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Download CUTANEOUS MANIFASTATIONS OF HIV/AIDS
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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 • • • • • • • • • 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 • Bunker CB, Pinguet V. HIV and the Skin. In: Griffiths C, Barker J, Bleiker T, 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.