Download Session 16 - Teaching Slides

Skin and Mucosal
Lesions in HIV-Infected
Children
HAIVN
Harvard Medical School AIDS
Initiative in Vietnam
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www.hivguidelines.org
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Learning Objectives
By the end of this session, participants
should be able to:
 Diagnose common skin
diseases/conditions in HIV-infected
children
 Understand the treatment of
common skin diseases in HIVinfected children
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Overview
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Diseases affecting skin and mucosal flora
are extremely common in HIV patients:
• Prevalence is approximately 36-84%
Certain skin conditions are the first
indicators of HIV infection
HIV patients are affected by the same skin
conditions in the general population, but
they tend to be more severe, more
extensive, and prone to relapse and
present atypically
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Manifestations of Local Infections
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Acne
Vesicles / blisters
Impetigo
Ulcers
Abscesses
Myositis, osteomyelitis
Fever
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Common Dermatologic Conditions
Seen in HIV-infected Children (1)
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Oral mucocutaneous conditions:
Oral candidiasis
Herpes simplex infection
Oral hairy leukoplakia
Aphthous ulcer
Dental problems: linear gingival
erythema, poor dentition
• Parotid enlargement
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Common Dermatologic Conditions
Seen in HIV-infected Children (2)
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Infectious etiologies:
• Bacteria:
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Staphylococcus
streptococcus
• Fungi: cutaneous or systemic
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Candida
Penicillium marneffei
• Viruses:
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Herpes Simplex (HSV)
Herpes Zoster (VZV)
Human Papilloma Virus (HPV)
Molluscum contagiosum
• Other:
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Scabies
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Common Dermatologic Conditions
Seen in HIV-infected Children (3)
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Non-infectious etiologies
Papular pruritic eruption (PPE)
Eczema
Psoriasis
Seborrheic dermatitis
Cutaneous hypersensitivity reaction to
drugs or insect bites
• Tumors:
• Non-Hodgkin lymphoma
• Kaposi Sarcoma
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Candidiasis
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Oral Mucosal Infection
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Oral candidiasis:
• Most common mucocutaneous disease seen in
HIV children
• Common types:
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Pseudomembranous (most common)
Atrophic/erythematous
Hypertrophic
Angular cheilitis
Esophageal candidiasis:
• secondary to extension of oral candida
infection
• probably present If the child has difficulty
feeding or swallowing, or complains of pain on
swallowing
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Skin Infection
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Ill-defined erythematous plaques
with satellite lesions
Diaper or intertriginous areas
Nail fold infection (paronychia) with
secondary nail dystrophy
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Nail Infections
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Note redness around
nails, and secondary nail
atrophy
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Diagnosis
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Mainly clinical
Empirically treat and if no relief:
• Further diagnostic such as
esophageal endoscopy, vaginal
exam
• Culture if atypical presentation
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Treatment
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Oral candidiasis:
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Esophageal candidiasis :
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Invasive infection:
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Nail infection:
• Miconazole 2% (daktarin), clotrimazole
2%, nystatin, oral
• apply on palate and tongue twice daily for
oral or cutaneous candida
• Fluconazole 6mg/kg/day on first day then
3-6mg/kg/day for 2-3 weeks
• Amphotericin B 0.5-1.0mg/ kg/ day for 2-3
weeks
• Treat as above for invasive infection
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Nodular Papules
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Nodular Papules
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Systemic symptoms may include:
high fever, signs of anemia,
hepatosplenomegaly,
lymphadenopathy, weight loss
Associated with severe
immunodeficiency
Diagnosis is mainly clinical
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Common Etiologies: Fungi
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Penicillium marneffei:
• Most common (up to 70% of fungal
diseases)
• Systemic symptoms
• Lesions: Papules with central necrotic
umbilication mainly on the head, face,
upper trunk
• CD4% typically <15%
• Can occur as immune system
reconstitutes (IRIS)
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Lesions similar to molluscum,
older lesions have central
necrosis, 1-5mm, distribution
most concentrated on face,
scattered on neck, back, arms,
and legs
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Less Common Fungi
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Cryptococcus neoformans:
• Less frequent (~10% of fungal diseases) but more
common in children> 6 years of age
• Systemic symptoms
• Lesions: Whole body nodular papules, may ulcerate
and may have central necrosis
• Often seen with meningitis or pneumonia, diarrhea
• CD4 cells typically <100/mm3.
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Histoplasmosis:
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Least common (~5-10% of fungal diseases)
Systemic symptoms
Can occur with lung process, meningitis, diarrhea.
Lesions: nodular papules and purpura
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Common Etiologies: Viruses (1)
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Molluscum contagiosum:
Common in children with HIV
No systemic symptoms
Caused by a poxvirus
Occurs by direct contact with lesion, or
contaminated towels, clothings, toys
• Lesions: Shiny surface, dome shaped
papules and central umbilication, often
granulomatous containing, no necrosis,
usually in the face or genitals, chest,
abdomen, arms, buttocks, thighs
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Common Etiologies: Viruses (2)
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Human papillomavirus (HPV)(genital
warts):
• Localized in anal, genital areas
• No systemic symptoms
• Lesions: Cauliflower-like warts, pink,
soft, no pain, easily bleeds; another
type is wide flat like grains of rice with
thickened horny papules
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Disseminated Fungal Infection
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Penicillium marneffei :
• Endemic to Southeast Asia
• Transmission: inhalation into lungs, then
hematogenously spread
• Clinical manifestations:
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Usually occurs in older children (≥5)
Always with systemic symptoms: prolonged
fevers, anemia, +/- hepatosplenomegaly
Skin lesions seen in 70-80% of penicillium cases
• Diagnosis: giemsa stain/culture of skin
scraping, blood culture (specify fungal)
• Treatment: amphotericin or itraconazole,
ART
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Diagnosis
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Fungi - Wet mount preparation or
culture
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Skin lesions
Lymph nodes
Bone marrow
Cerebrospinal fluid (CSF)
Blood
If suspect Cryptococcus neoformans
meningitis:
• check for antigen in serum and CSF
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8 year old boy, history of fevers,
anemia
weight loss, skin lesions > 1
month
Abundant penicillium conidia
seen on Giemsa stain of skin
scraping
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Treatment: Fungi
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Amphotericin B 0.5-1.0mg/kg/day:
• Penicillium marneffei: 2 months (or
itraconazole 200mg twice daily x 2 months)
• Cryptococcus neoformans: 2 weeks
induction then fluconazole 400-800mg /
day x 8 weeks maintenance (can also use
itraconazole 400mg / day for maintenance)
• Histoplasma: if severe (CNS disease,
hemodynamic instability), treat until
symptoms resolve then itraconazole
400mg/day for 6 months
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Treatment: Viruses
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Molluscum contagiosum
• Cryotherapy or curettage, surgery
• If not effective, use topical Imiquimod or cidofovir
• ARV therapy is effective to prevent and treat
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HPV (warts):
• Apply Podophyllin 10-25% / time / day or 3
times/week or trichloroacetic acid 30% / time / day
• If lesions in mouth and throat, just use
cryotherapy, electrocautery, laser
• When using Podophyllin, apply only to lesions,
instruct patient to rinse after 1-4 hours and if no
improvement after 4-6 weeks, change to
electrocautery
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Healed and active lesions
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Vesicular Lesions
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-Vesicular lesions on
erythematous base
-At different stages of healing
-Some are pustular
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Disseminated Infection
Herpes Zoster
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Etiologies: Viruses (1)
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Herpes Varicella Zoster Virus (VZV)
• Chickenpox - primary:
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Vesicular lesions throughout the body which rupture
then scab
Varying stages of healing
Highly infectious
• Zoster / Shingles - reactivation:
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Vesicular lesions often preceded by or occurring with
burning pain
Along dermatome, unilateral, commonly on the ribs,
chest, back and face
Only infectious to those without history of primary
infection / vaccination
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Etiologies: Viruses (2)
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Herpes simplex (HSV):
• Cluster of vesicles which rupture then
scab, typically around mouth, anus,
genitals
• If spread to esophagus, can cause
difficulty or pain in swallowing
• Possible complications of encephalitis
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Herpes Zoster
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Diagnosis
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Mainly clinical
VZV:
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Tzanck smear: giant cells
Viral culture
Immunofluorescent antibody
PCR if available
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Photo quiz
What is the diagnosis?
How do you manage/ treat?
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Chronic, present >1 month
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Treatment
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Apply methylene, milian on lesions to
prevent superinfections
Topical antivirals often less effective and
can irritate lesions
Systemic therapy ideally within 72 hours of
appearance of first vesicles
• Mild: Oral Acyclovir 40-80mg/kg/day divided
into 3 times/day for 7 days
• Severe, invasive Shingles: IV Acyclovir 1530mg/kg/day divided into 3 times/day for 7-14
days
• Prevention of relapse (≥ 1 time/month):
Acyclovir 400 mg 2 times/day
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Maculopapular Lesions
- Erythema
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Drug Related
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Measles-like, morbiliform,
erythematous
Severe cases – Stevens-Johnson
syndrome (antibiotics, ARVs)
Nevirapine-associated rash
• Typically presents in first 2 weeks
• Can occur with hypersensitivity
syndrome of fever, hepatitis,
transaminitis; can be fatal
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Disease Related
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HIV-associated: Pruritic papular eruption (PPE)
• Hyperpigmented, palpable
• Often occurs on extremities
• Typically in patients with severe
immunosuppression
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Syphilis
• Lesions found on palms and soles as well as trunk
• Can manifest with severe systemic signs (fever,
hepatosplenomegaly, lymphadenopathy, jaundice,
anemia)
• Serum RPR, VDRL usually positive
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Histoplasmosis (discussed previously)
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Treatment
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Steroids
Antihistamines
Apply UVB therapy if rash is
associated with HIV
If drug allergy suspected:
• Stop drug
• If rash is related to NVP, change to nonNNRTI ARV
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Treatment: Syphilis
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Congenital syphilis in children <2 years of age and:
• Normal CSF: IM benzathine penicillin 50,000 U/kg x
single dose
• Abnormal CSF: IV or IM benzyl penicillin 50,000 U/kg/
day divided twice per day x 10 days, or procaine
penicillin G 50.000 U/kg/day x 10 days
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Congenital syphilis in children> 2 years of age and:
• Normal CSF: IM benzyl penicillin 30,000 U/kg x single
dose
• Abnormal CSF: IV benzyl penicillin 20,000-30,000
U/kg/day divided twice per day x 14 days
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Penicillin allergy: replace with erythromycin 3050mg/kg/day orally divided 4 times a day x 30 days
If the mother was not treated with penicillin, children
should be treated even if asymptomatic and serum (-)
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Key points
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Oral candidiasis and PPE are the most
common skin/oral conditions associated
with HIV in children
Shallow non-healing ulcers on face may
be due to HSV
Invasive fungal diseases such as
Penicilliosis are life-threatening and
need immediate treatment with
antifungal and initiation of ART shortly
after
Drug hypersensitivity may occur with
NVP or other ARVs or antibiotics
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Thank you!
Questions?
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