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

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IMMUNODEFICIENCY VIRUS DISEASE

2

Initial Reports

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? June 5, 1981: 5 cases of PCP in

gay men from UCLA (MMWR)

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

describe cases
Human immunodeficiency virus

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? Discovered independently by Luc Montagnier of

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

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? Former names of the virus include:

Human T cell lymphotrophic virus (HTLV-III)

Lymphadenopathy associated virus (LAV)

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AIDS associated retrovirus (ARV)

HIV.....

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? 2 main types of HIV- 1 & 2

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

of AIDS.

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HIV.....

? HIV-2 discovered in 1986, antigenically distinct

virus , endemic in West Africa.

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

genes ,

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? apparently causes immune deficiency and AIDS

more slowly than HIV.1 and

? is less infectious with lower rates of either sexual

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or mother-to-child transmission.

Transmission:::::::

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

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? MTCT- 30%


Characteristics of the virus

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? Icosahedral (20 sided), enveloped virus of the

lentivirus subfamily of retroviruses.

? Retroviruses transcribe RNA to DNA.

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? Two viral strands of RNA found in core

surrounded by protein outer coat.

Outer envelope contains a lipid matrix within which

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specific viral glycoproteins are imbedded.

These knob-like structures responsible for binding to

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target cell.
HIV STRUCTURE

Structural Genes

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? Three main structural genes:

Group Specific Antigen (Gag)
Envelope (Env)
Polymerase (Pol)

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? Regulatory & accessory genes
? Tat
? Nef
? Rev
? Vif

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? Vpu/ vpx
? vpr

Viral Replication

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? First step, HIV attaches to susceptible host cell.

Site of attachment is the CD4 antigen found on a

variety of cells

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helper T cells
macrophages
monocytes
B cells

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Microglial, glial cells
Alveolar macrophages
Langerhans cells

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Disease progression in HIV-infected

individuals
Natural History of HIV Infection

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? 5 stages:

? Primary HIV infection: acute retroviral

syndrome or be asymptomatic.

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? Clinical stage 1: which may manifest as

persistent generalized lymphadenopathy or be

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asymptomatic.

? Clinical stage 2: unexplained symptoms,

infections, oral lesions or itchy dermatoses.

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? Clinical stage 3: unexplained symptoms,

infections, oral lesions itchy dermatoses or

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`penic' hematological changes.


? Clinical stage 4: wasting disease, infections,

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neoplasms and neurological disease.



? MUCOCUTANEOUS

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MANIFESTATIONS OF HIV

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Primary HIV infection/ acute

retroviral syndrome (90% pts)

? Mononucleosis-like, occur 1 to 6 weeks after

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infection.

lymphadenopathy

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Fever, Fatigue

Rash

Myalgia, arthralgia

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pharyngitis

Headache,

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Diarrhea, N, V

sore throat

neurologic manifestations.

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Oral +/- genital ulcers

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? diagnosed by positive plasma HIV polymerase

chain reaction (PCR) alongside negative or

equivocal HIV antibody tests

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Established HIV infection....

Pruritus, xerosis, ichthyosis

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? common in HIV

? HIV ? D/d of generalized pruritus

? mech-uncertain

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? Severe intractable pruritus with eosinophilia


Pruritis and pruritic

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eruptions of

HIV disease

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Eosinophilic folliculitis
? chronic pruritic dermatosis occurring in

persons with advanced HIV disease.

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? small pink to red edematous, folliculocentric

papules occur symmetrically above the nipple

line on the chest, proximal arms, head, and

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neck.

? Peripheral eosinophilia

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

? Sedating antihistamines

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Papular pruritic eruption of HIV

? primary lesion- firm urticarial papule
? distributed symmetrically

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? trunk and extremities and less commonly on

the face

? occasionally folliculocentric

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? Insect bite hypersensitivity is a speculative

pathomechanism

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? PPE is a sign of an advanced degree of

immunosuppression, occurring at CD4 T-cell

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counts below 100?200 ? 106/L


? Moderately responsive to antihistaminics and

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steroids

? UV B phototherapy

Seborrhoeic dermatitis

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? General population- 1-3%

? HIV- 20- 85%

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? represents an aberrant

cutaneous reaction to

commensal Malassezia yeast

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species.
? Management follows conventional lines:

emollients, topical steroids and antifungals and

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oral imidazoles.

Atopic dermatitis

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? Patients with HIV infection commonly manifest

atopic-like dermatitis & often have severe

disease that is recalcitrant to therapy

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? Explained by similar cytokine profile in both AD

& HIV

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? Th2 cytokine profile? elevated IgG levels,

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

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? Effective anti retroviral therapy reduces the

prevalence & severity of HIV related AD

Psoriasis

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? Prevalence of psoriasis vulgaris & psoriatic

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

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population)

? The immune dysregulation resulting from HIV

infection may trigger psoriasis in those

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genetically predisposed by the CW 0602 allele


Cutaneous infections associated

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with HIV/ AIDS....

? Bacterial infections
? Staphylococcus aureus ?

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? 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

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infection/ baceteremia- thru I/V lines

? Bullous impetigo,
? ecthyma,
? SSSS,

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? plaque like folliculitis,
? pyomyositis,
? botryomycosis

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Psedomonas aeruginosa-

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Ecthyma gangrenosum,

panniculitis, septicemia

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Bacillary angiomatosis-

? Bartonella hensalae, B

quintana

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? Angioproliferative lesions


? Red to violaceous, dome shaped papules,

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

? Soft to firm

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? May be tender to palpation


? Biopsy- vascular proliferation ?prominent

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neutrophilic infiltrate.

? Warthin starry silver stain- for organism

? Immunoperoxidase stain- for organism

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? Antibiotic of choice

- erythromycin,

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doxycycline

? Rifampicin,

ciprofloxacin, TMP

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-SMX
? Mycobacterium tuberculosis

? Reinfection with, or reactivation of,

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Mycobacterium tuberculosis -occur early in HIV

infection

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? extrapulmonary, including cutaneous,

tuberculosis is common and becoming

commoner

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? Atypical mycobacterial skin disease- due to

Mycobacterium avium?intracellulare.

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? 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).

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? Lesions described include- violaceous papules,

nodules and ulcers.

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

and M. marinum- after primary infection of the

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skin by the organism

? characteristic histopathological features such as

caseating granuloma may be absent due to

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diminished cell-mediated immunity

? Stain for AFB
? Mycobacterial culture

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Fungal infections

? Dermatophytosis:

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? Extensive in HIV disease

? Chronic & recurrent

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? Proximal subungual

onychomycosis- T rubrum

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? Majocchi's granuloma- nodular granulomatous

perifolliculitis ? firm violaceous nodules &

papules ? atypical manifestation of T.rubrum

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? Mucocutaneous candidiasis:
? Pseudomembranous oral candidiasis (thrush)
? Erythematous / atrophic candidiasis

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? Angular cheilitis
? Vaginal candidiasis
? Oesophageal candidosis- an AIDS-defining

diagnosis.

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Oral Candidiasis (thrush)

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? Cryptococcosois:
? Most common invasive fungal infection in HIV

patients

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

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? Metastatic cutaneous cryptococcosis- AIDS

defining illness

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

nodules

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

pustules, ulcers

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? Histoplasmosis:

? an AIDS-defining illness.

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

saharan Africa, East Asia

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? Disseminated histoplasmosis- skin involvement

in 10% of patients.

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? An exanthem, lesions resembling molluscum

contagiosum, acneiform folliculitis,psoriasiform

eruptions

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? Gomori methenamine silver

stain of a skin biopsy section.

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? Penicillinosis:
? Dimorphic fungi- penicillium marneffei
? 3rd most common opportunistic infection after

TB & cryptococcosis

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

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? Umbilicated papules with a necrotic central pore

? Ecthyma-like, folliculitis, subcutaneous nodules,

morbilliform eruption

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? Face & neck


sporotrichosis

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Viral infections

? Herpes simplex virus I & 2

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? HSV lesions tend to be

chronic, indolent & atypical

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? Respond less promptly to

antiviral therapy

? Anogenital involvement is

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frequent

? Any site can be affected-

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vesicobullous? eroded,

crusted, vegetative , ulcerating

? May not be self limiting

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? Chronic herpetic ulcers of longer than 1 month

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duration- AIDS defining illness

? Persistent necrotic digits & perioral ulceration

? Foscarnet & cidofovir ? i/v ? if Acyclovir

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resistant

? Varicella zoster virus

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infection:

? Severe varicella
? Persistent varicella
? Disseminated HZ

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? Chronic or reccurent HZ


? Molluscum contagiosum

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

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? Human papilloma virus

? Advancing disease? verrucae may enlarge,

become confluent & unresponsive to therapy

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? HPV 5 ? unusual pattern

of extensive verruca plana

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& P versicolor like warts


? Oral florid pappilomatosis

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? HPV- induced dysplasia- risk factors for high

grade dysplasia & cancer

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Protozoal infections

? Scabies:

? Extensive papulosquamous

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eruption ( hyperkeratotic ,

crusted scabies)

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? Secondary staph aureus

infection

Protozoal infections

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

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with GI & pulmonary involvement


? Cutaneous KS is multicentric

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often involves the face, oral

mucosa, palate and genitalia.

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? The classical lesion in HIV is a

purple patch, plaque or

nodule, which may ulcerate

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? Lesions may be multiple,

follow skin creases and may be

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grouped or linear and

koebnerize

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Malignancies- Melanoma & Non

Melanoma skin cancer (scc)

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? Increased incidence

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ORAL CAVITY & HIV

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Oral hairy leukoplakia:

? EBV

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? Upto 28% of HIV patients

? Whitish epithelial plaques

on the lateral tongue with

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corrugations accentuating

the normal tongue ridges

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HAIR & NAILS

IN HIV

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STD & HIV

? Co factor effect of ulcerative & non ulcerative

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STD on HIV transmission:

? Lack of mechanical skin/ mucous membrane /

endocervical epithelium

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? Inflammatory millieu
? SYPHILIS

? Giant chancre

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

malaise, headache, nodules, indurated plaques

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with/ without ulceration

? CHANCROID

? Genital ulcers tends to be larger & persist longer

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

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persist or progress to chronic enlarged painful

ulcers with raised margins, ulcer may bleed

? Higher dose & longer period treatment with

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Acyclovir

? GRANULOMA INGUINALE

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? Lesion may be larger, extensive, pseudobubo

formation which may burst producing

ulceration, slow response to treatment

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? LGV

? Acute inflammation with bilateral inguinal bubo

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which may burst ulceration

? prolonged therapy may be required.

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Gonococcal infection


? Adverse cutaneous drug reaction and

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HIV


?Thank You

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