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Hiv

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  • 1. Dr BAMUZA MBCHB(MEDUNSA) HIV DERMATOLOGY
  • 2. Classification • • • • Infection Non-specific dermatitis Neoplasm Drug eruption
  • 3. 1. Infectious coetaneous conditions: • • • • • • • • • Staphylococcus aureus infections. Herpes simplex infection. Varicella Zoster infection. Molluscum contagiosum. Human papillomavirus (warts). Acute HIV exanthema and anathema. Syphilis. Dermatophytosis. Candidiasis.
  • 4. Viral infection Herpes simplex virus infection  Varicella-Zoster virus infection  Cytomegalovirus infection  Epstein-Barr virus infection  Human papillomavirus infection  Poxvirus infection 
  • 5. HERPIS SIMPLEX:clinical features Deep seated (hemorrhagic) vesicles Chronic ulcerative mucocutaneous lesion Exophytic lesion Ulcerated tumor like lesion
  • 6. • Diagnosis: – Direct fluorescent Ab staining – Polymerase chain reaction – Electron microscopy Rx • 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)
  • 7. Varicella-Zoster virus  Varicella:  Clinical features (Monomorphism) # hemorrhagic infarcted vesiclesinfection # clear vesicles  Herpes zoster:  Clinical features # groups of vesicles in dermatomal distribution # ecthymatous crusted punch out ulcer
  • 8. • 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)
  • 9. Varicella Zoster infection
  • 10. Candidiasis of mucous membranes
  • 11. Pyogenic diseases • Pathogen: -staphylococcus aureus* -pseudomonas aeruginosa • Pathogenesis: -B-cell defect -neutropenia -defective chemotaxis of neutrophil
  • 12. STAPHYLOCOCUS • Bullous impetigo. • Ecthyma. • Folliculitis: a. Folliculitis due to S. aureus. b. Often the follicular lesions of the trunk are intensely pruritic and may be mistaken for scabies. About 50 % of HIV-infection persons with scabies have coexistent S. aureus folliculitis.
  • 13. Pyogenic disease • Diagnosis: – clinical features – Gram stain & culture – blood culture – skin biopsy
  • 14. 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
  • 15. Molluscum contagiosum • Molluscum contagiosum is manifesting as flesh-colored hemispheric papules. A faint whitish core usually is visible at the centre of each papule, some of which may be slightly umbilicated. This eruption is seen commonly in immunocompetent young children (ages 3 to 8 years), whose lesions are scattered widely over the face, arms, and trunk. • In adults, this mild infection is usually sexually transmitted and occurs in the pubic area .
  • 16. Molluscum contagiosum
  • 17. Rx • Molluscum Seen frequently in young women not on ART 1st line therapy is ART Liquid nitrogen only temporary Curretage of large molluscum
  • 18. SYPHILIS • Coetaneous presentation of primary and secondary syphilis in HIV-infected persons are usually similar to those in now-HIV-infected persons. HIV may delay development of serological evidence of Treponema pallidum, resulting in negative tests. In the HIV- infected person, a negative serological test may not be adequate to rule out rule out secondary syphilis.
  • 19. 2.Non-specific dermatitis • • • • • • • Pruritic papular eruption (PPE) Seborrheic dermatitis Psoriasis Exfoliative dermatitis Drug eruption Prurigo nodularis Miscellaneous skin diseases
  • 20. Seborrheic dermatitis • greasy scaly erythematous patch • more severe in late stage of disease • refractory to treatment
  • 21. Seborhoeic dermatitis
  • 22. Treatment of seborrheic dermatitis • • • • • • ketoconazole + hydrocortisone cream clotrimazole cream ketoconazole shampoo selenium sulfide shampoo zinc pyrithione shampoo ciclopirox olamine shampoo
  • 23. Psoriasis • • • • • Incidence ~ 5-13 % (normal ~ 1-2%) more severity multiple types of lesion often occur with seborrheic dermatitis secondary infection with candida albicans or staphyllococcus aureus (esp. psoriatic erythroderma)
  • 24. Treatment of psoriasis • • • • • Acitretin 50-75mg/d Low-dose MTX (should prophylaxis OI) Cyclosporin High-dose Zidovudine (1,200 mg/d) Highly active antiretroviral therapy
  • 25. Treatment of psoriasis • • • • • Topical tar & corticosteroid preparation Topical calcipotriol preparation UVB phototherapy Narrow-band UVB phototherapy Systemic PUVA
  • 26. Drug eruption • Incidence: ~ • Etiology: times of general population – multiple drugs treatment – abnormal immune response – metabolic factor
  • 27. Common causative drugs: • sulfonamide (TMP-SMZ, sulfadiazine) • dapsone • anti-tuberculous drugs(INH, RFP) • ofloxacin • fluconazole Common causative drugs: • pentamidine • carbamazepine • foscarnet • nevirapine • efavirenz • indinavir
  • 28. • Clinical feature: – – – – Morbiliform reaction Fixed drug eruption Urticaria Photoallergic reaction • Clinical feature: – Exfoliative dermatitis – Hypersensitivity syndrome – Stevens-Johnson syndrome – Toxic epidermal necrolysis
  • 29. Treatment of drug eruption • Mild form: – offending drug may be stopped – topical corticosteroid – antihistamine
  • 30. Treatment of drug eruption • Severe form: – offending drug must be stopped – short course high dose systemic corticosteroid – antihistamine – antibiotic if necessary
  • 31. 2.NEOPLASMS
  • 32. Kaposi’s Sarcoma
  • 33. Extensive tumor lesions of Kaposis’s sarcoma in AIDS patient. Source: AIDS, 1997
  • 34. Kaposi’s sarcoma
  • 35. kp • Etiology: – genetic marker – immune dysregulation – retrovirus – HHV-8 (Human Herpes Virus-8)
  • 36. KS may effect any portion of the coetaneous surface. Initially, it appears as red-to brown flat macules. Papules, nodules, and tumors may also be present or develop later. Numbering from one to hundreds, they range in size from several millimeters to over 10 cm and may be widespread, grouped, or zosteriform. KS may affect mucosal surfaces and internal organs. Visceral involvement occurs in 71% of patients with advanced HIV disease and KS, most often affecting the gastrointestinal tract (50%), lymph nodes (50%), and lungs (37%).
  • 37. • Clinical features: – common at nose,eyelids & pinna – skin lesions may be numerous & disseminated – bleeding ulcers – symptom & sign of respiratory & gastrointestinal tract • Diagnosis: – histopathology & immunopathology
  • 38. • Treatment: – simple excision – Cryotherapy, Radiotherapy – Carbondioxide or Argon LASER – Photodynamic therapy,Chemotherpy – Interferon alpha & beta – Highly active antiretroviral therapy
  • 39. LYMPHOMA • Non-Hodgkin Lymphoma • Hodgkin’s disease • Cutaneous T-Cell Lymphoma (CTCL)
  • 40. Cause of HIV-related Lymphoma • Polyclonal proliferation & lymph node follicular hyperplasia • Chromosomal abnormalities • Epstein-Barr Virus (EBV) infection Treatment • chemotherapy • immunostimulator • antiviral agent
  • 41. Anal Warts (Condyloma)
  • 42. Oral HPV (Concerning for immunosuppression)
  • 43. WAKE-UP….What do you think is this??
  • 44. Interestening manifestation of extrapulmonary tuberculosis • Systemic examination: no abnormalities. • Local examination: there was an ill-defined swelling in left inguinal region measuring 10 x 8 cm, with single opening discharging pus. On palpation swelling was nontender, local temperature was not raised. Similar swelling was also present in opposite region. There was edema of penis with difficulty in retracting the prepuce. • Haemoglobin: 7.1 gm%. • Peripheral smear: microcytic hypochromic anaemia. • Renal and liver functions: normal. • CD4 cell count :96 /µl. • AFB positive in the pus from inguinal swelling. • Final Diagnosis: PLHA with tuberculous inguinal lymphadenopathy
  • 45. 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
  • 46. Treatment of M. tuberculosis Standard short course regimen: – 2HRZE/4HR for 6 months
  • 47. Photodermatitis HIV makes pts sensitive to the sun Pts with CD4 under 200 on photosensitizing drugs Either ART allows pts to go off photosensitizing drugs or immune reconstitution decreases reaction Tx: sunscreen, tx the dermatitis with potent topical steroids and lubricants, doxepin 25 mg qhs (as antihistamine)
  • 48. INFECTIOUS MONOCLEOSIS • EBV is transmitted via intimate contact with body secretions, primarily oropharyngeal secretions. EBV infects the B cells in the oropharyngeal epithelium. The organism may also be shed from the uterine cervix, implicating the role of genital transmission in some cases. On rare occasion, EBV is spread via blood transfusion. • Circulating B cells spread the infection throughout the entire reticular endothelial system (liver, spleen, and peripheral lymph nodes). EBV infection of B lymphocytes results in a humoral and cellular response to the virus. • Early signs include fever, lymphadenopathy, pharyngitis, rash, and/or periorbital edema. Relative bradycardia has been described in some patients with EBV mononucleosis, but it is not a constant finding. • Later physical findings include hepatomegaly, palatal petechiae, jaundice, uvular edema, splenomegaly, and, rarely (1-2%), findings associated with splenic rupture.
  • 49. Cryptococcosis • Pathogen: Cryptococcus neoformans • Clinical features: skin lesions ~ 10-20% – Molluscum-like papulonecrotic lesion – Subcutaneous nodule – Oral nodule – Oral ulcer – Verrucous tumor – Localized cellulitis
  • 50. Cryptococcosis • Diagnosis: – Skin scraping – Skin biopsy touch smear – Histopathology – Culture: -skin -CSF -blood
  • 51. 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
  • 52. Histoplasmosis • Pathogen: Histoplasma capsulatum • Clinical features: skin lesions ~ – exanthema-like maculopapular eruption – molluscum-like papulonecrotic lesion – oral ulcer or oral mass – vegetative plaque – diffuse purpura – panniculitis
  • 53. Histoplasmosis • Diagnosis: – Skin scraping – Skin biopsy touch smear – Histopathology – Culture: -skin -blood -bone marrow
  • 54. 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
  • 55. THANK YOU