Transcript CUTANEOUS MANIFASTATIONS OF HIV/AIDS

Cutaneous manifestation of HIV
infection and AIDS
Deepa v saka
INTRODUCTION
• Cutaneous manifestations are first amongst the clinical features of
AIDS.
• Seen at every stage of HIV infection.
• 90% of HIV infected patients develop skin manifestations.
• Act as markers & reflect underlying immune status.
• HIV predisposes patients to numerous opportunistic infections,
malignancies, and neurologic disease.
PATHOGENESIS
Primary inf. ( Fever, joint pain, night sweats)
Viral replication in lymphoid organs
Continuous stimulation of immune response
Exhaustion of immune response
Destruction of lymphoid tissue
Impairment of immune response to new pathogens
Epidermal langerhans cells become infected by HIV, decreasing their
function
Cutaneous manifestations
A) INFECTIOUS DERMATOSES
VIRAL
VIRALINFECTIONS
INFECTIONS
a)
a) Acute
Acuteexanthema
exanthemaof
ofHIV
HIV
b)
b) HSV/VZV
HSV/VZV
c)
c) EBV/CMV
EBV/CMV
d)
d) HPV
HPV
e)
e) Molluscum
Molluscumcontagiosum
contagiosum
FUNGAL
FUNGALINFECTIONS
INFECTIONS
a)Dermatophytoses
a)Dermatophytoses
b)Candidiasis
b)Candidiasis
c)Deep
c)Deepfungal
fungalinfection
infection
d)Other mycoses
BACTERIAL
BACTERIALINFECTIONS
INFECTIONS
a)
a) Staphylococcus
Staphylococcusaureus
aureus
b)
b) Mycobacterial
Mycobacterialinfection
infection
c)
c) Bacillary
Bacillaryangiomatosis.
angiomatosis.
PARASITIC
PARASITICINFECTIONS
INFECTIONS
a)
a) Protozoal
Protozoal––Leishmaniasis
Leishmaniasis
Toxoplasmosis
Toxoplasmosis
a)
a) Parasitic
Parasitic––Crusted
Crustedscabies
scabies
B) NON-INFECTIOUS DERMATOSES
• Papulosquamous/ Scaly
Psoriasis
Seborrheic dermatitis
Reiter’s disease
Icthyosiform dermatosis
Xerosis
Pruritic dermatoses
Eosinophilic folliculitis
Demodex folliclitis
Papular pruritic eruption
Papular urticaria
Pruritis
Eczema
• Pigmentary changes
Diffuse pigmentation
Pigmentation of oral cavity
• Neoplasms
Kaposi’s sarcoma
Lymphoma
Squamous cell carcinoma
Cont…
•
HAIR CHANGES
Diffuse alopecia/ sparseness of
hair
Alopecia areata/ Long eyelashes
• NAIL CHANGES
Onychomycosis
Melanotic band
Bluish black discolouration due to
AZT
• MUCOSAL CHANGES
Gingivitis
Angular cheilitis
Necrotizing stomatitis
Salivary gland hypertrophy
AIDS defining illness
• Oral hairy leukoplakia
• Cytomegalo virus infection
• Bacillary angiomatosis
• Oeosphageal candidiasis
• Kaposi’s sarcoma
VIRAL INFECTIONS
ACUTE EXANTHEM
 Acute retroviral syndrome.
 Earliest cutaneous manifestation of HIV infection.
 Occurs 2-3 weeks after HIV exposure.
 Denote seroconversion.
 May be asymptomatic; Fever, lymphadenopathy, pharyngitis,
cutaneous eruption.
 Generalised symmetrically distributed maculopapular rash.
 May be roseolar or vesicular.
 Mucosal lesions (enathems, ulcers) in mouth, palate & pharynx.
 Neurological symptoms may be present.
 Self limiting; Last for few days to > 10 weeks
Dermatological manifestation of HIV seroconversion
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Exanthem
Enanthem
Urticaria
Toxic erythema
Erythema multiforme
Orophargeal candidiasis
Acute genitocrural intertrigo
Oral ulceration
Genital ulceration
HERPES SIMPLEX VIRUS INFECTION:
 HSV infection both 1 and 2 are common in HIV patients.
 C / F: - Atypical, run long course, poor response to treatment.
- Mouth, face.
- Ulcers are tender, large, deep, persistent and hemorrhagic.
 Any nonhealing Ulcer of HSV for >1 month – s/o active HIV infection.
 Herpetic whitlow: Entire digit with intensely painful ulcer.
 Perioral lesion polycyclic with raised vesicular border spread to
oesophagus & oropharynx: Odynophagia.
HSV 2
• Genital herpes : risk factor for acquisition of HIV
• Atypical large deep ulcers extend to perianal area, buttocks and
abdomen
•
Hyperkeratotic, verrucous lesions resembling condyloma.
• Lesions may become large .
 Herpetic folliculitis, Esophagitis & Cervicitis: reported
 Treatment: Acyclovir 400mg three times daily for 5-10days or
IV Acyclovir(5mg/kg) every 8th hourly- severe
cases
IV Foscarnet 40mg/kg every 8th hourly: Acyclovir
resistant
Other: Valcyclovir/ Famciclovir
Varicella zoster virus
• Varicella – Primary infection
• Severe, prolonged and frequent recurrences
• Complications: Pneumonitis, bacterial superinfection and meningitis.
• Lesions persist for >1month – Persistance/ Chronic
• Lesions appear after 1 month of complete resolution of primary
episode – Recurrence
• Verrucous
Herpes zoster
• Reactivation of dormant infection
• Multidermatomal
• Longer course
• Necrotic,hemorrhagic, ulcerative and heal with scar
• Dissemination – advanced AIDS
• Systemic complications: Fulminant hepatitis, Acute
meningoencephalitis
VZV…
• Treatment: -Initiated early and duration 7-10days
- Acyclovir 800mg four or five times daily
- Valcyclovir: 500mg three times daily
- Foscarnet – acyclovir resistant cases
- Cryotherapy – verrucous lesions.
HUMAN PAPILLOMA VIRUS (HPV)
• Higher risk of HPV in immunocompromised
patients.
• Most cases: common or flat warts
• An unusal pattern of extensive verruca plana and tinea.versicolor like
warts, similar to epidermodysplasia verruciformis
• Numerous and refractory to treatment.
• Genital warts are more common in HIV- are diffuse, dysplastic and
subclinical
• Higher rates of cervical, anal cancers.
• CD4< 200 – higher risk of malignancy
HPV…
• Treatment: Imiquimod 5% cream and
Cidofovir 1% cream or I/L or IV.
Cryotherapy or surgery
HAART controls HPV.
MOLLUSCUM CONTAGIOSUM
• CD4 counts are very low.
• C/F: Extensive, giant, warty
- Large confluent lesions: face
- Extensive B/L periorbital and intraoral : common
- Sexually active adults- Lower abdomen, inner thighs & genitalia
Others: face and neck.
- Prolonged course
• D/D: Warts, cutaneous aspergillosis, cryptococcosis,
penicilliosis.
• Treatment: Difficult to treat
Curettage & cryosurgery
Cidofovir or imiquimod 5% gel
HAART
Photodynamic therapy
Oral hairy leukoplakia
• CD4<250 cells/μl
• Epstein Barr virus
• Indicates more rapid progression towards AIDS
• C/ F: - Males, heterosexuals and can be seen in children
- Asymptomatic
- Raised, corrugated white lesions frequently on lateral side of
tongue
• Treatment: HAART
High doses of Acyclovir or
Ganciclovir
CYTOMEGALOVIRUS INFECTION:
• CD4 < 50
• Skin involvement rare; when affected mortality is 85% in 6 months.
• C/f :Chronic perineal ulceration
Ulcers can also be on thighs, buttocks and oral cavity
Others: pruritic maculopapular rash, prurigi nodularis, diaper
dermatitis like
• Treatment: I.V foscarnet, ganciclovir or cidofovir.
BACTERIAL INFECTIONS
STAPHYLOCOCCUS AUREUS INFECTION:
• CD4< 200cells/mm3
• Most common
• Colonises the nose initially & infects other sites.
• Diseases caused: Folliculitis, Furuncles, Carbuncles, Cellulitis, Ecthyma,
Impetigo, Botryomycosis.
• Treatment: Co-trimaxozole twice daily with or without clindamycin
500mg three times daily
For recurrent inf: Rifampicin 600mg/d for 5 to 10 days
Topically mupirocin (carrier site app)
BACILLARY ANGIOMATOSIS:
• CD4< 100
• Causative agent: Bartonella hensalae or
Bartonella quintana
• Reservoirs: domestic cats & homeless people.
• C/F :- Characterised by angioproliferative lesions.
- Solitary or multiple red, purple, flesh colored hemangioma like
papules or nodules with adherent scales
- Ulceration, discharge and crusting associated
tender lymphadenopathy
• Diagnosis- Warthin-Starry stain, H and E staining.
• Treatment: Erythromycin 250 four times
daily for 14days
MYCOBACTERIAL INFECTIONS
CUTANEOUS TUBERCULOSIS:
• Causative agent: Mycobacterium tuberculosis
• Diverse: Scrofuloderma, scattered violaceous papules, acute miliary TB
of skin, keratotic papules, nodules, Palmar/plantar keratoderma,
tuberculides.
• Tuberculous lymphadenitis- characteristic manifestation of HIV.
• Treatment: HAART & specific anti-TB drugs depending on CD4 count.
ATYPICAL MYCOBACTERIAL SKIN DISEASE:
 Causative agent: Mycobacterium avium- intracellulare
 Dissemination occurs in CD4 < 50
 C/F : Violaceous papules, nodules, ulcers.
 Treatment: Macrolide & Ethambutol.
FUNGAL INFECTIONS
CANDIDIASIS

Causative agent: candida albicans

Diseases caused:
1.
Oropharyngeal candidiasis: most common OIs.
•
CD4 < 200/ mm3
• Usually asymptomatic, may present with soreness, altered taste,
burning sensation or odynophagia.
• 4 types:
a) Pseudomembranous (oral thrush)- M/C

Appears as creamy white plaques (cottage cheese
appearance).
 Mostly on tongue, palate, buccal mucosa and oropharynx
 Easily removed – erythematous surface
b. Atrophic (erythematous) candidiasis:

M/c site are dorsum of tongue & palate.

Shedding of filiform papillae giving erythematous bald appearance
to the tongue.
c. Hyperplastic candidiasis:
 White raised plaques which are non scrapable
 Seen in lower surface of tongue, palate & buccal mucosa.
 Similar to oral hairy leukoplakia.
d. Angular chelitis
2. Candidial oesophagitis:
 Second most common AIDS defining disease.
 M/c cause of dysphagia in HIV.
 Prevents intake of adequate nutrition, contributes to weight loss.
3. Vulvovaginal candidiasis:
 Vagina –curdy white discharge and erythematous plaque on vaginal
wall and often associated with itching.
 Vulva – morbilliform rash may extend to thighs.
4. Cutaneous candidiasis:
- Paronychia, onychodystrophy and intertrigo.
Cond…
• Treatment :
- Oropharyngeal:
Fluconazole 100mg or 200mg – 10-14days
Clotrimazole or Nystatin suspension
Itraconazole – fluconazole failure
Voriconazole, Posaconazole or Amphotericin-B suspension
- Vulvovaginal candidiasis:
Fluconazole 150mg – stat
Topical azoles: 3-7 days
- Esophageal candidiasis:
Fluconazole 200-400mg- 14-21days
Itraconazole
DERMATOPHYTOSIS
• Severity and variability of presentation .
•
Tinea cruris may extend on to genitalia and trunk.
• T. Capitis in adults
• Invasive dermatophyte: fluctuant or firm,
haemorrhagic nodules.
• Nails: Proximal subungual onychomychosis
- Chalky white colour of proximal nail folds
• Treatment: Topical & Systemic antifungals- imidazoles/ triazoles.
Onychomycosis- fluconazole & itraconazoles
SYSTEMIC MYCOSIS
CRYPTOCOCCOSIS:
• CD4< 50cells/ mm3
• Encapsulated yeast - Cryptococcus neoformans.
• Skin manifestation occur before systemic symptoms.
• M/c: Head & neck.
• Skin- coloured or erythematous papulonodular necrotizing skin lesions with
central umbilication.
• KOH smear, fungal culture, Biopsy
Capsule- mucicarmine and Alcian Blue stains
Cryptococcosis…
• Treatment
- I.V amphotericin B 0.7mg/kg with flucytosine 100mg/kg orally -->
oral fluconazole 400mg/day or itraconazole 200mg bd for 8 weeks.
- Secondary prophylaxis: Fluconazole or itraconazole 200mg bd -->
lifelong or CD4 count > 100cells/μl
- CD4 count < 100cells/μl -> Fluconazole 400mg weekly
HISTOPLASMOSIS
• Causative agent: Histoplasma capsulatum.
• C/F: m/c- face, extremities and trunk
Polymorphic papules, plaques, with or without crusts, nodules,
punched out ulcers, purpuric lesions.
Oral cavity- nodules, plaques, ulcers
• Biopsy : budding yeasts within histiocytes.
• Diagnosis: Wright stain of blood smear: intracellular fungi.
• Treatment: Amphotercin-B 3-5mg/kg – 2weeks -> Itraconazole 200mg
bd-12months
PENICILLIOSIS - Penicillium marneffei (CD4 <100)
• Fever, cough, lymphadenopathy, hepatosplenomegaly, skin lesions, wt loss,
and anemia.
• Generalised papular eruption with umbilicated or central necrotic over face,
pinna, upper trunk & arms.
• Nodules, folliculitis, macular rash and mouth ulcers.
• Diagnosis- Isolation from blood, BM, CSF, skin or LN, by microscopy &
culture.
• Wright’s stain- Intra & extracellular round or oval yeast with central
septations.
• Treatment –
IV Amphotercin B (0.6mg/kg/day) for 2 weeks followed by Itraconazole
400mg/d x 10wks
CRYPTOCOCCOSIS
HISTOPLASMOSIS
PENICILLIOSIS
PARASITIC INFESTATIONS
SCABIES
• Common in HIV pts.
• C/f depends on degree of immunosuppresion.
• Can be divided into two over lapping broad categories:
a) Papular (atypical or exaggerated )
• Generalised papule topped by scabetic burrow
b) Crusted (norwegian or hyperkeratotic)
• Thick friable white grey plaques with fissuring over the scalp, face,
back, buttocks, nails and feet
Treatment:
Topical scabicidal agents (Multiple applications)
Crusted scabies- keratolytic agents
Oral ivermectin (200 µg/kg weekly)
NEOPLASMS
KAPOSI SARCOMA(KS):
• Vascular neoplasm: HHV-8 infection.
• Oral cavity, face, arm, leg, trunk.
• Asymptomatic erythematous macule or papule with yellow-green bruiselike halo.
• Violaceous nodules or plaques and usually oval or fusiform in shape
• Radiotherapy, chemotherapy, surgerical excision, cryotherapy.
NON-INFECTIOUS DERMATITIS
SEBORRHEIC DERMATITIS
• CD4>500cells/μl
• Indicate rapid progression of HIV.
• Erythema, greasy scaling over scalp, eyebrows, nasolabial fold and post
auricular area.
• In advanced HIV: forehead, malar area, chest, back, axillae and groin.
• Erythroderma : due to SD
• Treatment: Topical low potent steroid, ketoconazole shampoo.
Twice application of lithium succinate ointment.
Pruritus associated with HIV
PAPULAR ERUPTION OF HIV:
• Most common cutaneous manifestation of HIV
• Pruritis and inflammatory dermatoses increases as helper T cell
count falls.
• Pruritic, waxing and waning skin coloured papules
• Head, neck and trunk
• Exaggerated response to insect bites or type of folliculitis.
• Treatment: Topical steroids, antihistamines
Phototherapy
Eosinophilic folliculitis
• CD4: < 250/mm3.
• Multiple follicular and non-follicular, urticarial papules.
• Upper trunk, face and proximal arms.
• Secondary changes like excoriation, lichenification and post inflammatory
hyperpigmentation.
• Waxing and waning course
•
Phototherapy, Topical potent corticosteroids and Non-sedating
antihistamines.
PITYROSPORUM INFEction
 P.folliculitis: Numerous pruritic erythematous papules over upper trunk
and proximal arms.
P.versicolor

Severe & prolonged course.
 Treatment : Topical antifungals or oral azoles for 10-14days.
REITER’S SYNDROME
• Triad of Non Gonococcal Urethritis + Conjuntivitis + Arthritis.
• An episode of peripheral arthritis of >1 month duration along with
urethritis & cervicitis.
• Increased incidence of both Reiter’s syndrome and psoriasis in HIV
infection.
• Treatment: Acitretin
Zidovudine
Infliximab
PSORIASIS
• In HIV, immune dysregulation could be a triggering factor in genetical
predisposed.
• Recurrent infection like staphyloccocal or candidiasis exacerbates
psoriasis in HIV.
• Psoriasis in HIV manifests in two clinical forms:
- A benign form with guttate or lagre plaque type lesions
- A diffuse form or psorisiform dermatitis comprising palmoplantar
keratoderma that -> generalised
• Treatment: Antiinflammatory agents
Systemic retinoids
Phototherapy
CONCLUSION
• Dermatologic disease is extremely common & varied in HIVinfected patients.
• HIV-infected individuals: Increased prevalence or severity, atypical
presentations, or difficulty with treatment of disease.
• Dermatological manifestation may be the first clue of HIV
infection.
• Offering HIV testing to affected individuals can lead to early
diagnosis & treatment of HIV infection and, ideally, a decrease in
disease progression & transmission.
REFERENCES
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Chalmers R and Creamer D, editors. Rook’s textbook of dermatology, 9th
edn. Blackwell Publishing;2016.p.31.1-36.
• Betkerur JB, Ashwini PK, Ranugha PS, Sachdev A . Mucocutaneous
manifestation of HIV-AIDS . In: Sacchidanand S, Oberoi C, Inamadar AC,
editors. IADVL Textbook of dermatology, 4th edn. Mumbai: Bhalani
Publishing House;2015.p.2962-2996
• Thappa DM. Mucocutaneous manifestations of HIV infection and AIDS.
In: Kumar B, Gupta S . Mucocutaneous manifestation of HIV and AIDS. 1st
edn. 2005,673-693.
• Garman M E, Tyring S K. The cutaneous manifestations of HIV infection.
Dermatol Clin. 2002;20:193–208.
• Shobhana A, Guha S K, Neogi D K. Mucocutaneous manifestations
of HIV infection. Indian J Dermatol Venereol Leprol. 2004;70:82-86.
• Hogan M T. Dermatol Clin.2006; 24:473–495. Cutaneous Infections
Associated with HIV/AIDS.