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SKIN MANIFESTATIONS IN AIDS

SKIN MANIFESTATIONS IN AIDS. Pornchai Chirachanakul M.D. Bamrasnaradura Institute. Classification. Infection Non-specific dermatitis Neoplasm. Bacterial infection. Pyogenic diseases Mycobacterial diseases Nocardiosis Bacillary angiomatosis. Pyogenic disease. Impetigo

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SKIN MANIFESTATIONS IN AIDS

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  1. SKIN MANIFESTATIONS IN AIDS Pornchai Chirachanakul M.D. Bamrasnaradura Institute

  2. Classification • Infection • Non-specific dermatitis • Neoplasm

  3. Bacterial infection • Pyogenic diseases • Mycobacterial diseases • Nocardiosis • Bacillary angiomatosis

  4. Pyogenic disease • Impetigo • Hemorrhagic ecthyma • Ecthyma gangrenosum • Folliculitis • Furuncle

  5. Pyogenic disease • Abscess • Carbuncle • Cellulitis • Pyomyositis • Pyoderma • Secondary infection of scabies, eczematous dermatitis & intravenous catheter site

  6. Pyogenic diseases • Pathogen: -staphylococcus aureus* -pseudomonas aeruginosa • Pathogenesis: -B-cell defect -neutropenia -defective chemotaxis of neutrophil

  7. Pyogenic disease • Diagnosis: • clinical features • Gram stain & culture • blood culture • skin biopsy

  8. Treatment of pyogenic disease (Staphylococcus aureus) • Semisynthetic penicillin • dicloxacillin,cloxacillin,oxacillin • First-generation cephalosporin • *Rifampicin 450-600 mg/d for 5-10 days or topical mupirocin ointment

  9. Treatment of pyogenic disease (Pseudomonas aeruginosa) • debridement • compress with 5% acetic acid • oral ciprofloxacin • i.v.imipenem

  10. Mycobacterium tuberculosis • Clinical features: • Neck mass (necrotic enlarged lymph node) • Folliculitis-like lesion • Necrotic papules • Diagnosis: • Acid fast staining of pus,skin,lymph node • skin biopsy • Culture & sensitivity test

  11. Treatment of M. tuberculosis Standard short course regimen: • 2HRZE/4HR for 6 months

  12. Nocardiosis • Low incidence (0.2-1.8%) • Pathogen: Nocardia species

  13. Nocardiosis • Clinical features: • fever • productive cough • hemoptysis • chest pain • dyspnea • weight loss

  14. Nocardiosis • Clinical features: • subcutaneous abscess • cellulitis • pustules • pyoderma • paronychia • ulcer

  15. Nocardiosis • Diagnosis: • clinical features • Gram stain • modified acid fast stain • culture

  16. Nocardiosis • Treatment: • TMP-SMZ (2.5-10 mg/kg of TMP) twice a day • Sulfadiazine 4-6 g/d • Ceftriaxone 2 g/d • Amikacin 1 g/d • Minocycline 200 mg/d • >6-12 months duration

  17. Bacillary angiomatosis • Clinical features: • Elevated friable bright red granulation tissue like papules 1-1,000 lesions • Subcutaneous nodules • Ulcerating tumor • Cellulitic plaque • Pathogen: • Bartonella quintana (or B. henselae)

  18. Bacillary angiomatosis • Diagnosis: • Histopathology: -Warthin-Starry stain or -modified Brown-Hopp’s stain • Culture: -brain heart infusion agar or -trypticase soy agar with 5% sheep blood

  19. Treatment of Bacillary angiomatosis • Erythromycin 250-500 mg qid for 6 weeks or until lesions cleared • Doxycycline, minocycline, tetracycline • Co-trimoxazole • Rifampicin, isoniazid • Azithromycin, roxithromycin • Norfloxacin, ciprofloxacin

  20. Viral infection • Herpes simplex virus infection • Varicella-Zoster virus infection • Cytomegalovirus infection • Epstein-Barr virus infection • Human papillomavirus infection • Poxvirus infection

  21. Herpes simplex virus infection • Clinical features: • Deep seated (hemorrhagic) vesicles • Chronic ulcerative mucocutaneous lesion • Exophytic lesion • Ulcerated tumor like lesion

  22. Herpes simplex virus infection • Diagnosis: • Clinicalfeature • Tzanck smear • Histopathology • Viral culture

  23. Herpes simplex virus infection • Diagnosis: • Direct fluorescent Ab staining • Polymerase chain reaction • Electron microscopy

  24. Treatment of HSV infection • Oral acyclovir 200-800 mg five times daily • I.V. acyclovir 5mg/kg/dose three times daily • I.V. trisodium phosphonoformate (Foscarnet) 40mg/kg/dose two-three times daily or cidofovir (ACV resistant mutant)

  25. Treatment of HSV infection • Oral valaciclovir 1,000 mg two times daily for 7-10 days • Oral famciclovir 250 mg three times daily for 7-10 days

  26. Varicella-Zoster virus infection • Varicella: • Clinical features (Monomorphism) #hemorrhagic infarcted vesicles # clear vesicles • Herpes zoster: • Clinical features # groups of vesicles in dermatomal distribution # ecthymatous crusted punch out ulcer

  27. Varicella-Zoster virus infection • 8-13% of HIV- infected patients had previous history of herpes zoster • incidence is more than normal population 7 times • common in young adult (<60 years)

  28. Varicella-Zoster virus infection • post-herpetic neuralgia is uncommon • may be disseminated infection • more skin necrosis • high risk cases have 73% positive anti-HIV Ab

  29. Varicella-Zoster virus infection • Diagnosis: • clinical features • Tzanck smears • Histopathology • Viral culture

  30. Varicella-Zoster virus infection • Diagnosis: • Direct fluorescent Ab staining • Polymerase chain reaction • Electron microscopy

  31. Varicella-Zoster virus infection Treatment • Oral acyclovir 800 mg five times daily for 7-10 days • Oral famciclovir 500 mg three times daily for 7-10 days • Oral valaciclovir 1,000 mg three times daily for 7-10 days • I.V. acyclovir 10 mg/kg/dose three times daily • Foscarnet (resistance to ACV)

  32. Molluscum contagiosum • Incidence 10-20% • common at genitalia, face(periorbital area),axilla,groin & buttock • ่may be larger than 1 cm. • CD4+ count <250 cells/cu.mm. • Diagnosis: • clinical feature • Histopathology

  33. Treatment of molluscum contagiosum • Curettage • Electrocoaggulation • Cryosurgery • Carbon dioxide LASER vaporization

  34. Treatment of molluscum contagiosum • Topical wart agents • Topical retinoic acid • Highly active antiretroviral therapy • Cidofovir • 5% Imiquimod cream

  35. Systemic fungal infection • Penicilliosis • Cryptococcosis • Histoplasmosis

  36. Penicilliosis • Pathogen: - Penicillium marneffei, a dimorphic fungi - endemic in Southeast Asia • Reservoirs: - bamboo rat

  37. Penicilliosis • Clinical features: skin lesions ~71.2% • Molluscum-like papulonecrotic lesions • Crusted plaque • Pustulo-nodular lesions • Ulcer (oral or extraoral lesion)

  38. Penicilliosis • Clinical features: • Erythema nodosum-like lesions • Subcutaneous nodule (lymphadenopathy) • Illusion of vesiculation

  39. Penicilliosis • Diagnosis: • Skin scraping • Skin biopsy touch smear • Skin biopsy (histopathology) • Culture:-blood sensitivity ~ 76% -skin sensitivity ~90% -bone marrow sensitivity ~100%

  40. Treatment of penicilliosis • Initial therapy: • Amphotericin-B 0.6-1.0 mg/kg/d (~2 weeks) & follow with itraconazole 400 mg/d (~10 weeks) • Suppressive therapy: • Itraconazole 200 mg/d

  41. HAART-induced penicilliosis • Pathogenesis: • restoration of CD4+ and CD8+ T lymphocyte • may be cytokine-mediated reaction

  42. HAART-induced penicilliosis • Clinical feature: • shiny erythematous papulo-nodular plaques • non pruritic lesions • occur within the first 2 months after HAART

  43. HAART-induced penicilliosis • Diagnosis: • history of previous treated penicilliosis • history of HAART • skin biopsy (granulomatous dermatitis with yeast cells) • skin culture for fungus

  44. HAART-indued penicilliosis • Treatment: • Amphotericin B or itraconazole • Short course systemic corticosteroid

  45. Cryptococcosis • Pathogen: Cryptococcus neoformans • Clinical features: skin lesions ~ 10-20% • Molluscum-like papulonecrotic lesion • Subcutaneous nodule • Oral nodule • Oral ulcer • Verrucous tumor • Localized cellulitis

  46. Cryptococcosis • Diagnosis: • Skin scraping • Skin biopsy touch smear • Histopathology • Culture: -skin -CSF -blood

  47. Treatment of cryptococcosis • Initial therapy: • Amphotericin-B 0.6-1.0 mg/kg/d (~2 weeks) & follow with fluconazole 400 mg/d (~10 weeks) • Suppressive therapy: • Fluconazole 200 mg/d • Itraconazole 200 mg/d

  48. Histoplasmosis • Pathogen: Histoplasma capsulatum • Clinical features: skin lesions ~ 10-20% • exanthema-like maculopapular eruption • molluscum-like papulonecrotic lesion • oral ulcer or oral mass • vegetative plaque • diffuse purpura • panniculitis

  49. Histoplasmosis • Diagnosis: • Skin scraping • Skin biopsy touch smear • Histopathology • Culture: -skin -blood -bone marrow

  50. Treatment of histoplasmosis • Initial therapy: • Amphotericin-B 0.6-1.0 mg/kg/d (~ 2 weeks) & follow with itraconazole 400 mg/d (~ 10 weeks) or fluconazole 400 mg/d • Suppressive therapy: • Itraconazole 200 mg/d or • Fluconazole 200 mg/d

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