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Paper text:
cutaneous complications caused by human immunodeficiency virus ( hiv)/acquired immune deficiency syndrome have been reported , including , all kinds of opportunistic infections , psoriasis , seborrheic dermatitis , hairy leucoplakia , and granuloma annulare , among others .
alopecia areata and vitiligo are generally frequent in patients , and their solitary associations with hiv are probably fortuitous in most cases . in the current paper , we report a case of an hiv - infected patient with these conditions .
two years ago , several dispersed hair - loss patches appeared on the patient 's scalp without any subjective symptom .
he previously visited a dermatologist and was diagnosed with alopecia areata as well as vitiligo .
no member of his family had vitiligo or alopecia . dermatological examination revealed several depigmented macules measuring 2 cm to 5 cm with clear boundaries distributed on the face and neck .
several smooth hair - loss patches measuring 1 - 2 cm were also distributed on the top of the head , and diffuse alopecia was observed around the head [ figure 1a , b , and c ] .
( a ) hair loss at his first visit to the clinic ; ( b ) and ( c ) status of vitiligo at his first visit ; ( d ) hair loss at his second visit a month later enzyme - linked immunosorbent assay and western blot revealed a positive result for serum anti - hiv antibody .
flow cytometry revealed that the patient 's cd4 lymphocyte count and cd4/cd8 ratio were 20 cells/l ( 3.7% ) and 0.04 , respectively , which are considerably low .
the thyrotropic - stimulating hormone and free thyroxine levels were 7.69 iu / ml and 10.06 pmol / l , respectively .
serological test of syphilis showed a positive t. pallidum particle agglutination , but the toluidine red unheated serum test was negative .
the patient did not accept any therapy for 1 month until his second visit to the clinic .
his alopecia areata worsened , presented ophiasis pattern with 80% hair loss on his head , and even his brows [ figure 1d ] .
the patient 's general state of health was still good , and manifestations of opportunistic infection and malignant tumor were not observed .
one month after antiretroviral therapy ( art ) , the patient 's alopecia areata dramatically improved , but no evident improvement in his vitiligo was found [ figure 2 ] .
his cd8 lymphocyte count had a more considerable increase , resulting in a cd4/cd8 ratio of 0.03 .
although , his cd4 lymphocyte count was still very low , no other complaints were reported .
the patient received benzathine penicillin injection for 3 times , but his vitiligo was not still improved .
( b ) status of alopecia areata dramatically improved ; ( c ) and ( d ) vitiligo did not have obvious improvements
alopecia areata is one of the most common autoimmune diseases that can be considered a t - cell - mediated autoimmune disease , whereby the gradual loss of protection provided by the immunity of normal hair follicle plays an important role .
alopecia areata has been shown as a cd8 + t - cell - dependent and organ - specific autoimmune disease in a rat model of alopecia areata , in which depleting cd8 + t - cells could restore hair growth .
vitiligo is a common depigmentation disease characterized by the presence of circumscribed white macules in the skin caused by the destruction of melanocytes in the epidermis .
skin biopsies of vitiligo patients show that inflammatory cells are prominent in the perilesional areas , consisting of cd8 + and cd4 + t - cells , often with an increased cd8+/cd4 + ratio .
although , syphilis infection may also cause alopecia areata or vitiligo like lessions , the laboratory studies in this case only confirmed that the patient had been infected with syphilis .
rawson et al . suggested an autoimmune mechanism that involves the release of protein fragments from dying cd4 + t - cells that , in turn , promote the formation of auto - reactive cd8 + t - cells in hiv infection .
the massive level of death and destruction of lymphocytes in hiv infection breaks the tolerance for self - peptides and leads to the production of auto - reactive cytotoxic t - cells that respond to the cleavage products of apoptotic cells .
this mechanism explains the successive occurrence of alopecia areata and vitiligo in the same patient with hiv . although , the patient 's cd4 lymphocyte count was only 20 cells/l , he had no other complaints , except for alopecia areata and vitiligo .
after art , his cd4 lymphocyte count increased , simultaneously accompanied by improvement in his alopecia areata without anti - alopecia treatment .
hence , the improvement of alopecia areata and increased cd4 lymphocyte count are positively correlated .
the patient represents a very rare case of alopecia areata and vitiligo associated with hiv infection .
self - reactive cd8 + t - cells are generated because the release of protein fragments from dying cd4 + t - cells breaks the tolerance for hidden antigens during progressive immune exhaustion .
this mechanism explains the occurrence of some autoimmune diseases , including , alopecia areata and vitiligo , with hiv infection .
written informed consent was obtained from the patient for the publication of this case report and any accompanying images .
alopecia areata and vitiligo associated with hiv infection might be connected with the generation and maintenance of self - reactive cd8 + t - cells .
a 26-year - old chinese male consulted with the team regarding his alopecia areata and vitiligo for which previous treatment was ineffective . 
 the patient , a homosexual man , denied having a history of drug abuse and of blood transfusion . 
 no member of his family had vitiligo or alopecia . 
 laboratory studies revealed that the serum for anti - human immunodeficiency virus ( hiv ) antibody was positive . 
 the patient 's cd4 lymphocyte count and cd4/cd8 ratio were both strikingly low ( 20 cells / ml and 0.04 ) , but no other complaints or opportunistic infections were reported . 
 one month after antiretroviral therapy , the patient 's alopecia areata dramatically improved , but no evident improvement in his vitiligo was found . 
 this case is a very rare case of alopecia areata and vitiligo associated with hiv infection that might be attributed to the generation and maintenance of self - reactive cd8 + t - cells due to chronic immune activation with progressive immune exhaustion in hiv infection .