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Last Updated: June 27, 2008

Case 1: A 43-Year-Old with a Persistent Skin Rash

Authors: David H. Spach, MD Roy Colven, MD

Learning Objectives

A 43-year-old HIV-infected man with advanced AIDS and a CD4 count of 22 cells/mm3 had the gradual development of a nonpruritic, diffuse, erythematous, macular rash. Initially, the rash was thought to be a drug eruption secondary to phenobarbital, but the condition steadily progressed for 2 weeks after discontinuing this medication. At that point, the rash had evolved into hyperkeratotic plaques on the thighs, chest, back, shoulders, and upper arms. Marked fissuring had also developed on the shoulder (Figure 1). The rash never became pruritic. Scale was collected by scraping and examined at low power under a microscope (Figure 2) ).

Which of the following is the most likely diagnosis of this patient’s skin problem?

A Psoriasis with secondary lice infestation.
B Seborrheic dermatitis.
C Secondary syphilis.
D Crusted scabies.

  • The following link will open in a new window.
    Figure 1. Rash in Patient with Advanced AIDS

    This image of a patient with advanced AIDS shows a diffuse, erythematous, rash, with plaque-like lesions in the shoulder region.
    From: Spach DH, Fritsche TR. Images in Clinical Medicine. N Engl J Med 1994;331:777
    This image is reproduced with permission from the Massachusetts Medical Society. Copyright © 1994 Massachusetts Medical Society. All rights reserved.


    Figure 1
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    Figure 2. Microscopic View of Skin Scraping

    This image shows a microscopic view (x1100) of a skin scraping taken from the patient shown in Figure 1.
    From: Spach DH, Fritsche TR. Images in Clinical Medicine. N Engl J Med 1994;331:777
    This image is reproduced with permission from the Massachusetts Medical Society. Copyright © 1994 Massachusetts Medical Society. All rights reserved.


    Figure 2