions,

differentiating infectious from inflammatory and neoplastic conditions, and guiding appropriate treatment.

Because HIV-associated dermatoses often exhibit altered or overlapping clinical features,

clinicopathological correlation is essential for accurate diagnosis. Furthermore, correlating these

manifestations with CD4 cell counts assists clinicians in predicting the severity of immunosuppression,

identifying patients at increased risk of opportunistic infections, and monitoring therapeutic response

following initiation of antiretroviral therapy.[6,7]

Although several studies have described the prevalence and clinical spectrum of mucocutaneous

manifestations in HIV infection, relatively few have comprehensively evaluated their clinicopathological

characteristics in relation to CD4 cell count. Understanding this relationship may facilitate earlier diagnosis,

improve prognostic assessment, and enhance patient management. Therefore, the present study was

undertaken to evaluate the clinicopathological spectrum of mucocutaneous manifestations in HIV-infected

patients and to correlate these findings with CD4 cell counts, thereby emphasizing their importance as

reliable clinical indicators of immune status and disease progression.[7,8]

Milan M et al | DOI: 10.65188/nurexus.1096

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Materials & Methods

Study Design

This was a hospital-based observational cross-sectional study conducted to evaluate the clinicopathological

spectrum of mucocutaneous manifestations in HIV-infected patients and to determine their correlation with

CD4+ T-cell count and HIV viral load.

Study Setting

The study was carried out in the Department of Dermatology in collaboration with the Department of

Pathology and the Anti-Retroviral Therapy (ART) Centre of a tertiary care teaching hospital over a period

of 12 months (specify the study duration).

Study Population

All consecutive HIV-positive patients presenting with one or more mucocutaneous manifestations during

the study period were screened for eligibility.

Sample Size

A total of 100 HIV-infected patients with clinically evident mucocutaneous manifestations who fulfilled the

eligibility criteria were included in the study.

Inclusion Criteria

• Patients aged 18 years and above with confirmed HIV infection.

• Patients presenting with one or more mucocutaneous manifestations.

• Patients willing to participate and provide written informed consent.

• Patients with available CD4+ T-cell count and HIV viral load reports or willing to undergo these

investigations.

Exclusion Criteria

• Patients receiving systemic immunosuppressive therapy for conditions other than HIV.

• Patients with dermatological disorders unrelated to HIV infection.

• Patients with incomplete clinical records or unavailable CD4 count/viral load data.

• Patients unwilling to provide informed consent.

Data Collection

After obtaining written informed consent, detailed demographic information, socioeconomic status,

duration of HIV infection, ART status, presenting complaints, associated systemic illnesses, and relevant

medical history were recorded using a predesigned structured proforma. A comprehensive general physical

examination, systemic examination, and detailed dermatological examination were performed. The

morphology, distribution, duration, and clinical diagnosis of each mucocutaneous lesion were documented.

Oral cavity, hair, nail, and genital mucosal examinations were also carried out whenever indicated.

Histopathological Evaluation

Patients with atypical, persistent, or clinically uncertain lesions underwent skin or mucosal biopsy after

obtaining informed consent. Biopsy specimens were fixed in 10% neutral buffered formalin, processed

routinely, embedded in paraffin, sectioned, and stained with hematoxylin and eosin. Special stains such as

Periodic Acid-Schiff (PAS), Ziehl-Neelsen (ZN), Gomori methenamine silver (GMS), or

immunohistochemistry were performed whenever clinically indicated to confirm the diagnosis.

Laboratory Investigations

Routine laboratory investigations included complete blood count, liver function tests, renal function tests,

blood glucose, and relevant microbiological investigations whenever required. CD4+ T-cell count was

determined using flow cytometry, while HIV viral load was estimated using real-time polymerase chain

reaction (RT-PCR) according to standard institutional protocols.

Statistical Analysis

Data were entered into Microsoft Excel and analyzed using Statistical Package for the Social Sciences

(SPSS) version 27.0 (IBM Corp., Armonk, NY, USA). Continuous variables were expressed as mean ±

standard deviation or median (interquartile range), while categorical variables were presented as

frequencies and percentages. The association between mucocutaneous manifestations and CD4+ T-cell

count or viral load was analyzed using the Chi-square test or Fisher's exact test for categorical variables.

Milan M et al | DOI: 10.65188/nurexus.1096

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Correlation between continuous variables was assessed using Pearson's or Spearman's correlation

coefficient depending on data distribution. A p-value <0.05 was considered statistically significant.

Ethical Considerations

The study protocol was approved by the Institutional Ethics Committee before commencement of the study.

Written informed consent was obtained from all participants prior to enrollment. Patient confidentiality was

maintained throughout the study by anonymizing personal identifiers, and all procedures were conducted

in accordance with the ethical principles of the Declaration of Helsinki.

Result

Table 1. Distribution of mucocutaneous manifestations among HIV-infected patients (n=95)

Mucocutaneous manifestation

Frequency (n)

Percentage (%)

Infectious lesions

40

42.1

Non-infectious lesions

55

57.9

Total

95

100.0

Among the 95 HIV-infected patients included in the study, 55 (57.9%) had non-infectious mucocutaneous

manifestations, whereas 40 (42.1%) had infectious lesions. Thus, non-infectious dermatoses were more

common than infectious dermatoses in the study population.

Table 2. Spectrum of infectious mucocutaneous manifestations (n=40)

Infectious lesion

Frequency (n)

Percentage (%)

Dermatophytosis

20

50.0

Candidiasis

5

12.5

Phaeohyphomycosis

1

2.5

Verruca vulgaris

3

7.5

Molluscum contagiosum

1

2.5

Herpes genitalis

1

2.5

Folliculitis

3

7.5

Cutaneous tuberculosis

3

7.5

Borderline tuberculoid leprosy

1

2.5

Scabies

2

5.0

Among the 40 patients with infectious mucocutaneous lesions, dermatophytosis was the most common

infection (50.0%), followed by candidiasis (12.5%). Viral infections such as verruca vulgaris (7.5%), herpes

genitalis (2.5%), and molluscum contagiosum (2.5%) were less frequent. Bacterial infections including

folliculitis (7.5%) and cutaneous tuberculosis (7.5%) were also observed, while scabies accounted for 5.0%

of infectious lesions.

Table 3. Spectrum of non-infectious mucocutaneous manifestations (n=55)

Non-infectious lesion

Frequency (n)

Percentage (%)

Papulopruritic eruption

15

27.3

Psoriasis

5

9.1

Eczema

5

9.1

Polymorphous light eruption

5

9.1

Lichen planus

4

7.3

Allergic contact dermatitis

4

7.3

Seborrheic dermatitis

3

5.5

Milan M et al | DOI: 10.65188/nurexus.1096

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Cutaneous drug reaction

3

5.5

Prurigo nodularis

2

3.7

Bullous pemphigoid

1

1.8

Lymphomatoid papulosis

1

1.8

Acrokeratosis verruciformis of Hopf

1

1.8

Erythema nodosum

1

1.8

Localized scleroderma

1

1.8

Vitiligo

1

1.8

Post-inflammatory hypopigmentation

1

1.8

Bullous lupus erythematosus

1

1.8

Squamous cell carcinoma

1

1.8

Total

55

100.0

Among the 55 patients with non-infectious lesions, papulopruritic eruption was the most common

manifestation (27.3%). Psoriasis, eczema, and polymorphous light eruption each accounted for 9.1% of

cases. Lichen planus and allergic contact dermatitis were observed in 7.3% of patients each, while

seborrheic dermatitis and cutaneous drug reactions each contributed 5.5%. The remaining dermatoses were

relatively uncommon.

Table 4. Distribution of study participants according to CD4 count (n=95)

CD4 count (cells/mm³)

Frequency (n)

Percentage (%)

<200

8

8.4

200–350

38

40.0

350–500

25

26.3

>500

24

25.3

Total

95

100.0

The majority of patients (40.0%) had a CD4 count between 200 and 350 cells/mm³, followed by 26.3%

with CD4 counts between 350 and 500 cells/mm³. Patients with CD4 counts greater than 500 cells/mm³

constituted 25.3%, whereas only 8.4% had severe immunosuppression with CD4 counts below 200

cells/mm³.

Table 5. Association between type of mucocutaneous manifestation and CD4 count

CD4 count (cells/mm³)

Infectious lesions n (%)

Non-infectious lesions n (%)

Total

p

<200

4 (10.0)

4 (7.3)

8

0.0027

200–350

21 (52.5)

17 (30.9)

38

350–500

12 (30.0)

13 (23.6)

25

>500

3 (7.5)

21 (38.2)

24

Total

40 (42.1)

55 (57.9)

95

Infectious mucocutaneous manifestations were predominantly observed among patients with lower CD4

counts, particularly those with CD4 counts between 200–350 cells/mm³ (52.5%), whereas non-infectious

lesions were more common among patients with CD4 counts above 500 cells/mm³ (38.2%). The association

between the type of mucocutaneous manifestation and CD4 count was statistically significant (Chi-square

= 11.81; p = 0.0027), indicating that the occurrence of infectious lesions increased with declining immune

status.

Table 6. Correlation of infectious mucocutaneous lesions with CD4 count and viral load

Infectious lesion

Mean CD4 count ± SD (cells/mm³)

Mean viral load ± SD

Fungal infection

359.03 ± 140.15

4222.07 ± 11265.23

Milan M et al | DOI: 10.65188/nurexus.1096

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Viral infection

197.40 ± 41.77

1405.20 ± 1506.23

Bacterial infection

354.71 ± 157.57

6400.40 ± 11436.02

Parasitic infestation

292.50 ± 77.07

75.00 ± 53.03

Among infectious dermatoses, viral infections were associated with the lowest mean CD4 count (197.40 ±

41.77 cells/mm³), indicating greater immunosuppression. Bacterial infections demonstrated the highest

mean viral load, whereas fungal infections occurred across a relatively broader range of immune status.

Table 7. Correlation of non-infectious mucocutaneous lesions with CD4 count and viral load

Non-infectious lesion

Mean CD4 count (cells/mm³)

Mean viral load

Papulopruritic eruption

409.3

2803.33

Psoriasis

554.5

7921.36

Seborrheic dermatitis

316.33

17041.33

Lichen planus

615.0

365.25

Prurigo nodularis

256.5

20080

Eczema

374.6

6577

Polymorphous light eruption

419.6

1558.5

Cutaneous drug reaction

507.0

Not done

Allergic contact dermatitis

766.75

118.5

Bullous pemphigoid

898

Target not detectable

Lymphomatoid papulosis

631

Not done

Localized scleroderma

814

22

Acrokeratosis verruciformis of Hopf

162

1123

Erythema nodosum

327

24323

Vitiligo

854

Not done

Post-inflammatory hypopigmentation

320

3424

Bullous lupus erythematosus

1101

Target not detectable

Squamous cell carcinoma

432

Not done

The mean CD4 count varied considerably among patients with different non-infectious dermatoses.

Conditions such as bullous lupus erythematosus, bullous pemphigoid, vitiligo, and localized scleroderma

were observed in patients with relatively higher CD4 counts, whereas prurigo nodularis, seborrheic

dermatitis, and acrokeratosis verruciformis of Hopf were associated with comparatively lower CD4 counts.

Viral load also showed considerable variability among different non-infectious lesions.

Table 8. Comparison of infectious and non-infectious mucocutaneous lesions according to CD4

count and viral load

Variable

Infectious lesions

Non-infectious

lesions

p-value

Number of patients

40

55

—

Mean CD4 count ±

SD

334.75 ± 140.42

487.27 ± 243.43

0.001

Patients with viral

load data (n)

31

40

—

Mean viral load ± SD

5575.10 ± 11688.13

5720.03 ± 11189.09

0.695

.

Milan M et al | DOI: 10.65188/nurexus.1096

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Discussion

The present study evaluated the clinicopathological spectrum of mucocutaneous manifestations in HIV-

infected patients and examined their correlation with CD4 count and viral load. Mucocutaneous

disorders remain among the earliest and most common clinical manifestations of HIV infection and

frequently reflect the degree of underlying immunosuppression. Recognition of these lesions is therefore

important for early diagnosis, assessment of disease progression, and timely initiation of appropriate

management.[1-4]

In the present study, non-infectious mucocutaneous manifestations constituted 57.9% of cases, whereas

infectious lesions accounted for 42.1%. Similar findings have been reported by Singh et al., who

observed a predominance of non-infectious dermatoses among patients receiving antiretroviral therapy,

suggesting that improved immune status and prolonged survival have altered the spectrum of HIV-

associated skin diseases.[6] In contrast, Sharma et al. and Goh et al. reported a higher prevalence of

infectious dermatoses, particularly among patients with advanced immunosuppression and lower CD4

counts.[5,7]

Among infectious lesions, dermatophytosis was the most common fungal infection, followed by

candidiasis, while bacterial and viral infections occurred less frequently. Similar observations were

reported by Sharma et al. and Goh et al., who found fungal infections to be the predominant

opportunistic cutaneous infections in HIV patients because of progressive impairment of cell-mediated

immunity.[5,7] Cedeno-Laurent et al. also described fungal dermatoses as important clinical indicators

of declining immune function in HIV-infected individuals.[4]

Papulopruritic eruption was the commonest non-infectious mucocutaneous manifestation in the present

study, followed by psoriasis, eczema, polymorphous light eruption, lichen planus, and allergic contact

dermatitis. Similar findings have been documented by Sharma et al. and Singh et al., where

papulopruritic eruption represented one of the most frequent inflammatory dermatoses associated with

HIV infection.[5,6] Fitzpatrick's Dermatology likewise describes papulopruritic eruption as a

characteristic manifestation resulting from immune dysregulation in HIV infection.[1]

A major finding of the present study was the significant association between the type of mucocutaneous

manifestation and CD4 count (χ² test, p = 0.0027). Infectious mucocutaneous lesions occurred

predominantly in patients with lower CD4 counts, whereas non-infectious manifestations were more

frequent among patients with relatively preserved immune function. Similar observations have been

reported by Sharma et al., Singh et al., and Baveja and Chattopadhyay, all of whom demonstrated that

the frequency and severity of opportunistic skin infections increase significantly with progressive

decline in CD4 lymphocyte count.[5,6,16]

The comparison of mean CD4 counts further supported this association. Patients with infectious

mucocutaneous manifestations had a significantly lower mean CD4 count (334.75 ± 140.42 cells/mm³)

than those with non-infectious lesions (487.27 ± 243.43 cells/mm³), and this difference was statistically

significant (Independent t-test, p = 0.001). Gupta and Kumar similarly demonstrated that opportunistic

infectious dermatoses are significantly associated with advanced immunosuppression, whereas

inflammatory dermatoses occur more commonly at relatively higher CD4 counts.[17] Sharma et al. also

reported a progressive increase in opportunistic infections as CD4 counts decline.[5]

In contrast, viral load did not differ significantly between patients with infectious and non-infectious

Milan M et al | DOI: 10.65188/nurexus.1096

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mucocutaneous manifestations (p = 0.695), indicating that viral replication alone may not predict the

occurrence or pattern of dermatological manifestations. Comparable findings have been described by

Cedeno-Laurent et al., Singh et al., and Kumarasamy et al., who observed that CD4 count demonstrates

a stronger clinical correlation with mucocutaneous manifestations than plasma viral load.[4,6,18]

The findings of the present study are consistent with current WHO and UNAIDS recommendations

emphasizing regular dermatological examination as an essential component of HIV care, particularly in

resource-limited settings where mucocutaneous manifestations often provide valuable clinical indicators

of immune deterioration.[2,3] Early recognition of these lesions facilitates prompt diagnosis, timely

initiation or optimization of antiretroviral therapy, and appropriate management of opportunistic

infections.

The strength of this study is the combined clinicopathological evaluation of mucocutaneous lesions

together with their correlation with immunological and virological parameters. Histopathological

confirmation of selected lesions improved diagnostic accuracy and minimized clinical misclassification.

However, the study was conducted at a single tertiary care centre with a relatively small sample size,

limiting the generalizability of the findings. In addition, the cross-sectional design precluded assessment

of longitudinal changes in mucocutaneous manifestations following antiretroviral therapy.

Conclusion

Mucocutaneous manifestations are very common in HIV patients. The usual lesions can present with

unusual and atypical manifestations in HIV patients. The non-infectious lesions were more common than

infectious lesions. Among infectious lesions, fungal infections were more common and papulopruritic

eruption was more common among non-infectious lesions. Neoplastic lesions were seen in only 1.8% of

patients. There was a significant correlation between the CD4 count and the mucocutaneous lesions. In our

study, the mean CD4 count was found to be low (< 350 cells/cumm) in patients with infectious lesions,

whereas non infectious lesion was associated with CD4 count of >350 cells/cumm. No significant

correlation was seen between viral load and mucocutaneous lesions in our study.

Declaration

Conflict of Interest: The authors declare that they have no competing interests or conflicts of interest

related to this work.

Funding: Nil

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