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We have read with interest the article by Toro et al,1 "Granuloma Annulare and Human Immunodeficiency Virus Infection," and the comment by Cohen2 in the same issue of the ARCHIVES. Toro et al1 report 34 cases of the association between these diseases and review 23 more from the English-language literature, including 2 cases of perforating granuloma annulare (PGA). Of their 34 cases, 2 were PGA, constituting a 6% prevalence.
In 1997, we published a review of the 52 cases of PGA found in the literature and reported 6 additional cases.3 In our institution, PGA accounts for 5% of the reported cases of granuloma annulare in the general population, very close to the results reported by Toro et al in their population of patients with human immunodeficiency virus (HIV). This suggests that the number of cases of PGA among the HIV-infected population does not strongly differ from that in the general population. Although Toro et al conclude that granuloma annulare is a relatively common eruption in HIV-infected patients, they do not report the number of HIV-infected patients they have seen in the 11 years of study, so no incidence or prevalence can be inferred to support their statement.
In regard to the association of PGA and HIV, one of our patients with PGA also had HIV. She was a 34-year-old woman who came to our clinic in 1994 reporting a 1-month history of asymptomatic papular lesions on her hands, arms, and legs. She had a mix of clinically perforating and nonperforating papular lesions on her elbows and dorsal hands. Findings of a complete blood cell and chemical analysis did not disclose any relevant information except 302 CD4 cells/µL3. No diabetes mellitus was detected. Results of serologic studies revealed positive titers of 1:64 for herpes simplex, 1:16 for Epstein-Barr, and negative findings for cytomegalovirus. Histologic findings were similar to other cases of PGA.
The patient also reported that lesions appeared 4 months after starting treatment with zalcitabine, which was added to her zidovudine regimen. Zalcitabine therapy was stopped owing to myalgias and PGA, and both disappeared in 1 month. No other topical or systemic treatment was initiated. Once the lesions disappeared, zalcitabine was added to the zidovudine regimen, and there has been no recurrence.
Although a rechallenge with zalcitabine therapy was not tried, the evolution of the disease supports the relationship between the drug treatment and PGA. Toro et al1 did not report that the occurrence of granuloma annulare was associated with medication in any other HIV-infected patient. In our publication,3 we also reported an additional case of PGA in an HIV-infected patient from the Spanish literature,4 raising the total number of cases at least to 6.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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