Scholarly article on topic 'Urticaria pigmentosa in a patient with acquired immunodeficiency syndrome – a case report / Urtikarija pigmentoza kod obolelog od sindroma stečene imunodeficijencije – prikaz slučaja'

Urticaria pigmentosa in a patient with acquired immunodeficiency syndrome – a case report / Urtikarija pigmentoza kod obolelog od sindroma stečene imunodeficijencije – prikaz slučaja Academic research paper on "Clinical medicine"

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Academic research paper on topic "Urticaria pigmentosa in a patient with acquired immunodeficiency syndrome – a case report / Urtikarija pigmentoza kod obolelog od sindroma stečene imunodeficijencije – prikaz slučaja"

DOI: 10.2478/v10249-011-0043-7

Urticaria Pigmentosa in a Patient with

Acquired Immunodeficiency Syndrome - a case report

Slobodan STOJANOVIC1*, Snezana BRKIC2, Marina JOVANOVIC1, Nada VUCKOVIC3

1 Clinic of Dermatovenereology Diseases, Clinical Center of Vojvodina, Novi Sad, Republic of Serbia

2 Infectious Diseases Clinic, Clinical Center of Vojvodina, Novi Sad, Republic of Serbia 3Center of Pathology and Histology, Clinical Center of Vojvodina, Novi Sad, Republic of Serbia Correspondence: Slobodan STOJANOVIC, e-mail: slobodanstojanovicns@sbb.rs

UDC 616.5:[616.988:578.828

Abstract

The authors present a case of a man with urticaria pigmentosa and acquired immunodeficiency syndrome - AIDS. The patient was diagnosed as HIV (human immunodeficiency virus) - positive in the year 2000, at the Infectious Diseases Clinic, Clinical Center of Vojvodina in Novi Sad. Urticaria pigmentosa was detected (nine years later) during a dermatological examination at the Dermatovenerology Department of the Outpatient Clinic, Clinical Center of Vojvodina. Urticaria pigmentosa is the most common manifestation of cutaneous mastocytosis. The patient was taking long term antiviral therapy for several years. Approximately 2 years after the onset of urticaria pigmentosa, this patient developed septicemia and ascites along with hepatosplenomegaly, liver damage, chronic cholecystitis, leukopenia, thrombocytopenia and relative eosinophilia. The patient had increased total serum IgE levels and tested positive for 5-hydroxyindoleacetic acid in a 24-hour urine test from the very beginning of urticaria pigmnentosa and during the course of his illness. Immunohistochemical results of dermal biopsy of the affected area confirmed the diagnosis of urticaria pigmentosa. Histology findings confirmed presence of typical dermal mast cell infiltrates with distinct oval and spindle granules that were CD117+ and CD1a-. Systemic mastocytosis was excluded by liver and bone marrow biopsies. To our knowledge, we present the third case of associated mastocytosis and acquired immunodeficiency syndrome published in world literature so far, in order to indicate the possible interaction between HIV infection and mast cells.

Key words

Urticaria Pigmentosa; HIV; Acquired Immunodeficiency Syndrome; Comorbidity

Urticaria pigmentosa is the most common manifestation of cutaneous mastocytosis in children and adults. In children cutaneous mastocytosis can recur, but may also spontaneously involute (1, 2, 3, 4, 5, 6, 7). The clinical picture differs in childhood and adulthood, both regarding the course and prognosis (1,2). Typical clinical manifestations of urticaria pigmentosa are symmetrically distributed yellowish-brown macules or red papular skin changes. The hairy part of the head, hands, feet and face may be spared. Mucosa is rarely affected. Mild irritation (rubbing or

scratching) causes release of inflammatory response mediators (histamine, prostaglandins, leukotrienes, cytokines) causing urtica on the irritated site, which is referred to as the Darier's sign (1, 2, 5, 6, 7).

As far as we are concerned, this is a rather peculiar case report, since it represents only the third report of associated acquired immunodeficiency syndrome and mastocytosis in the world literature (8,9); furthermore it arises the question whether this association developes due to possible immunogenetic disorders and immunogenetic rearrangements.

Case report

A male patient 36 years of age, an employed worker, single, with HIV confirmed in the year 2000, was initially diagnosed with idiopathic thrombocytopenia. The patient was taking the same highly active antiretroviral therapy (HAART): ddi (didanosine), 3TC (lamivudine), EFV (efavirenz). His CD4 lymphocyte blood count has been stable ever since (with approximately 300 cells/ml), while HIV Ribonucleic acid (RNA) was undetected in his blood via polymerase chain reaction (PCR). The onset of symptoms occurred approximately 2 years before, when yellowish-brown macules and red papular skin changes appeared mostly on his torso and upper extremities, occasionaly followed by severe itching and reddness when scratched. These symptoms intensified in Fall 2009, when the patient was admitted to the Dermatovenerology Department of the Outpatient Clinic, Clinical Center ofVojvodina. The examination revealed many yellowish-brown maculopapular eflorescences on the torso and upper extremities, associated with severe itching, and a positive Darier's

Figure 1. Urticaria pigmentosa in an AIDS patient

sign (Figures 1 and 2). A punch biopsy was performed by a dermatologist in order to clarify skin changes. Ten days later, the patient was admitted to the Infectious Diseases Clinic due to high fever (up to 39 degrees celsius) and abdominal pain. Streptococcus agalactiae was isolated using hemoculture. Inflammatory parameters were lowered by appropriate antibiotic therapy and the patient felt better. However, there was a sudden development of ascites. Control blood CD4 count was decreased (198/ml), while HIV RNA PCR still showed negative results. Symptomatic therapy lead to disappearance of ascites, but splenomegaly persisted.

During 2009, the patient was hospitalized at the Infectious Diseases Clinic, Clinical Center of Vojvodina in Novi Sad four more times, in 2010 six times, and in 2011 on two occasions, when systemic mastocytosis was excluded. The patient had to receive the same highly active antiretroviral HAART therapy, but desloratadine 5mg/day was added as well.

Personal history. Hypersensitivity to various food allergenes. Other problems include irregular bowel movement and diarrhea.

Family history. Negative.

Physical examination. Upon skin examination, yellowish-brown macules and a large number of reddish papules, up to 5mm in size, with a positive Darier's sign were found mainly on the abdomen, chest, back, arms and legs (Figures 1 and 2). No changes were found on patient's mucosa and lips.

Figure 2. Darier's sign

Laboratory and other test results

Laboratory test revealed the following abnormal results: Leukopenia (low WBC 2.70 x 109/L, normally 4-10x109/L), thrombocytopenia (78,1 x 109/L, normally 140-400 x 109/L), relative eosinophilia [0,316 x 109/L (normally > 0.470 x 109/L); 11.7% of the total white blood count (normally 0-5%)], slightly elevated transaminase activity (ALT 47 UI/mL, AST 56 UI/mL) along with slightly elevated alkaline phosphatase levels 218 U/I (normally < 198 U/I); increased gamma glutamyl transpeptidase levels (223 IU/mL); hemostatic mechanism within reference values (APTT 0.88: PT 1.91; TT 1,10, D-dimer 110); total serum proteins 76 g/l; serum protein electrophoresis indicated hypergammaglobulinemia of 24,9 g/L (normally 7-16 g/L); other basic laboratory test results were normal.

Positive finding of 5-hydroxyindoleacetic acid - 5-HIAA in the 24-hour urine test: 46,9 ^mol/dU (reference range 10,4-31.2 ^imol/dU).

Total IgE serum levels: significantly increased 1425 IU/ml (reference value 100 IU/ml).

Histopathologic»! result from September 2009: A skin fragment was histologically examined in 12 sections stained with HE, PAS, Gomory and Giemsa methods. The epidermis was uneven and atrophic, with focal irregular elongations and anastomoses with diffuse hyperkeratoses. Slight chronic inflammatory infiltrate with enlarged number of mast cells was found perivascularly in the papilar dermis. Skin adnexa were missing (Figures 3 and 4).

Histological and immunohistochemical test done in September/09 (methods used: HE, Giemsa, immunohistochemical: C-kit): The skin sample revealed a slight ortokeratotic hyperkeratosis, as well as moderate acanthosis with a mild epidermal atrophy and spongiosis. There were dermal edema and moderate perivascular infiltrations of lymphocytes and oval and spindle-shaped cells (CD117+, CD1-). Giemsa staining focally revealed granules within those cells, which undoubtedly indicated mast cells (Figure 4).

Control HIV RNA PCR test: in January/2011 was still negative in the patient's blood.

Control blood CD4 counts: were decreased during the 2009-2011 period: in 0ctober/09 and January/11 levels were 198/ml and 237/ml, respectively (normally 600-1600/ml).

Figure 3. Histological presentation of cutaneous mastocytosis (HE staining x100): scanty perivascular infiltrate in the upper half of dermis.

Control peripheral blood smears: did not

point to increased presence of mast cells, but to thrombocytopenia.

Blind liver biopsy showed: signs of a mild form of chronic persisting hepatitis with moderate fibrosis. An increased count of mast cells was not found.

Fig. 4. Histological presentation of mastocytosis (Giemsa staining x400): perivascular infiltrate of mononuclear cells with predominant mastocytes in papillary dermis; the cytoplasms of mast cells are filled with small, faintly visible, eosinophilic or amphiphilic granules which stain metachromatically with the Giemsa stains.

Control bone marrow biopsy: in April/2011 the finding showed no presence of mast cells.

Serum osteocalcin levels were within reference values (21.1 ng/ml; normally 11-46 ng/ml), while Crosslabs levels were elevated (857 pg/ml; normally 158-442 pg/ml).

Control immunology tests results were negative: ANA, ANCA, antimitochondrial antibodies, antiparietal cell antibodies, smooth muscle antibodies, and Hep-2 cells ANA test results were negative.

Ultrasound of the upper abdomen: Spleen 167mm. The gallbladder wall was thickened up to 16mm and stratified, without gallstones. A minimal amount of free fluid was registered in the Morison's pouch and around the spleen.

Diagnosis: Splenomegaly, Ascites, Chronic Cholecystitis.

Control Doppler US of the portal vein showed: cryptogenic portal vein hypertension; grade IV esophageal varices; thrombosis exclused.

Chest X-ray — normal.

Echocardiography finding normal: without pericardial effusion.

DEXA scan results: within the normal range.

Abdominal computed tomography: Diagnosis: Splenomegaly, Ascites.

Abdominal nuclear magnetic resonance:

Diagnosis: Splenomegaly, Ascites.

Discussion

In our case, the diagnosis of urticaria pigmentosa was established primarily by clinical presentation and the histology of skin biopsy. Taking into consideration the diagnostic criteria which include significantly increased total serum IgE levels and increased levels of 5-hydroxyindoleacetic acid in 24-hour urine, the clinical diagnosis was clearly confirmed. Our patient also had liver damage, chronic cholecystitis, leukopenia, thrombocytopenia and eosinophilia, which at one point suggested a systemic disease.

So far, only two papers have been published on mastocytosis and HIV infection association. The first case was an AIDS patient with systemic mastocytosis and eosinophilia treated with imatinib mesylate therapy (8), and the second was an AIDS patient with cutaneous mastocytosis (9).

According to the The WHO classification of mastocytosis, the following types of mastocytosis and mastocytosis syndromes were differentiated: 1. cutaneous mastocytosis (e.g.urticaria pigmentosa) involving only the skin with excellent prognosis in children, tends to regress spontaneously during adolescence; 2. systemic mastocytosis: mostly affecting more than one organ, without documented cases of spontaneous remission, it exists in several forms: a. indolent systemic mastocytosis, usually occurs with skin changes that are similar to those of urticaria pigmentosa, along with visceral organs involvement with relatively mature mast cells, with absence of hematological abnormalities and signs of progressive damage to internal organs, this form is associated with an almost normal life expectancy; b. aggressive systemic mastocytosis, characterised by progressive infiltration of mast cells which often exhibit cellular atypia into different organs, hematologic abnormalities and splenomegaly are common, while appearance of skin lesions is rare (10%), the prognosis is poor; c. systemic mastocytosis with chronic myelomonocytic leukemia (SM-CMML), characterized by over 10% atypical mast cells in peripheral circulation and diffuse bone marrow infiltration. The disease has a rapid fatal course (3, 4). Due to the suspicion of indolent systemic mastocytosis, the following procedures were repeated in our patient: Doppler portal vein US (which excluded thrombosis); computed tomography and abdominal nuclear magnetic resonance imaging; DEXA-scan — recommended by a hematologist due to elevated alkaline phosphatase levels; bone marrow biopsy. Repeated liver and bone marrow biopsy showed normal count of mast cells, so systemic mastocytosis was excluded as well as the need for interferon therapy.

In differential diagnosis systemic mastocytosis is often mistaken for other lymphoreticular diseases, hairy cell leukemia and histiocytic proliferation due to mast cells granules that may be hard to notice in routine histological sections. The main indication for their identification is the presence of nests of cells that "resemble monocytes" associated with eosinophilia and sclerosis. The systemic mastocytosis diagnosis is than easily confirmed by Giemsa stain method (purple granules), toluidine stain method (metachromatic granules), chloroacetate esterase stain method (bright red granules, with positive granulocytes). Tryptase

immunostaining method is more sensitive than histochemical staining technique for confirming the presence of mast cell differentiation. CD117/c-kit, which shows cell membrane immunoreactivity, also promises to be a sensitive marker (1, 10-13). In our case the diagnosis of urticaria pigmentosa was also confirmed by immunohistochemical findings of numerous spindle-shaped and oval cells (CD117 + and CDla-) present in the dermis. Immunohistochemical finding of mastocytosis is based on the presence of antigen CD117+ on the surface of mast cells (11, 12).

In terms of the aforementioned, systemic mastocytosis is characterised by abnormal mast cell infiltration of the spleen, lymph nodes, bone marrow and liver, with or without skin involvement. There is a predominance of middle-aged male patients, approximately 60 years of age. Patients suffer from skin changes, anaphylaxsis, pain and/or bone fractures (osteoporosis, osteolytic changes, osteosclerosis, or mixed), gastrointestinal symptoms (abdominal pain, diarrhea and peptic ulcer), respiratory difficulties (wheezing, dyspnea), hematological changes (cytopenia, eosinophilia, monocytosis, mast cells in blood circulation) or hepatosplenomegaly. Many of these symptoms are related to the release of histamine from mast cells. Therefore, a third-generation antihistamine was introduced into the therapy of our patient.

Absence of skin changes, presence of cellular atypia, and association with hematological diseases are unfavorable prognostic factors. (1, 10, 11). There are reports on rare association of systemic mastocytosis with mediastinal germ cell tumors (3, 4).

According to several authors, although there are no specific reports on the interaction of human immunodeficiency virus (HIV) and mast cells in AIDS patients, there is an interaction with basophilic granulocytes which are also FceRIa (a subunit of the human high-affinity IgE -receptor) - carriers like mast cells. Firstly, HIV transactivator protein (Tat) acts as a specific chemoattractant for FceRIa-positive cells through its interaction with the CCR3 chemokine receptor (type 3 — protein encoded by CCR3 gene, recently designated as CD 193) (13); Secondly, peptides derived from HIV such as HIV-1 envelope gp41 peptides are chemo tactic for basophilic granulocytes (14), and finally, basophils show wide HIV receptor surface expression, such as

CD4, CCR3, CCR5 (chemokine receptor type 5 -protein encoded by CCR5 gene, recently designated as CD195) and CXCR4 (chemokine receptor type 4 -protein encoded by CXCR4 gene, recently designated CD 184) (15), which, together with HIV Tat protein, can up regulate CCR3 (13). Although there is evidence of HIV infected basophilic granulocytes, the presence of similar analogy between HIV and mast cells remains unclear (9, 13, 16). Nevertheless, recent data provided in vivo, showed that in infected persons during HAART, tissue mast cells, raised from infected circulating progenitor mast cells, represent a long-lived reservoir of persistent HIV (17).

Conclusion

We present a case of mastocytosis in an AIDS patient as a third case published in world literature, in order to underline the possibility of development of cutaneous mastocytosis in persons with AIDS, due to immunogenetic damage and possible immunogenetic rearrangements.

Abbreviations

AIDS - Acquired immunodeficiency syndrome

HIV - Human immunodeficiency virus

HAART - Highly active antiretroviral therapy

ddi - Didanosine

3TC - Amivudine

EFV - Efavirenz

RNA - Ribonucleic acid

PCR - Polymerase chain reaction

WBC - White blood count

ALT - Alanine aminotransferase

AST - Aspartate aminotransferase

PT - Prothrombin time

APTT - Activated partial thromboplastin time ( ANA - Antinuclear antibodies ANCA - Antineutrophil cytoplasmic antibodies Hep-2 cells.- Ceels derived from a human laryngeal epithelial cell line US - Ultrasound

DEXA - Dual-energy X-ray absorptiometry WHO - World Health Organization SM-CMML - Systemic Mastocytosis with

Chronic Myelomonocytic Leukemia Tat - HIV transactivator protein

FcsRIa - a subunit of the human high-affinity

IgE - receptor CCR3 - chemokine receptor type 3 — protein

encoded by CCR3 gene CCR5 - chemokine receptor type 5 — protein

encoded by CCR5 gene CXCR4 - chemokine receptor type 4 - protein encoded by CXCR4 gene

References

1. Carter CM, Metcalfe DD. Biology of mast cells and the mastocytosis syndromes. In: Wolff K, Lowel A, Stephen

1. Gilchrest BA, Paller AS, Leffel DJ, editors. Fitzpatrick's Dermatology in general medicine. 7th ed. New York: Mc Graw Hill; 2008. p. 1435-43.

2. Prcic S, Duran V, Gajinov Z, Ceke M, Tomic J, Vijatov G, et al. Nodular mastocytosis of the vulva and coexisting urticaria pigmentosa. Serb J Dermatol Venereol 2009;1(4):153-6.

3. Chan JK. Tumors of the lymphoreticular system. In: Flecher CD, editor. Diagnostic histopathology of tumors. 3rd ed. Edinburgh: Churchill Livingstone Elsevier; 2007. p. 1139-289.

4. Valent P, Horny HP, Li CY, Longley BJ, Metcalfe DD, Parwaresch RM, et al. Mastocytosis. In: Jaffe ES, Lee Harris N, Stein H, Vardiman JW, editors. Pathology and genetics of tumours of haematopoetic and lymphoid tissues. Oxford: Oxford University Press; 2001. p. 291-304.

5. Flaquel B. Cutaneous mastocytosis. Rev Prat 2006;56(16):1745-51.

6. Akoglu G, Erkin G, Cakir B, Boztepe G, Sahin S, Karaduman A, et al. Cutaneous mastocytosis: demographic aspects and clinical features of 55 patients. J Eur Acad Dermatol Venereol 2006;20(8):969-73.

7. Ben-Amitai D, Metzker A, Cohen HA. Pediatric cutaneous mastocytosis: a review of 180 patients. Isr Med Assoc J 2005;7(5):320-2.

8. Merante S, Chichino G, Boveri E, Gottardi E, Soverini S, Cilloni D, et al. First case an AIDS patient with systemic mast cell disease associated with eosinophilia FIP1-positive treated with Immatinab mesylate therapy. J Clin Oncol 2006;24(4):e6-e7.

9. Soilleux EJ, Grills C, Cooper SM. Cutaneous mastocytosis in human immunodeficiency virus: an unfortunate coincidence? Clin Exp Dermatol 2008;33:619-21.

10. Escribano L, Alvarez-Twose I, Sanches-Munoz L, Montero AG, Nuriez R, Almeida J, et al. Prognosis in adult indolent systemic mastocytosis: a long term study of the Spanish network on mastocytosis in a series of 145 patients. J Allergy Clin Immunol 2009;124(3):514-21.

11. Valent P, Horny HP, Escribano L, Longley BJ, Li CY, Schwartz LB, et al. Diagnostic criteria and classification of mastocytosis: a consensus proposal. Leuk Res 2001;25(7):603-25.

12. Akin C, Valent P, Escribano L. Urticaria pigmentosa and mastocytosis: the role of immunophenotyping in diagnosis and determining response to treatment. Curr Allergy Asthma Rep 2006;6:282-8.

13. Marone G, Florio G, Petraroli A, Triggiani M, de Paulis A. Human mast cells and basophils in HIV-1 infection. Trends Immunol 2001;22(5):229-32.

14. de Paulis A, Florio G, Prevete N, et al. HIV-1 envelope gp41 peptides promote migration of human Fc epsilon RI+ cells and inhibit IL-13 synthesis through interaction with formyl peptide receptors. J Immunol 2002;169:4559-67.

15. Li Y, Li L, Wadley R, et al. Mast cells/basophils in the peripheral blood ofallergic individuals who are HIV-1 susceptible due to their surface expression of CD4 and the chemokine receptors CCR3, CCR5, and CXCR4. Blood 2001;97:3484-90.

16. Nelson AM, Auerbach A, Man YG. Failure to detect active virus replication in mast cells at various tissue sites of HIV patients by immunohistochemistry. Int J Biol Sci 2009;5(6):603-10.

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Urtikarija pigmentoza kod obolelog od sindroma stecene imunodencijencije - prikaz slucaja

Sazetak

Uvod: Urtikarija pigmentoza je najcesca manifestacija kutane mastocitoze kod dece i odraslih. Kod dece kutana mastocitoza moze da recidivira ali i da spontano involuira. Klinicka prezentacija oboljenja kod dece i odraslih razlikuje se, kako po toku tako i po prognozi. Bolest ima tipicne klinicke manifestacije u smislu pojave zutosmedih makuloznih ili crvenih papuloznih promena na kozi sa simetricnim rasporedom. Kosmati deo glave, sake, stopala i lice mogu biti postedeni. Sluznice su retko zahvacene. Blaga iritacija (trljanje

ili grebanje) izazivaju oslobadanje medijatora inflamatorne reakcije (histamina, prostaglandina, leukotrijena, citokina) koji dovode do pojave urtika na mestu iritacije, sto se oznacava kao Darijeov znak. Cilj: Prikazujemo slucaj kutane mastocitoze sa urtikarijom pigmentozom kod obolelog od sindroma stecene imunodeficijencije kao treci do sada objavljeni slucaj u nama dostupnoj svetskoj literaturi. Cilj nam je da ukazemo na mogucnost razvoja kutane mastocitoze kod obolelih od AIDS-a zbog imunogenetskih

ostecenja i mogucih imunogenetskih rearanzmana. Prikaz slucaja: Kod bolesnika (osoba, muskog pola, 36 godine, radnik, zaposlen, neozenjen) je 2000. godine utvrdeno prisustvo infekcije sa virusom humane imunodeficijencije (eng. Human immunodeficiency virus - HIV). U Dermatoveneroloskom odeljenju Poliklinike Klinickog centra Vojvodine urtikarija pigmentoza je otkrivena devet godina kasnije pri dermatoloskom pregledu. Bolesnik se nalazi na HAART (Highly Active Anti Retroviral Therapy) terapiji: (HAART): ddi (didanosine), 3TC (lamivudine), EFV (efavirenz) od 2001. godine. Od tada ima stabilan broj CD4 limfocita oko 300 celija/ml i sve vreme nakon uvodenja terapije ima nedetektabilan PCR HIV RNK u krvi. Od pre oko 2 godine dolazi do pojave zuckastosmedih makula i crvenkastih papula na kozi poglavito trupa i gornjih udova, pracenih povremeno jacim svrabom i crvenilom pri trljanju istih. Ove promene se intenziviraju s jeseni 2009. godine. Tada se javlja na pregled u dermatovenerolosku sluzbu Poliklinike Klinickog centra Vojvodine. Na pregledu je utvrden veci broj zuckastosmedih makulo-papuloznih eflorescencija na kozi trupa i udova, pracenih jacim svrabom. Uradena je „punch biopsija" koznih promena od strane dermatologa, kojom je (Giemsa bojenjem) potvrdena dijagnoza urtikarije pigmentoze. Od pojave urtikarije pigmentoze pa nadalje, bolesnik je imao povisen nivo ukupnih IgE u serumu i pozitivan nalaz 5-hidroksiindol-sircetne kiseline u 24-casovnom urinu. Imunohistohemijski nalaz, posle uzete biopsije sa mesta kozne promene, potvrdio je dijagnozu pigmentne urtikarije, otkrivanjem tipicnih dermalnih infiltrata mast celija sa izrazenim granulama, ovalnog i vretenastog oblika koji su bili CD117 + i CD 1a-. Bolesnik se javlja na Kliniku za infektivne bolesti zbog visoke temperature do 39° C i bolova u stomaku, deset dana kasnije. Iz krvi je iskultivasan Streptococcus agalactiae. Bolesnik se dobro osecao posle zapocinjanja odgovarajuce antibiotske terapije, pokazatelji inflamacije u serumu su bili u padu. Medutim, tada dolazi do naglog razvoja ascitesa. Kontrolni broj CD4 limfocita bio je u daljem padu i iznosio je 198/ ml, a PCR HIV RNK u krvi je i dalje bio negativan. Primenjena simptomatska terapija je dovela do iscezavanja ascitesa ali sa odrzavanjem splenomegalije. U licnoj anamnezi postojao je podatak o svrabu na mestu promena na kozi, neredovnom praznjenju creva, prolivu, kao i o preosetljivosti na razlicite nutritivne

alergene. Podaci dobijeni u porodicnoj anamnezi nisu imali znacaj za sadasnju bolest. U toku 2009. godine pacijent je hospitalizovan na Klinici za infektivne bolesti Klinickog centra Vojvodine u Novom Sadu jos 4 puta, 2010. godine 6 puta, a 2011. godine dvaput, kada je invazivnim dijagnostickim procedurama (ponovljene kostne srzi i biopsije jetre) iskljuceno postojanje sistemske mastocitoze. Broj CD4+ celija je u toku poslednje hospitalizacije iznosio 237/ml, a PCR HIV RNK u krvi je i dalje bio negativan. Pregledom abdomena doplerom, kompjuterizovane tomografije i pomocu nuklearne magnetne rezonancije utvrdena je samo kriptogena portna hipertenzija sa prisustvom variksa jednjaka IV stepena, prisusustvo manje kolicine ascitesa i hronicni holecistitis. Bolesnik je nastavio da po otpustu prima HAART terapiju i desloratadin (5 mg dnevno).

Diskusija: Dijagnoza urtikarije pigmentoze je kod bolesnika postavljena na osnovu anamneze, klinicke slike, relevantnih laboratorijskih nalaza (znacajno povisene vrednosti ukupnih IgE u serumu i povisene vrednosti 5-hidroksi-indol sircetne kiseline u 24-casovnom urinu i histoloskim pregledom (specificno bojenje) biopsije koznih promena i, posebno, imunohistohemijskim nalazom prisustva brojnih vretenastih i ovalnih celija u dermisu koje su CD117+ i CD1a-. Kod naseg bolesnika pronadena su i ostecenja jetre, hronicni holecistitis, leukopenija, trombocitopenija i eozinofilija (relativna) koji su u jednom momentu pobudivali ozbiljnu sumnju na sistemsku mastocitozu. Sistemska mastocitoza se karakterise progresivnom infiltracijom razlicitih organa mast celijama koje cesto ispoljavaju celijsku atipiju. Hematoloske abnormalnosti i splenomegalija su uobicajene. Iz ovih razloga radene su visestruke biopsije jetre i kostne srzi, kao i CT i MR pregled jetre i abdomena. Kako ovi pregledi i metode nisu mogle potvrditi prisustvo mast celija u vecem broju, doslo se do zakljucka da u ovom momentu nema elemenata za dijagnozu sistemske bolesti. Biopsija jetre je otkrila samo blag oblik hronicnog persistentnog hepatitisa sa fibrozom.

Prema podacima iz literature, kod obolelih od AIDS-a utvrdena je interakcija izmedu virusa i bazofilnih granulocita: HIV transaktivacioni protein (Tat) predstavlja specificni hemoatraktant za celije koje na svojoj povrsini poseduju receptore visokog afiniteta za vezivanje imunoglobulina klase E (FceRIa pozitivne celije), hemotaksija se odvija uz pomoc hemokinskog

receptora tip 3 (CCR3); peptidi u sastavu virusnog glikoproteina gp41 - HIV gp41 predstavljaju hemoatraktante za bazofilne granulocite; na svojoj povrsini, bazofilni granulociti poseduju HIV receptore (CD4, CCR3, CCR5, CXCR4) koji zajedno sa HIVTat proteinom povecavaju ekspresiju CCR3. Ipak, za sada nedostaju publikovani radovi o interakciji izmedu virusa humane imunodeficijencije (HIV) i mast celija

(koji takode na svojoj povrsini nose isti receptor FczRI, kao i bazofili).

Zakljucak: Prikazani slucaj ne predstavlja samo treci do sada u svetu publikovan slucaj mastocitoze kod bolesnika sa AIDS-om, nego, ukazuje i na potrebu za daljim ispitivanjem moguce patogenetske uloge imunogenetskih ostecenja i imunogenetskih rearanzmana kod obolelih od AIDS-a.

Kljucne reci

Urticaria Pigmentosa; HIV; Sindrom stecene imunodeficijencije; Komorbiditet