Transcript Acute HIV infection

DERMATOLOGIC MANIFESTATIONS OF
HIV INFECTION
Dr:a,beheshti
dermatologist
DERMATOLOGIC MANIFESTATIONS IN HIV
Dermatologic manifestations affect 80 to 90
percent of individuals infected with the human
immunodeficiency virus (HIV)
Importantly, a higher number of mucocutaneous
diseases in HIV-infected patients has been shown
to correlate with poor prognosis and a shorter
time to the development of AIDS.
DERMATOLOGIC MANIFESTATIONS IN HIV
Dermatologic manifestations affect 80 to 90
percent of individuals infected with the human
immunodeficiency virus (HIV)
Importantly, a higher number of mucocutaneous
diseases in HIV-infected patients has been shown
to correlate with poor prognosis and a shorter
time to the development of AIDS.
DERMATOLOGIC MANIFESTATIONS IN HIV
Rash duo to HIV infection
 Rash duo to other infection
 Neoplasms
 Drug reaction

ACUTE HIV INFECTION
Skin rash can be one manifestation of the acute
retroviral syndrome, a mononucleosis- or flu-like
syndrome that occurs after primary HIV infection
in up to 75 percent of cases.
Additional signs and symptoms include fever,
night sweats, fatigue, malaise, generalized
lymphadenopathy, sore throat, arthralgias,
myalgias, headache, nausea/vomiting, and
diarrhea
RASH
A generalized rash is also a common finding in
symptomatic acute HIV infection.
The eruption typically occurs 48 to 72 hours after
the onset of fever and persists for five to eight
days.
RASH
The upper trunk, neck, and face are most often involved
though the scalp and extremities, including the palms
and soles, may be affected.
The lesions are characteristically small (5 to 10 mm),
well-circumscribed, oval or round, pink to deeply red
colored macules or maculopapules.
Vesicular, pustular, and urticarial eruptions have also
been reported ,but are not nearly as common as a
maculopapular rash.
Pruritus is unusual and only mild when present.
Oropharyngeal enanthems and ulcerations can occur.
ACUTE HIV INFECTION
Skin rash can be one manifestation of the acute
retroviral syndrome, a mononucleosis- or flulike syndrome that occurs after primary HIV
infection in up to 75 percent of cases
ACUTE HIV INFECTION
Acute HIV infection should be considered in the
differential diagnosis of a patient presenting with
a mononucleosis-like illness.
In a retrospective study of 563 serum samples
obtained from patients with suspected mono-like
illness with negative heterophile antibody tests,
11 (2 percent) were positive for HIV-1 RNA and
four had greater than 100,000 copies/mL of HIV1 viral RNA, consistent with acute HIV-1
infection.
ACUTE HIV INFECTION
RASH
Rash can occur as a manifestation of HIV infection,
another infection, some neoplasms, and frequently as a
reaction to a drug.
ACUTE HIV INFECTION
AIDS PATIENT WITH CD4 COUNT 40
PRESENTS WITH NONHEALING ULCER.
BACTERIAL INFECTIONS
Patients with HIV infection have an increased
incidence of bacterial infections that is related to
both deficiencies in T cell function and
dysregulation of humoral immunity in advanced
disease.
STAPHYLOCOCCUS AUREUS
Staphylococcus aureus is a common cause of skin
infection and bacteremia in patients with the
acquired immunodeficiency syndrome (AIDS).
Risk factors for S. aureus bacteremia include nasal
colonization with S. aureus, injection drug use
(IDU), lymphedema due to Kaposi sarcoma (KS),
neutropenia, and indwelling vascular.
STAPHYLOCOCCUS AUREUS
The varied skin manifestations of S. aureus
infection include impetigo, folliculitis, cellulitis,
abscesses, ulcerations, or ecthyma gangrenosum
and Progression of staphylococcal infections can
lead to cutaneous botryomycosis, a plaque-like,
nodular, or papular lesion that clinically
resembles a fungal infection and is characterized
by aggregates of bacteria in the skin.
CUTANEOUS BOTRYOMYCOSIS
is a chronic focal infection characterized by a
granulomatous inflammatory response to
bacterial pathogens such as Staphylococcus
aureus. Treatment requires antibiotic therapy
and may also require surgical debridement.
STAPHYLOCOCCUS AUREUS
Secondary staphylococcal infections of underlying skin
disorders such as herpetic ulcers, abrasions/trauma,
eczema, adverse cutaneous drug eruptions, and other
dermatoses should also be considered.
STAPHYLOCOCCUS AUREUS
BACILLARY ANGIOMATOSIS
Bacillary angiomatosis, a vascular skin lesion
that can mimic KS ,and pyogenic granuloma, is
usually seen in HIV-infected patients when the
CD4 cell count is less than 100 cells/microL.
These cutaneous lesions result from proliferation
of small blood vessels.
The etiologic agents of this disease, Bartonella
henselae and Bartonella quintana, can also cause
bloodstream, liver, lymph node, lung, bone, bone
marrow, brain, and heart valve infection. Cat and
flea exposure have been associated with B.
henselae infections and body louse exposure with
B. quintana.
BACILLARY ANGIOMATOSIS
BACILLARY ANGIOMATOSIS
The skin lesions associated with Bartonella,
which may be isolated or multiple, are
typically hemangiomatous, small, and papular
before becoming larger, nodular, and
potentially friable. Occasional lesions are
subcutaneous in location (with or without
overlying erythema) and appear cyst-like or
manifest as a small mass.
NEISSERIA GONORRHEA
HIV-infected patients have an increased rate of
gonococcal infection that is related more to sexual
behavior than to immunosuppression.
Fever, rash, tenosynovitis, and polyarthralgia are
typically part of disseminated gonococcal infection
(DGI). The rash typically consists of painless lesions,
often between two and ten in number, often located
over trunk, extremities, or soles/palms.
The lesions are usually pustular or vesiculopustular,
although hemorrhagic macules, papules, or nodules
rarely occur. Pustular or vesicular skin lesions are
often transient and, even without treatment, may
only last for three to four days.
NEISSERIA GONORRHEA
SYPHILIS
Syphilis is important to recognize because of its
important public health implications .
The skin manifestations of syphilis are often an
important diagnostic clue and, although they
may be altered in the setting of HIV infection,
usually present in a manner similar to HIVuninfected individuals.
There remains a need for more large welldesigned studies to evaluate effect of HIV status
on presentation and course of syphilis
PRIMARY SYPHILIS
The first, or primary stage of syphilis, presents as a
chancre usually two to three weeks after sexual
contact with an infected partner.
A painless papule forms at the mucosal surface where
Treponema pallidum, the causative agent of syphilis,
was inoculated.
The papule can grow to 0.5 to 2 cm in diameter, and
ulcerate to form a clean-based, well-demarcated lesion
with firm and indurated margins.
Associated non-tender regional lymph nodes are often
seen. Although chancres are usually solitary, multiple
chancres can occur, particularly in the setting of HIV
infection
SYPHILIS
SECONDARY SYPHILIS
Rash is the most characteristic finding in
secondary syphilis, occurring in more than
80 percent of patients.
Secondary syphilis occurs three to six
weeks after the primary stage resolves
and is characterized by hematogenous
dissemination of treponemes.
SKIN MANIFESTATIONS
OF
SECONDARY SYPHILIS
including a nonpruritic macular, maculopapular,
papular, papulosquamous, plaque-like, erythema
multiforme-like or pustular rash; vesicular lesions are
notably absent.
The anogenital region and other moist intertriginous
areas may contain condylomata lata, wart-like lesions
consisting of flat eroded papules.
Mucous patches consisting of slightly raised grayishwhite painless ulcerations may be seen on mucous
membranes.
The rash usually begins on the trunk and extremities.
When lesions are seen on the palms and soles,
secondary syphilis should be strongly considered.
the great imitator
TERTIARY SYPHILIS
Gummatous lesions of late benign
syphilis can involve any organ, including the
skin.
Often solitary, gummas can present as ulcerative,
nodular, or papulosquamous lesions, usually
located over the trunk, extremities, and face.
HIV-infected patients are reported to have a
shorter interval to the development of destructive
localized gummatous lesions.
MYCOBACTERIAL INFECTIONS
Cutaneous tuberculous manifestations include
scrofuloderma, gummatous lesions, lupus vulgaris
,nodules, pustules, and ulcerations.
Cutaneous disease may be a clue to underlying
disseminated mycobacterial infection.
Cutaneous miliary tuberculosis, an unusual
manifestation, has been reported in HIV-infected
patients .
Microscopic examination of the skin lesions will
demonstrate numerous acid-fast bacilli.
ATYPICAL MYCOBACTERIA
including Mycobacterium avium
intracellulare and Mycobacterium
kansasii, may also present as isolated
cutaneous disease. Mycobacterium
haemophilum, an uncommon cause of
mycobacterial infections, primarily
presents as cutaneous or subcutaneous
disease in the setting of
immunocompromise.
VIRAL INFECTIONS
Skin lesions due to viral infections are common in
HIV-infected patients, and include acute HIV
infection itself.
Since many of these viral infections are vaccinepreventable, a thorough vaccination history
should be obtained.
VIRAL INFECTIONS
The clinical presentation of symptomatic HSV
episodes may include extensive mucocutaneous
involvement, a variable appearance of genital
lesions, and the development of chronic
nonhealing and recurrent ulcers.
Tumor-like lesions have also been reported.
Recurrences are often more frequent, more
extensive, and of longer duration than in
immunocompetent
GENITAL HERPES VIRUS
GENITAL HERPES VIRUS
The primary episode of genital herpes simplex virus
(HSV) infection usually presents with fever,
headache, and malaise, in association with localized
symptoms of pain and pruritus in the area of the
vesicular lesions.
most genital HSV infections occurring in HIV-infected
patients reflect reactivation syndromes, and the
appearance of lesions is usually not accompanied by
fever.
Rates of reactivation appear to be inversely correlated
with CD4 counts .
immune reconstitution inflammatory syndrome (IRIS)associated events involving genital herpes virus
infection appear to be more common than other
manifestations
‫توجه‬
herpes simplex virus
type 2 infections may
increase the risk of HIV
acquisition
VARICELLA ZOSTER VIRUS
The incidence of Herpes Zoster (HZ) (including
recurrent HZ) is higher in HIV-infected patients
compared with those without HIV,
recurrent HZ reporting in up to 20 percent of HIV
infected patients.
In general, the risk of HZ increases as CD4 cell
counts fall.
However, an increased frequency of VZV
reactivation can be seen during immune recovery
following initiation of ART.
VIRAL INFECTIONS (ZONA)
VARICELLA ZOSTER
chronic ( greater than one month) mucocutaneous
infections with varicella zoster virus (VZV) are
well described in HIV-infected individuals.
Atypical presentations of HZ also include
verrucous varicella, which has been mainly
reported in the setting of HIV infection.
This diagnosis should be considered in the patient
with multiple, chronic, wart-like lesions.
PARVOVIRUS
Parvovirus B19 can cause fever, arthralgia and
a lacy reticular rash on the trunk and
extremities in both immunocompetent and
immunocompromised individuals.
Cutaneous vasculitis due to human parvovirus
B19 has also been reported.
MOLLUSCUM
Seen frequently in young women
not on ART
Treatment:
1st line therapy is ART
Liquid nitrogen only temporary
Curretage of large molluscum
WARTS
Past evidence showed that,warts
would not resolve over 24 month
period with treatment if CD4
count is under 50.
PENILE WARTS (HYPERPIGMENTED)
ANAL WARTS (CONDYLOMA)
ORAL HPV (CONCERNING FOR
IMMUNOSUPPRESSION)
FUNGAL INFECTIONS
Skin lesions may be the initial sign of
a systemic fungal infection.
Endemic fungi must be considered in
any HIV-infected patient with skin
lesions and systemic disease.
Fungi can disseminate when cell-mediated immunity
falls, either during the acute stage of infection or as a
result of reactivation of prior disease.
HIV-infected patients may harbor more than one
fungus responsible for systemic infection and
associated cutaneous manifestations, underscoring
the importance of histopathologic and microbiologic
evaluation of suspicious skin lesions.
FUNGAL INFECTIONS
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Coccidioidomycosis
Sporotrichosis
Penicillium marneffei
Pneumocystis
Skin findings include macular,
papular, polypoid, nodular, and
molluscum contagiosum-like
lesions
CRYPTOCOCCOSIS
Approximately 10 percent of HIV-infected patients who
develop cryptococcal infection have cutaneous
manifestations of disease.
Skin lesions secondary to C. neoformans may represent the
sentinel clue to underlying disseminated infection.
The skin lesions of cryptococcosis may be quite diverse, but
ulcers, nodules/papules, pustules, or molluscum
contagiosum-like centrally umbilicated vesicular lesions
are commonly described. Presentations can also mimic
cellulitis or cutaneous malignancies such as basal cell or
squamous cell carcinoma(s).
Lesions are frequently located on the head and neck .
Since cryptococcal skin infection can mimic molluscum
contagiosum, a helpful diagnostic clue for cryptococcosis is
the finding of a small hemorrhagic center in the lesion and
a rapid onset of development of the papules.
CRYPTOCOCCOSIS
CRYPTOCOCCOSIS
HISTOPLASMOSIS
Approximately 10 percent of HIV-infected
patients with disseminated histoplasmosis
have mucocutaneous manifestations
including oropharyngeal ulcerations,
macules, papules, pustules, plaques (can be
verrucous), nodules, or vesicles.
Cutaneous histoplasmosis can mimic
erythema-multiforme, molluscum
contagiosum, pyoderma gangrenosum,
vasculitic, exfoliative dermatitis, herpetic,
acneiform, and psoriatic-like lesions.
Lesions are commonly located over the face,
chest, and upper extremities.
MUCOCUTANEOUS HISTOPLASMOSIS IN HIV WITH
AN ATYPICAL ECTHYMA LIKE PRESENTATION
Vandana Mehta, Abhishek De, C Balachandran, Puja Monga
Dermatology Online Journal 15 (4): 10
From the Dept of Skin & STD, Kasturba Medical College,
Manipal, Karnataka, India. [email protected]
Abstract
Pulmonary and disseminated forms of
histoplasmosis are very common in AIDS, but
primary cutaneous histoplasmosis is rare. We
report a case of primary mucocutaneous
histoplasmosis in the setting of HIV.
HISTOPLASMOSIS
BLASTOMYCOSIS
A retrospective survey of 15 HIV-infected patients
with blastomycosis included eight patients with
disseminated disease.
All of these individuals had CD4 lymphocyte
counts below 200 cells/microL and three had
evidence of cutaneous disease.
Possible dermatologic manifestations of
blastomycosis include papules, pustules, deep
ulcers, and papulopustular and papulonodular
ulcers, or verrucoid lesions
BLASTOMYCOSIS
PARASITIC INFECTIONS
In the United States, parasitic infections with
cutaneous manifestations are not common in
HIV-infected patients with the exception of
scabies, which has a worldwide distribution.
CUTANEOUS LARVAL MIGRANS (CLM)
IN A PERSON'S FOOT
SCABIES
In HIV-infected patients, scabies can be widespread,
presenting as a diffuse pruritic erythematous
papulosquamous or papulovesicular eruption.
Lesions typically involve the extremities, and, less
commonly, the ears, face, scalp, back, and nailfold
areas .
Psoriatic-like lesions, a maculopapular dermatitis, and
red papules have also been described.
These highly infectious lesions contain thousands of
organisms and are a source for nosocomial infection.
They can become secondarily infected with bacteria,
leading to fever, cellulitis, and bacteremia.
This patient with crusted scabies
developed extensive yellow-grey,
crusted, scaly, and hyperkeratotic
plaques covering his face and hands
LEISHMANIASIS
The cutaneous findings included macular, papular,
nodular, and plaque-like lesions.
Some Leishmania species are primarily
dermatotropic, while others are mainly
viscerotropic. It has become increasingly clear
however, that some species frequently associated
with visceral leishmaniasis can produce skin
lesions, and conversely, species usually found in
the skin can disseminate viscerally.
This was illustrated in a report of 32 HIV-infected
patients with visceral leishmaniasis, six of whom
had cutaneous lesions
LEISHMANIASIS
In patients with AIDS, this emerging infectious disease
represents the second most common tissueassociated protozoan infection.
CD4 UNDER 200 AND NOT ON
ART
Psoriasis over 50% of body surface
area
Extreme photodermatitis
Prurigo Nodularis
Molluscum
Recurrent drug reactions
PSORIASIS
With ART, HIV psoriasis easily controlled with topicals
(clobetasol and calcipotriene) and ultraviolet light.
Until ART kicks in or for more complex psoriasis-acitretin
10-25 mg /day
46 YEAR OLD PATIENT WITH AIDS PRESENTS
WITH A SEVERE RASH
SEBORRHEIC DERMATITIS HIV PATIENTS
SEBORRHEIC DERMATITIS HIV PATIENTS
ACNE
Acne
vulgaris
Acne rosacea
Perioral/periorbital dermatitis
Tx: TCN, doxycycline, minocycline,
accutane for cystic acne
ACNE
ACNE
ACNE
PHOTODERMATITIS
HIV makes pts sensitive to the sun Pts with
CD4 under 200 on photosensitizing drugs.
Tx: sunscreen, the dermatitis with potent
topical steroids and lubricants, doxepin 25
mg qhs (as antihistamine)
PRURIGO NODULARIS
Pts consumed by itch
CD4 50 and under May be a photocomponent to this
ART helpful
Potent topical steroids
Thalidomide
CUTANEOUS LYMPHOMA
See it in CD4’s under 200
Work-up necessary to R/O systemic lymphoma
If just cutaneous, radiotherapy or surgery
Before ART era, cutaneous lymphoma had tendency to
metastasize
Improves with ART (limited experience)
EOSINOPHILIC FOLLICULITIS
Itchy, urticarial bumps in face,
neck, SCALP, chest and back
Usually in CD4 counts under 200
or in pts within 3-6 months of
initiating ART
Itraconazole 200-400 mg /day
Permethrin from waist up
Wait for immune reconstitution to settle (3-6 months
after starting ART)
EOSINOPHILIC FOLLICULITIS
HIV AND HCV
Co-infection rate high and leads to
many skin problems:
l) Lichen planus
2) Xerosis
3) Leukocytoclastic vasculitis
4) Itch without a rash
ITCH WITHOUT A RASH
Seems to be central itch
Naltrexone (opoid antagonist) may
be helpful. ?Dose-start with 50 mg
qhs.
Antihistamines not helpful
Ultraviolet light not helpful
Treatment for HCV helpful unless
pt gets the ribavirin itch
XEROSIS
Pts noting that skin barrier changing
and more dry
Lubricants, steroids
LEUKOCYTOCLASTIC VASCULITIS
R/O reactions to drugs
R/O infection-strep, endocarditis, Hep A, B, C
R/O collagen vascular disease and cryoglobulinemia
R/O leukemia, lympho
Tx: colchicine, steroids?, treat the Hep C
LEUKOCYTOCLASTIC VASCULITIS
DISEASES THAT JUST DON’T GO
AWAY WITH ART
Eczema/ Xerosis-if CD4 was below
200, will always be recurrent
Tx: mid-potency steroids (ointment better th
an cream), antihistamines, can use the newer topicals
-tacrolimus and pimecrolimus
HIV AND HCV
Co-infection
rate high and leads to
many skin problems:
l) Lichen planus
2) Xerosis
3) Leukocytoclastic vasculitis
4) Itch without a rash
HEPATITIS B
Because of shared routes of transmission, HIVinfected patients may also acquire hepatitis B
through unprotected intercourse with a
chronically infected partner or through injection
drug use.
Acute hepatitis B infection may be heralded by a
serum sickness-like syndrome manifested as
fever, skin rash, arthralgia and arthritis, which
usually subside with the onset of jaundice
KAPOSI SARCOMA
Kaposi sarcoma (KS), although not often a cause of
fever, has been convincingly linked to human herpes
virus (HHV)-8 infection.
In the United States, the incidence, mortality and
morbidity of KS has declined significantly since the
introduction of highly active antiretroviral therapy
against HIV and associated improved CD4 counts.
KS is no longer the most common HIV-associated
tumor.
In fact, in the ART era, the most common cutaneous
cancers in patients with HIV infection are non-AIDSdefining cancers, particularly basal cell carcinoma.
KS presenting within eight weeks after initiation of
ART is well recognized
KAPOSI SARCOMA
Oral lesions are classically found on the hard
palate, although the tonsils, gingiva.
soft palate, tongue, or lips may be involved.
Cutaneous lesions occur most commonly on the
trunk, the extremities, and the face.
Initially papular or patch-like KS lesions later
develop into plaques or nodules.
The color of these lesions changes with time from
light brown or pink to a darker violet.
Other cutaneous variants are described as patchlike, exophytic, keloidal, telangiectatic,
infiltrative, lymphangioma-like, cystic-like,
bullous, lymphadenopathic or ecchymotic
DRUG REACTIONS
Drug reactions, particularly cutaneous
manifestations, are common in HIV-infected
patients and appear to be directly related to the
degree of immunocompromise.
A morbilliform rash (74 percent) has been most
frequently described (particularly with the use of
nonnucleoside reverse transcriptase inhibitors),
followed by urticarial eruptions (17 percent).
Fever may be a prominent part of the clinical
presentation.
DRUG REACTIONS
In one review of 684 patients with HIV infection,
trimethoprim-sulfamethoxazole, sulfadiazine,
trimethoprim-dapsone, and amino penicillins
were associated with the highest incidence of
adverse cutaneous drug reactions
DRUG REACTIONS
Amprenavir, atazanavir, abacavir, efavirenz,
nevirapine, and delavirdine are antiretroviral
agents that are most commonly associated with
hypersensitivity reactions
DRUG REACTIONS
Other anti-HIV agents including tipranavir,
darunavir, etravirine, raltegravir and maraviroc
have also been associated with adverse cutaneous
reactions of various types. Enfuvirtide, a fusion
inhibitor, almost always results in a local
injection site reaction, which includes
pain/discomfort, induration, erythema,
nodules/cysts, pruritus, and/or ecchymosis
DRUG REACTIONS
StevensJohnson syndrome and toxic
epidermal necrolysis (TEN) are
Severe cutaneous reactions such as
described more frequently in HIV-infected
patients compared to HIV-seronegative patients
and are commonly associated with sulfa-based
drugs
DRUG REACTIONS
In addition, risk for adverse cutaneous drug
reactions secondary to antituberculous therapy is
increased in the setting of HIV infection
HAIR AND NAIL IN HIV
HAIR AND NAIL IN HIV