2
Initial Reports
--- Content provided by FirstRanker.com ---
? June 5, 1981: 5 cases of PCP in
gay men from UCLA (MMWR)
--- Content provided by FirstRanker.com ---
? July 3, 1981: 26 additional cases? Dec 10, 1981: 3 NEJM papers
describe cases
Human immunodeficiency virus
--- Content provided by FirstRanker.com ---
? Discovered independently by Luc Montagnier of
France and Robert Gallo of the US in 1983-84.
--- Content provided by FirstRanker.com ---
? Former names of the virus include:Human T cell lymphotrophic virus (HTLV-III)
Lymphadenopathy associated virus (LAV)
--- Content provided by FirstRanker.com ---
AIDS associated retrovirus (ARV)
HIV.....
--- Content provided by FirstRanker.com ---
? 2 main types of HIV- 1 & 2? Worldwide, HIV.1 is by far the commonest cause
of AIDS.
--- Content provided by FirstRanker.com ---
HIV.....? HIV-2 discovered in 1986, antigenically distinct
virus , endemic in West Africa.
--- Content provided by FirstRanker.com ---
? HIV.2- differs in a number of its regulatory
genes ,
--- Content provided by FirstRanker.com ---
? apparently causes immune deficiency and AIDSmore slowly than HIV.1 and
? is less infectious with lower rates of either sexual
--- Content provided by FirstRanker.com ---
or mother-to-child transmission.
Transmission:::::::
--- Content provided by FirstRanker.com ---
? Sexual- 0.1 ? 1.o%? Blood & blood products- >90%
? Tissue & organ donation- 50-90%
? Inj ? 0.3%
? IDU- 1-10%
--- Content provided by FirstRanker.com ---
? MTCT- 30%Characteristics of the virus
--- Content provided by FirstRanker.com ---
? Icosahedral (20 sided), enveloped virus of thelentivirus subfamily of retroviruses.
? Retroviruses transcribe RNA to DNA.
--- Content provided by FirstRanker.com ---
? Two viral strands of RNA found in coresurrounded by protein outer coat.
Outer envelope contains a lipid matrix within which
--- Content provided by FirstRanker.com ---
specific viral glycoproteins are imbedded.
These knob-like structures responsible for binding to
--- Content provided by FirstRanker.com ---
target cell.HIV STRUCTURE
Structural Genes
--- Content provided by FirstRanker.com ---
? Three main structural genes:Group Specific Antigen (Gag)
Envelope (Env)
Polymerase (Pol)
--- Content provided by FirstRanker.com ---
? Regulatory & accessory genes? Tat
? Nef
? Rev
? Vif
--- Content provided by FirstRanker.com ---
? Vpu/ vpx? vpr
Viral Replication
--- Content provided by FirstRanker.com ---
? First step, HIV attaches to susceptible host cell.Site of attachment is the CD4 antigen found on a
variety of cells
--- Content provided by FirstRanker.com ---
helper T cells
macrophages
monocytes
B cells
--- Content provided by FirstRanker.com ---
Microglial, glial cellsAlveolar macrophages
Langerhans cells
--- Content provided by FirstRanker.com ---
Disease progression in HIV-infectedindividuals
Natural History of HIV Infection
--- Content provided by FirstRanker.com ---
? 5 stages:? Primary HIV infection: acute retroviral
syndrome or be asymptomatic.
--- Content provided by FirstRanker.com ---
? Clinical stage 1: which may manifest as
persistent generalized lymphadenopathy or be
--- Content provided by FirstRanker.com ---
asymptomatic.? Clinical stage 2: unexplained symptoms,
infections, oral lesions or itchy dermatoses.
--- Content provided by FirstRanker.com ---
? Clinical stage 3: unexplained symptoms,
infections, oral lesions itchy dermatoses or
--- Content provided by FirstRanker.com ---
`penic' hematological changes.? Clinical stage 4: wasting disease, infections,
--- Content provided by FirstRanker.com ---
neoplasms and neurological disease.? MUCOCUTANEOUS
--- Content provided by FirstRanker.com ---
MANIFESTATIONS OF HIV
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
Primary HIV infection/ acuteretroviral syndrome (90% pts)
? Mononucleosis-like, occur 1 to 6 weeks after
--- Content provided by FirstRanker.com ---
infection.
lymphadenopathy
--- Content provided by FirstRanker.com ---
Fever, FatigueRash
Myalgia, arthralgia
--- Content provided by FirstRanker.com ---
pharyngitis
Headache,
--- Content provided by FirstRanker.com ---
Diarrhea, N, Vsore throat
neurologic manifestations.
--- Content provided by FirstRanker.com ---
Oral +/- genital ulcers
--- Content provided by FirstRanker.com ---
? diagnosed by positive plasma HIV polymerasechain reaction (PCR) alongside negative or
equivocal HIV antibody tests
--- Content provided by FirstRanker.com ---
Established HIV infection....
Pruritus, xerosis, ichthyosis
--- Content provided by FirstRanker.com ---
? common in HIV? HIV ? D/d of generalized pruritus
? mech-uncertain
--- Content provided by FirstRanker.com ---
? Severe intractable pruritus with eosinophilia
Pruritis and pruritic
--- Content provided by FirstRanker.com ---
eruptions of
HIV disease
--- Content provided by FirstRanker.com ---
Eosinophilic folliculitis? chronic pruritic dermatosis occurring in
persons with advanced HIV disease.
--- Content provided by FirstRanker.com ---
? small pink to red edematous, folliculocentricpapules occur symmetrically above the nipple
line on the chest, proximal arms, head, and
--- Content provided by FirstRanker.com ---
neck.
? Peripheral eosinophilia
--- Content provided by FirstRanker.com ---
? Smear from intact papule/ pustule? eosinophils? Rx
? Phototherapy
? Sedating antihistamines
--- Content provided by FirstRanker.com ---
Papular pruritic eruption of HIV
? primary lesion- firm urticarial papule
? distributed symmetrically
--- Content provided by FirstRanker.com ---
? trunk and extremities and less commonly onthe face
? occasionally folliculocentric
--- Content provided by FirstRanker.com ---
? Insect bite hypersensitivity is a speculative
pathomechanism
--- Content provided by FirstRanker.com ---
? PPE is a sign of an advanced degree of
immunosuppression, occurring at CD4 T-cell
--- Content provided by FirstRanker.com ---
counts below 100?200 ? 106/L? Moderately responsive to antihistaminics and
--- Content provided by FirstRanker.com ---
steroids? UV B phototherapy
Seborrhoeic dermatitis
--- Content provided by FirstRanker.com ---
? General population- 1-3%
? HIV- 20- 85%
--- Content provided by FirstRanker.com ---
? represents an aberrantcutaneous reaction to
commensal Malassezia yeast
--- Content provided by FirstRanker.com ---
species.
? Management follows conventional lines:
emollients, topical steroids and antifungals and
--- Content provided by FirstRanker.com ---
oral imidazoles.
Atopic dermatitis
--- Content provided by FirstRanker.com ---
? Patients with HIV infection commonly manifestatopic-like dermatitis & often have severe
disease that is recalcitrant to therapy
--- Content provided by FirstRanker.com ---
? Explained by similar cytokine profile in both AD
& HIV
--- Content provided by FirstRanker.com ---
? Th2 cytokine profile? elevated IgG levels,increased eosinophils, IL4 , IL5
? Treatment similar to immunocompetent hosts
--- Content provided by FirstRanker.com ---
? Effective anti retroviral therapy reduces theprevalence & severity of HIV related AD
Psoriasis
--- Content provided by FirstRanker.com ---
? Prevalence of psoriasis vulgaris & psoriatic
arthritis ? increased? 5% (1-2% in general
--- Content provided by FirstRanker.com ---
population)? The immune dysregulation resulting from HIV
infection may trigger psoriasis in those
--- Content provided by FirstRanker.com ---
genetically predisposed by the CW 0602 allele
Cutaneous infections associated
--- Content provided by FirstRanker.com ---
with HIV/ AIDS....
? Bacterial infections
? Staphylococcus aureus ?
--- Content provided by FirstRanker.com ---
? high rates of S.aureus infn? atypical manifestations of the infection
? High rates of recurrent or chronic nasal carriage
? High rates of nosocomial infections/ deep tissue
--- Content provided by FirstRanker.com ---
infection/ baceteremia- thru I/V lines? Bullous impetigo,
? ecthyma,
? SSSS,
--- Content provided by FirstRanker.com ---
? plaque like folliculitis,? pyomyositis,
? botryomycosis
--- Content provided by FirstRanker.com ---
Psedomonas aeruginosa-
--- Content provided by FirstRanker.com ---
Ecthyma gangrenosum,
panniculitis, septicemia
--- Content provided by FirstRanker.com ---
Bacillary angiomatosis-? Bartonella hensalae, B
quintana
--- Content provided by FirstRanker.com ---
? Angioproliferative lesions
? Red to violaceous, dome shaped papules,
--- Content provided by FirstRanker.com ---
nodules or plaques, few mm to 2-3cm in size
? Soft to firm
--- Content provided by FirstRanker.com ---
? May be tender to palpation? Biopsy- vascular proliferation ?prominent
--- Content provided by FirstRanker.com ---
neutrophilic infiltrate.? Warthin starry silver stain- for organism
? Immunoperoxidase stain- for organism
--- Content provided by FirstRanker.com ---
? Antibiotic of choice
- erythromycin,
--- Content provided by FirstRanker.com ---
doxycycline? Rifampicin,
ciprofloxacin, TMP
--- Content provided by FirstRanker.com ---
-SMX
? Mycobacterium tuberculosis
? Reinfection with, or reactivation of,
--- Content provided by FirstRanker.com ---
Mycobacterium tuberculosis -occur early in HIV
infection
--- Content provided by FirstRanker.com ---
? extrapulmonary, including cutaneous,tuberculosis is common and becoming
commoner
--- Content provided by FirstRanker.com ---
? Atypical mycobacterial skin disease- due to
Mycobacterium avium?intracellulare.
--- Content provided by FirstRanker.com ---
? occcurs as part of a disseminated infection in upto one-third of patients at CD4 T-cell counts
below 50 ? 106/L (rare below 200 ? 106/L).
--- Content provided by FirstRanker.com ---
? Lesions described include- violaceous papules,
nodules and ulcers.
--- Content provided by FirstRanker.com ---
? M. kansasii, M. haemophilum , M. fortuitum
and M. marinum- after primary infection of the
--- Content provided by FirstRanker.com ---
skin by the organism? characteristic histopathological features such as
caseating granuloma may be absent due to
--- Content provided by FirstRanker.com ---
diminished cell-mediated immunity
? Stain for AFB
? Mycobacterial culture
--- Content provided by FirstRanker.com ---
Fungal infections
? Dermatophytosis:
--- Content provided by FirstRanker.com ---
? Extensive in HIV disease
? Chronic & recurrent
--- Content provided by FirstRanker.com ---
? Proximal subungualonychomycosis- T rubrum
--- Content provided by FirstRanker.com ---
? Majocchi's granuloma- nodular granulomatousperifolliculitis ? firm violaceous nodules &
papules ? atypical manifestation of T.rubrum
--- Content provided by FirstRanker.com ---
? Mucocutaneous candidiasis:
? Pseudomembranous oral candidiasis (thrush)
? Erythematous / atrophic candidiasis
--- Content provided by FirstRanker.com ---
? Angular cheilitis? Vaginal candidiasis
? Oesophageal candidosis- an AIDS-defining
diagnosis.
--- Content provided by FirstRanker.com ---
Oral Candidiasis (thrush)
--- Content provided by FirstRanker.com ---
? Cryptococcosois:
? Most common invasive fungal infection in HIV
patients
--- Content provided by FirstRanker.com ---
? CD4 counts < 100/ul
? Soil, pigeon species, eucalyptus
? Inhalation
? 10-20% have skin lesions
--- Content provided by FirstRanker.com ---
? Metastatic cutaneous cryptococcosis- AIDS
defining illness
--- Content provided by FirstRanker.com ---
? Poor prognosis? Most often- MC like umbilicated papules &
nodules
--- Content provided by FirstRanker.com ---
? Necrotising papules & nodules? Cellulitis, erythematous papules, nodules,
pustules, ulcers
--- Content provided by FirstRanker.com ---
? Histoplasmosis:
? an AIDS-defining illness.
--- Content provided by FirstRanker.com ---
? a travel history- eastern US, latin America, sub
saharan Africa, East Asia
--- Content provided by FirstRanker.com ---
? Disseminated histoplasmosis- skin involvement
in 10% of patients.
--- Content provided by FirstRanker.com ---
? An exanthem, lesions resembling molluscumcontagiosum, acneiform folliculitis,psoriasiform
eruptions
--- Content provided by FirstRanker.com ---
? Gomori methenamine silver
stain of a skin biopsy section.
--- Content provided by FirstRanker.com ---
? Penicillinosis:? Dimorphic fungi- penicillium marneffei
? 3rd most common opportunistic infection after
TB & cryptococcosis
--- Content provided by FirstRanker.com ---
? Soil
? Inhalation of conidia
? Cutaneous lesions- 75% pts
--- Content provided by FirstRanker.com ---
? Umbilicated papules with a necrotic central pore? Ecthyma-like, folliculitis, subcutaneous nodules,
morbilliform eruption
--- Content provided by FirstRanker.com ---
? Face & neck
sporotrichosis
--- Content provided by FirstRanker.com ---
Viral infections
? Herpes simplex virus I & 2
--- Content provided by FirstRanker.com ---
? HSV lesions tend to be
chronic, indolent & atypical
--- Content provided by FirstRanker.com ---
? Respond less promptly toantiviral therapy
? Anogenital involvement is
--- Content provided by FirstRanker.com ---
frequent
? Any site can be affected-
--- Content provided by FirstRanker.com ---
vesicobullous? eroded,crusted, vegetative , ulcerating
? May not be self limiting
--- Content provided by FirstRanker.com ---
? Chronic herpetic ulcers of longer than 1 month
--- Content provided by FirstRanker.com ---
duration- AIDS defining illness? Persistent necrotic digits & perioral ulceration
? Foscarnet & cidofovir ? i/v ? if Acyclovir
--- Content provided by FirstRanker.com ---
resistant
? Varicella zoster virus
--- Content provided by FirstRanker.com ---
infection:? Severe varicella
? Persistent varicella
? Disseminated HZ
--- Content provided by FirstRanker.com ---
? Chronic or reccurent HZ? Molluscum contagiosum
--- Content provided by FirstRanker.com ---
? 10% HIV Pts? 30% of those with CD4< 100 cells/ul
? Progressive & recurrent
--- Content provided by FirstRanker.com ---
? Human papilloma virus? Advancing disease? verrucae may enlarge,
become confluent & unresponsive to therapy
--- Content provided by FirstRanker.com ---
? HPV 5 ? unusual pattern
of extensive verruca plana
--- Content provided by FirstRanker.com ---
& P versicolor like warts? Oral florid pappilomatosis
--- Content provided by FirstRanker.com ---
? HPV- induced dysplasia- risk factors for highgrade dysplasia & cancer
--- Content provided by FirstRanker.com ---
Protozoal infections? Scabies:
? Extensive papulosquamous
--- Content provided by FirstRanker.com ---
eruption ( hyperkeratotic ,
crusted scabies)
--- Content provided by FirstRanker.com ---
? Secondary staph aureusinfection
Protozoal infections
--- Content provided by FirstRanker.com ---
? NEOPLASMS
? Kaposi sarcoma
? Caused by HHV 8
? HIV/ AIDS related KS- disseminated disease
--- Content provided by FirstRanker.com ---
with GI & pulmonary involvement
? Cutaneous KS is multicentric
--- Content provided by FirstRanker.com ---
often involves the face, oral
mucosa, palate and genitalia.
--- Content provided by FirstRanker.com ---
? The classical lesion in HIV is apurple patch, plaque or
nodule, which may ulcerate
--- Content provided by FirstRanker.com ---
? Lesions may be multiple,
follow skin creases and may be
--- Content provided by FirstRanker.com ---
grouped or linear and
koebnerize
--- Content provided by FirstRanker.com ---
Malignancies- Melanoma & Non
Melanoma skin cancer (scc)
--- Content provided by FirstRanker.com ---
? Increased incidence--- Content provided by FirstRanker.com ---
ORAL CAVITY & HIV
--- Content provided by FirstRanker.com ---
Oral hairy leukoplakia:
? EBV
--- Content provided by FirstRanker.com ---
? Upto 28% of HIV patients? Whitish epithelial plaques
on the lateral tongue with
--- Content provided by FirstRanker.com ---
corrugations accentuating
the normal tongue ridges
--- Content provided by FirstRanker.com ---
HAIR & NAILS
IN HIV
--- Content provided by FirstRanker.com ---
STD & HIV
? Co factor effect of ulcerative & non ulcerative
--- Content provided by FirstRanker.com ---
STD on HIV transmission:? Lack of mechanical skin/ mucous membrane /
endocervical epithelium
--- Content provided by FirstRanker.com ---
? Inflammatory millieu
? SYPHILIS
? Giant chancre
--- Content provided by FirstRanker.com ---
? lues maligna--sec syphilis with vasculitis? fever,
malaise, headache, nodules, indurated plaques
--- Content provided by FirstRanker.com ---
with/ without ulceration? CHANCROID
? Genital ulcers tends to be larger & persist longer
--- Content provided by FirstRanker.com ---
? Less responsive to standard therapy
? HERPES GENITALIS
? As immunosupression progresses , lesion smay
--- Content provided by FirstRanker.com ---
persist or progress to chronic enlarged painfululcers with raised margins, ulcer may bleed
? Higher dose & longer period treatment with
--- Content provided by FirstRanker.com ---
Acyclovir
? GRANULOMA INGUINALE
--- Content provided by FirstRanker.com ---
? Lesion may be larger, extensive, pseudobuboformation which may burst producing
ulceration, slow response to treatment
--- Content provided by FirstRanker.com ---
? LGV
? Acute inflammation with bilateral inguinal bubo
--- Content provided by FirstRanker.com ---
which may burst ulceration
? prolonged therapy may be required.
--- Content provided by FirstRanker.com ---
Gonococcal infection? Adverse cutaneous drug reaction and
--- Content provided by FirstRanker.com ---
HIV?Thank You
--- Content provided by FirstRanker.com ---