Dermatological Manifestations of HIV: Evaluation and Cases

1. Dermatological Manifestations of HIV Jameela J. Yusuff, M.D. STAR Health Center SUNY Downstate Medical Center

2. OVERVIEW • Epidemiology: • Prevalence, Relation to CD4/VL/Haart • Evaluation: • History, Physical and Definitions • Cases • by lesion type: Macular, Papular, Vesicular, etc. • Special Cases • Hair/Nails/Pruritus • Oral lesions • Medication related

4. Zancanaro, J Am Acad Derm 2006

6. Case • Pyoderma gangrenosum

7. Chronic Venous Stasis

8. Skin lesions and CD4 • Any CD4: • Syphilis, HSV, VZV, Scabies, Psoriasis, lymphoma, and drug reactions • <200 • CMV, molluscum contagiosum, Cryptococcus, pruiritic papular eruption • <100 • Eosinophilic folliculitis, seborrheic dermatitis, acq. Ichythosis, atopic dermatitis, MTB, xerosis

9. Zancanaro, J Am Acad Derm 2006

11. Evaluation of Dermatologic Manifestations • History: • Acute: Headache, chills, fever • Chronic: Weight loss, constitutional symptoms • Time of onset, Site of onset, Itch or hurt, Pattern of spread, Change in lesions, Provocation, Treatment? • ROS: Rheumatologic complaints—sicca sx, joints • PMH: Medications--ARV, atopic, allergies, • Social: travel, occupation, animal contact, hobbies • Sexual hx: Partners, Drug use, HIV status—CD4

12. Evaluation of Dermatologic Manifestations • Physical Exam • Toxic or not; VS: Pulse, Blood pressure, temperature • Mucosal Membranes, Palms/soles, Nikolsky’s sign • Skin Signs: • Type: • Color: White, Red, Violaceous, Blanching • Palpation: Consistency, Mobility, Temperature, tender, margination • Flat: Macule, Petechiae, Ecchymosis, Telangiectasia • Elevated: Papule, Plaque, Nodule, Wheal, Vesicle/bullae, cyst • Depressed: Atrophy, erosion, Scar, ulcer, gangrene, • Shape: Round, oval , annular, serpiginous • Arrangement: Grouped, disseminated • Distribution: Extent, Pattern , characteristics

13. Definitions • Macule: (spot) not palpable, circumscribed area of change in skin color w/o elevation or depression • Papule: (pimple) superficial, solid lesion, <0.5cm, mostly elevated, palpable---disseminated or grouped • Plaque: plateau/elevation, well defined, confluence of papules--psoriasis • Nodule: (small knot) palpable, solid, round, ellipsoidal lesion involving epidermis/dermis/SQ tissue—TB, mycoses, CA • Pustule: circumscribed cavity containing purulent exudate—HSV, VZV • Vesicle-Bulla: (little bladder, bubble) circumscribed, elevated, cavity • Ulcer: (sore) skin defect with loss of epidermis, erosion –heals without scarring

14. Dermatologic Manifestations • Maculopapular lesions • Nodular/Verrucous lesions • Vesicular/Pustular lesions • Papular/Squamous lesions • Skin/Hair/Nail abnormalities • Medication-Specific manifestations

15. Maculopapular Lesions

16. Case 1 • Pt is 37yo man recently released from jail 2 months ago • Pt c/o 5 days of fever, LAD, sore throat, myalgias and rash • Rash mostly upper back, arms • Temp 101, pharyngeal erythema • Lab: WBC 4.2, Plts: 120 • What is your differential? • What would you order?

17. Acute Exanthem of HIV Disease • Acute exanthem begins 2 to 4 weeks after exposure to the virus; a/w prodromal symptoms such as lymphadenopathy, fatigue, fever, and night sweats. • Erythematous morbilliform eruption of the trunk and upper extremities. • The entire syndrome generally lasts for 5 to 7 days and resolves with complete recovery. • DDx: Parvovirus, measles, and rubella. • Correct diagnosis at this stage requires a high index of suspicion as HIV antibodies are not detectable during this early phase of infection.—CHECK Viral Load

18. Case 2 • Pt is MSM, HIV+ presents with Diffuse macular rash over most of body including palms • Denies travel, medications • Pt notes recent unprotected sexual encounters What else causes palmar lesions?

19. Syphilis • Syphilis presents more frequently in patients who are either homosexual or bisexual or in those who use illicit drugs. • Syphilitic ulcers are believed to increase HIV transmission. • Multiple ulcers seen in HIV+ • Rapid Progression of syphilis • Appropriate serologic follow-up

20. Pt is 40 yo male h/o HIV, CD4: 66, VL >100K adm with SOB, hemopytsis, and const. sx x 2wk On Exam, pt had crackles and was hypoxic and ill appearing Pt also noted to have skin lesions seen here Pt was empirically tx for PCP, isolated for TB and underwent Bronchoscopy What else to consider? Case 3

21. Kaposi Sarcoma • Human Herpes Virus 8 (HHV8) identified in the pathological specimen in 1994. • Affects the skin, mucous membrane, lymphnodes and visceral organs. • Tx for Limited disease: • Local therapy with liquid nitrogen, alitretinoin, or intralesional vincristine may be effective. • Tx for Diffuse/systemic: • Radiotherapy, and systemic chemotherapy usually with a single agent (eg, vinblastine, vincristine, bleomycin, doxorubicin, etoposide) may be useful in the treatment of KS;

22. Case 4 • This 30 yo HIV+ male c/o numerous clear pearly papules on his face and hands during his clinic visit • Lesions are painless • Denies constituitional sx • Most recent CD4:23, VL>100K • What is in your DDx? • How is this treated?

23. Case 5 • This 38-year-old woman with AIDS and a low CD4 count developed increasing numbers of papules on her face with dissemination to her trunk and extremities several months earlier. • What’s your differential?

24. Molluscum contagiosum: Ablation and curettage may be useful in the treatment of MC Cryptococcus : systemic antifungal like Fluconazole, Amphotericin Molluscum vs Cryptococcosis

25. Molluscum Contagiosum • Molluscum contagiosum is a benign, self-limited viral infection of children and young adults • Approximately 20% of patients with AIDS. • Dome-shaped umbilicated translucent papules on any cutaneous site, especially the genital areas and the face, may be numerous and large • The mucosal surfaces are spared. • Treatment • Cryotherapy—dc of therapy is often a/w recurrence; • Electrosurgery • Application of topical keratolytic preparations • Removal by curettage or pulsed dye laser • Imiquod

26. Cryptococcosis • Disseminated cryptococcocemia may cause meningo-encephalitis, pneumonia, soft tissue diseases and skin manifestations • Lesions are typically papular, resembling molluscum contagiosum but lacking the central umbilication • Diagnosis bx of lesion and staining • Treatment: Systemic Antifungals—Amphotericin B (liposomal formulationor Fluconazole

27. Maculopapular • Acute retroviral syndrome • Molluscum Contagiosum • Syphilis • Kaposi Sarcoma • Insect bites • Fungal: • Candidiasis, Cryptoccosis, Histoplasmosis, P.marneffi • Mycobacterial: • M.Leprae, M. kansasii, M. haemophilum

28. Vesicular Bullous/Pustular Lesions

29. Case 6 • This 34-year-old man developed a painful unilateral blistering eruption over his right eye and forehead with erythema, edema, and crusting 3 days earlier Diagnosis and Treatment? What is he at risk for?

30. Herpes Zoster • Primary VZV can be severe in AIDS patient • Zoster is reactivation of varicella virus, occuring in 25% of AIDS pts, in any dermatome • If in V1 distribution (of CN V), patients are at risk of chorioretinitis and retinal necrosis

31. Case 7 • Pt c/o fever, erosive conjunctivitis and oral mucositis, and a widespread red eruption on the head neck, upper trunk and to a lesser extent the lower extremities following bactrim. • What sign could you Look for on PE?

32. Drug Eruptions • Incidence of drug eruptions is greatly increased in HIV disease –possibly from dysregulation of immune system • Incidence of TEN and SJS is also increased • Check for Nikolsky’s sign • Commonly offending drugs include: • Trimethoprim, sulfadiazine, aminopenicillins, dapsone

33. This 48 year old woman developed recurrent bullae, crusts and atrophic scars on the tops of her hands and feet. • She also complained of increased skin fragility and worsening of the rash during the summer months. • She drinks at least 3-4 beers a day. • +NSAID • CD4: 530, VL <75 • No FH of Blistering

34. Porphyria Cutanea Tarda • Association with HIV is described • Might also reflect co-existence of risk factors such as HCV, Etoh use • Areas affected sun exposed skin

35. Case9 • This 38-year-old woman complained of a burning blistering eruption around her mouth for a week. • What test would you do? • How would you treat her?

36. Herpes Simplex • Reactivation of HSV1 is one the most common viral infections in HIV/AIDS pts • With increasing immunosuppression, pts may present w/o vesicles—erosions or ulcers • Do a Tzanck smear • If ulcers persist after acyclovir- It may be A-resistant

37. Vesicular Bullous/Pustular • HSV • VZV • CMV • Staphyloccus impetigo • “Typical” Scabies • Stevens-Johnson Syndrome • Porphyria Cutanea Tarda

38. Nodular, Verrucous, Ulcerative Lesions

39. Case10 • Pt is 38 yo male h/o AIDS adm with tender red and erythematous appearing nodules on face. • What is your DDx? • How do you dx this? • Treatment?

40. Bacillary Angiomatosis • Bacillary angiomatosis (BA) is a bacterial infection caused by Bartonella • Appearance: • Small pinpoint reddish to purple papules are the earliest lesions • Subcutaneous nodule that occurs in approximately 50% of patients with skin lesions. They may be located deep in the subcutis extending to involve soft tissue and bone • Nondescript crusted ulcerations, plaques, and cellulitis may also be seen in 5% to 10% of patients. • DDx: Kaposi's sarcoma. • Tx: erythromycin or doxycycline

41. Case 11 • This 50-year-old man AIDS developed 3 ulcers on his extremities following insect bites while on a vacation to Panama. • What is the DDx?

42. Cutaneous Leishmaniasis • Four percent of all skin lesions in India • More common in “New World” • Among HIV/AIDS pts can be a cause of FUO, or reactivation disease • May produce wide spectrum of localized or cutaneous disease—ranges from small lesions to widely disseminate • Treatment: Antimonials increasing resistance, Liposomal amphotericin, mifepristine

43. Case12 • Pt is 49 yo h/o HIV CD4: 400, VL <75 adm for rapidly enlarging penile mass • Lesion is somewhat tender • +Constitutional symptoms • CT: Psoas Abscess • Thoughts?

44. Squamous Cell CA • Risk factors include: smoking, chronic penile inflammation, uncircumsized, HPV and HIV • Strong epidemiologic association btw HPV and genital squamous cell ca • Biopsy is ESSENTIAL! • (Psoas Abscess was M.TB) • Pt s/p TB Tx and Penilectomy

45. HPV Direct or indirect contact Verruca vulgaris, Veeuca plana warts and condyloma acuminata Rx – Cryotherpay, podophyllin, imiquimod,intra -lesional bleomycin Viral Warts

47. Case13 • 43 yo male w/no PMHx pres 9/20/05 c/o 3 days of scrotal edema, perirectal discharge, fever, chills. • States “1 day I had a small pimple on my penis, the next day the whole area just exploded” • +Hx unprotected sex w/both men and women • PE: On admission febrile to 103, VSS • Abd: S NTND BS+ No HSM. +tender R inguinal mass, warm, fluctuant • GU: extensive scrotal/perirectal abscess.

48. Penis

49. Labs • WBC: 28,560 88%N • Hb/Ht 12.7/40 • Plt 336 • BUN/Cr 14/1.0 • 9/22 perirectal abscess Cx x2: CA-MRSA S clinda, gent, rifampin, tetracycline, bactrim, vanc • 9/23 scrotal abscess Cx CA-MRSA • 9/27 HIV+ CD4 240 • 10/3 inguinal aspirate: CA-MRSA • All BCx NGTD

50. Hx Shortly after PCN introduced in 1940s, PCN resistant S. aureus emerged. Methicillin introduced in 1961, MRSA reported 1 yr later, now accounts for >50% S. aureus isolates from USA ICUs CA-MRSA 1st reported in 1982 among IVDU in Detroit, Michigan, now becoming much more common.