* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Acute HIV infection
Carbapenem-resistant enterobacteriaceae wikipedia , lookup
Anaerobic infection wikipedia , lookup
West Nile fever wikipedia , lookup
Trichinosis wikipedia , lookup
Dirofilaria immitis wikipedia , lookup
Rocky Mountain spotted fever wikipedia , lookup
Sarcocystis wikipedia , lookup
Hepatitis C wikipedia , lookup
Marburg virus disease wikipedia , lookup
Herpes simplex wikipedia , lookup
Onchocerciasis wikipedia , lookup
Herpes simplex virus wikipedia , lookup
Visceral leishmaniasis wikipedia , lookup
Oesophagostomum wikipedia , lookup
Human cytomegalovirus wikipedia , lookup
Epidemiology of HIV/AIDS wikipedia , lookup
Hepatitis B wikipedia , lookup
Diagnosis of HIV/AIDS wikipedia , lookup
Sexually transmitted infection wikipedia , lookup
Schistosomiasis wikipedia , lookup
Microbicides for sexually transmitted diseases wikipedia , lookup
Neonatal infection wikipedia , lookup
Leishmaniasis wikipedia , lookup
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 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