Download MBBS Dermatology PPT 6 Dermatological Manifestations Human Immunodeficiency Virus Disease Lecture Notes

Download MBBS (Bachelor of Medicine, Bachelor of Surgery) Dermatology PPT 6 Dermatological Manifestations Human Immunodeficiency Virus Disease Lecture Notes

DERMATOLOGICAL
MANIFESTATIONS OF HUMAN
IMMUNODEFICIENCY VIRUS DISEASE

2

Initial Reports

? June 5, 1981: 5 cases of PCP in

gay men from UCLA (MMWR)

? July 3, 1981: 26 additional cases
? Dec 10, 1981: 3 NEJM papers

describe cases
Human immunodeficiency virus

? Discovered independently by Luc Montagnier of

France and Robert Gallo of the US in 1983-84.

? Former names of the virus include:

Human T cell lymphotrophic virus (HTLV-III)

Lymphadenopathy associated virus (LAV)

AIDS associated retrovirus (ARV)

HIV.....

? 2 main types of HIV- 1 & 2

? Worldwide, HIV.1 is by far the commonest cause

of AIDS.
HIV.....

? HIV-2 discovered in 1986, antigenically distinct

virus , endemic in West Africa.

? HIV.2- differs in a number of its regulatory

genes ,

? apparently causes immune deficiency and AIDS

more slowly than HIV.1 and

? is less infectious with lower rates of either sexual

or mother-to-child transmission.

Transmission:::::::

? Sexual- 0.1 ? 1.o%
? Blood & blood products- >90%
? Tissue & organ donation- 50-90%
? Inj ? 0.3%
? IDU- 1-10%
? MTCT- 30%


Characteristics of the virus

? Icosahedral (20 sided), enveloped virus of the

lentivirus subfamily of retroviruses.

? Retroviruses transcribe RNA to DNA.
? Two viral strands of RNA found in core

surrounded by protein outer coat.

Outer envelope contains a lipid matrix within which

specific viral glycoproteins are imbedded.

These knob-like structures responsible for binding to

target cell.
HIV STRUCTURE

Structural Genes

? Three main structural genes:

Group Specific Antigen (Gag)
Envelope (Env)
Polymerase (Pol)
? Regulatory & accessory genes
? Tat
? Nef
? Rev
? Vif
? Vpu/ vpx
? vpr

Viral Replication

? First step, HIV attaches to susceptible host cell.

Site of attachment is the CD4 antigen found on a

variety of cells

helper T cells
macrophages
monocytes
B cells
Microglial, glial cells
Alveolar macrophages
Langerhans cells


Disease progression in HIV-infected

individuals
Natural History of HIV Infection

? 5 stages:

? Primary HIV infection: acute retroviral

syndrome or be asymptomatic.

? Clinical stage 1: which may manifest as

persistent generalized lymphadenopathy or be

asymptomatic.

? Clinical stage 2: unexplained symptoms,

infections, oral lesions or itchy dermatoses.

? Clinical stage 3: unexplained symptoms,

infections, oral lesions itchy dermatoses or

`penic' hematological changes.


? Clinical stage 4: wasting disease, infections,

neoplasms and neurological disease.



? MUCOCUTANEOUS

MANIFESTATIONS OF HIV








Primary HIV infection/ acute

retroviral syndrome (90% pts)

? Mononucleosis-like, occur 1 to 6 weeks after

infection.

lymphadenopathy

Fever, Fatigue

Rash

Myalgia, arthralgia

pharyngitis

Headache,

Diarrhea, N, V

sore throat

neurologic manifestations.

Oral +/- genital ulcers



? diagnosed by positive plasma HIV polymerase

chain reaction (PCR) alongside negative or

equivocal HIV antibody tests

Established HIV infection....

Pruritus, xerosis, ichthyosis

? common in HIV

? HIV ? D/d of generalized pruritus

? mech-uncertain

? Severe intractable pruritus with eosinophilia


Pruritis and pruritic

eruptions of

HIV disease

Eosinophilic folliculitis
? chronic pruritic dermatosis occurring in

persons with advanced HIV disease.

? small pink to red edematous, folliculocentric

papules occur symmetrically above the nipple

line on the chest, proximal arms, head, and

neck.

? Peripheral eosinophilia

? Smear from intact papule/ pustule? eosinophils
? Rx
? Phototherapy

? Sedating antihistamines

Papular pruritic eruption of HIV

? primary lesion- firm urticarial papule
? distributed symmetrically
? trunk and extremities and less commonly on

the face

? occasionally folliculocentric


? Insect bite hypersensitivity is a speculative

pathomechanism

? PPE is a sign of an advanced degree of

immunosuppression, occurring at CD4 T-cell

counts below 100?200 ? 106/L


? Moderately responsive to antihistaminics and

steroids

? UV B phototherapy

Seborrhoeic dermatitis

? General population- 1-3%

? HIV- 20- 85%

? represents an aberrant

cutaneous reaction to

commensal Malassezia yeast

species.
? Management follows conventional lines:

emollients, topical steroids and antifungals and

oral imidazoles.

Atopic dermatitis

? Patients with HIV infection commonly manifest

atopic-like dermatitis & often have severe

disease that is recalcitrant to therapy

? Explained by similar cytokine profile in both AD

& HIV

? Th2 cytokine profile? elevated IgG levels,

increased eosinophils, IL4 , IL5
? Treatment similar to immunocompetent hosts

? Effective anti retroviral therapy reduces the

prevalence & severity of HIV related AD

Psoriasis

? Prevalence of psoriasis vulgaris & psoriatic

arthritis ? increased? 5% (1-2% in general

population)

? The immune dysregulation resulting from HIV

infection may trigger psoriasis in those

genetically predisposed by the CW 0602 allele


Cutaneous infections associated

with HIV/ AIDS....

? Bacterial infections
? Staphylococcus aureus ?
? 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

infection/ baceteremia- thru I/V lines

? Bullous impetigo,
? ecthyma,
? SSSS,
? plaque like folliculitis,
? pyomyositis,
? botryomycosis






Psedomonas aeruginosa-

Ecthyma gangrenosum,

panniculitis, septicemia

Bacillary angiomatosis-

? Bartonella hensalae, B

quintana

? Angioproliferative lesions


? Red to violaceous, dome shaped papules,

nodules or plaques, few mm to 2-3cm in size

? Soft to firm

? May be tender to palpation


? Biopsy- vascular proliferation ?prominent

neutrophilic infiltrate.

? Warthin starry silver stain- for organism

? Immunoperoxidase stain- for organism

? Antibiotic of choice

- erythromycin,

doxycycline

? Rifampicin,

ciprofloxacin, TMP

-SMX
? Mycobacterium tuberculosis

? Reinfection with, or reactivation of,

Mycobacterium tuberculosis -occur early in HIV

infection

? extrapulmonary, including cutaneous,

tuberculosis is common and becoming

commoner

? Atypical mycobacterial skin disease- due to

Mycobacterium avium?intracellulare.

? occcurs as part of a disseminated infection in up

to one-third of patients at CD4 T-cell counts

below 50 ? 106/L (rare below 200 ? 106/L).

? Lesions described include- violaceous papules,

nodules and ulcers.


? M. kansasii, M. haemophilum , M. fortuitum

and M. marinum- after primary infection of the

skin by the organism

? characteristic histopathological features such as

caseating granuloma may be absent due to

diminished cell-mediated immunity

? Stain for AFB
? Mycobacterial culture


Fungal infections

? Dermatophytosis:

? Extensive in HIV disease

? Chronic & recurrent

? Proximal subungual

onychomycosis- T rubrum


? Majocchi's granuloma- nodular granulomatous

perifolliculitis ? firm violaceous nodules &

papules ? atypical manifestation of T.rubrum


? Mucocutaneous candidiasis:
? Pseudomembranous oral candidiasis (thrush)
? Erythematous / atrophic candidiasis
? Angular cheilitis
? Vaginal candidiasis
? Oesophageal candidosis- an AIDS-defining

diagnosis.


Oral Candidiasis (thrush)



? Cryptococcosois:
? Most common invasive fungal infection in HIV

patients

? CD4 counts < 100/ul
? Soil, pigeon species, eucalyptus
? Inhalation
? 10-20% have skin lesions

? Metastatic cutaneous cryptococcosis- AIDS

defining illness

? Poor prognosis
? Most often- MC like umbilicated papules &

nodules

? Necrotising papules & nodules
? Cellulitis, erythematous papules, nodules,

pustules, ulcers



? Histoplasmosis:

? an AIDS-defining illness.

? a travel history- eastern US, latin America, sub

saharan Africa, East Asia


? Disseminated histoplasmosis- skin involvement

in 10% of patients.

? An exanthem, lesions resembling molluscum

contagiosum, acneiform folliculitis,psoriasiform

eruptions


? Gomori methenamine silver

stain of a skin biopsy section.
? Penicillinosis:
? Dimorphic fungi- penicillium marneffei
? 3rd most common opportunistic infection after

TB & cryptococcosis

? Soil
? Inhalation of conidia
? Cutaneous lesions- 75% pts

? Umbilicated papules with a necrotic central pore

? Ecthyma-like, folliculitis, subcutaneous nodules,

morbilliform eruption

? Face & neck


sporotrichosis


Viral infections

? Herpes simplex virus I & 2

? HSV lesions tend to be

chronic, indolent & atypical

? Respond less promptly to

antiviral therapy

? Anogenital involvement is

frequent

? Any site can be affected-

vesicobullous? eroded,

crusted, vegetative , ulcerating

? May not be self limiting



? Chronic herpetic ulcers of longer than 1 month

duration- AIDS defining illness

? Persistent necrotic digits & perioral ulceration

? Foscarnet & cidofovir ? i/v ? if Acyclovir

resistant

? Varicella zoster virus

infection:

? Severe varicella
? Persistent varicella
? Disseminated HZ
? Chronic or reccurent HZ


? Molluscum contagiosum

? 10% HIV Pts
? 30% of those with CD4< 100 cells/ul
? Progressive & recurrent


? Human papilloma virus

? Advancing disease? verrucae may enlarge,

become confluent & unresponsive to therapy

? HPV 5 ? unusual pattern

of extensive verruca plana

& P versicolor like warts


? Oral florid pappilomatosis

? HPV- induced dysplasia- risk factors for high

grade dysplasia & cancer


Protozoal infections

? Scabies:

? Extensive papulosquamous

eruption ( hyperkeratotic ,

crusted scabies)

? Secondary staph aureus

infection

Protozoal infections

? NEOPLASMS
? Kaposi sarcoma
? Caused by HHV 8
? HIV/ AIDS related KS- disseminated disease

with GI & pulmonary involvement


? Cutaneous KS is multicentric

often involves the face, oral

mucosa, palate and genitalia.

? The classical lesion in HIV is a

purple patch, plaque or

nodule, which may ulcerate


? Lesions may be multiple,

follow skin creases and may be

grouped or linear and

koebnerize


Malignancies- Melanoma & Non

Melanoma skin cancer (scc)

? Increased incidence








ORAL CAVITY & HIV

Oral hairy leukoplakia:

? EBV

? Upto 28% of HIV patients

? Whitish epithelial plaques

on the lateral tongue with

corrugations accentuating

the normal tongue ridges



HAIR & NAILS

IN HIV

STD & HIV

? Co factor effect of ulcerative & non ulcerative

STD on HIV transmission:

? Lack of mechanical skin/ mucous membrane /

endocervical epithelium

? Inflammatory millieu
? SYPHILIS

? Giant chancre

? lues maligna--sec syphilis with vasculitis? fever,

malaise, headache, nodules, indurated plaques

with/ without ulceration

? CHANCROID

? Genital ulcers tends to be larger & persist longer

? Less responsive to standard therapy
? HERPES GENITALIS
? As immunosupression progresses , lesion smay

persist or progress to chronic enlarged painful

ulcers with raised margins, ulcer may bleed

? Higher dose & longer period treatment with

Acyclovir

? GRANULOMA INGUINALE

? Lesion may be larger, extensive, pseudobubo

formation which may burst producing

ulceration, slow response to treatment


? LGV

? Acute inflammation with bilateral inguinal bubo

which may burst ulceration

? prolonged therapy may be required.

Gonococcal infection


? Adverse cutaneous drug reaction and

HIV


?Thank You