Dermatological conditions that affect a stage 3/4 HIV patient who is not om treatment

1. DERMATOLOGIC CONDITIONS
ASSOCIATED WITH HIV AND SOME
KEY FEATURES TO TELL THEM
APART
Dr Che Edwin Chemutah
AND
NJETA CYPRAIN BUNYUI

2. THE CLINICAL DERMATOLOGIC PRESENTATION OF
HIV AIDS
The major presentation of HIV/AIDS as dermatologic condition is as
follows;
• Macular or popular lesions
• Nodular verrucous/ ulcerative lesion
• Vesicular bullous or pustular lesion
• Papulosquamous lesions
• Folliculitis
• Splenomegaly
• Systemic wasting

3. OVERVIEW
• skin disorders are commonly encounter in HIV-infected individuals and
they may be the first manifestation of HIV disease.
• Up to 90% of HIV infected persons suffer from a skin disease during the
course of their illness.(Martin, 1995)
• Declining immunity is associated with increase number and severity of skin
disorders and they are more likely to have unusual appearance in advance
HIV infection
• The availability of ARTs have changer the spectrum of skin disorders by
improving host immunity, which in turn reduce the occurrence of disorders
like KS and some skin infections and but the flare-up of others like herpes
zoster due to immune restoration and adverse drug reactions.

4. a. DRUG manifestation
b. Molluscum contagiosum
c. Candidiasis
d. Cryptococcosis
e. Histoplasmosis
f. Mycobacterium infection
g. Human papilloma virus
h. Kaposi sarcoma
Macular and popular manifestations are
characteristic of the following

5.  DRUGS
Common causes of rash eg cotrimoxazole and Nervirapine.
HIV patients have and increase frequency of skin reaction to
most drugs
Drug associated rash occur in about 5% of those initiating
ART.Overall ART is associated with decrease in dermatological
manifestation

6.  MOLLUSCUM CONTAGIOSUM
More common in young women
Occurs in 8-15% of AIDS patients
2 to 3 pearly flesh colored papules often with central
umbilication on the face, anogenital region, as disseminated
cryptococcosis

7.  CANDIDIASIS
In HIV/AIDS patients 47% have mucocutaneous candidiasis
infection in one series.
In children it manifests as diaper rash involving the trunk and
extremities
In adults it is red hemorrhagic macular or popular lesion
 CRYPTOCOCCOSIS
Common wide spread skin colored dome shape translucent
papulse 1-4mm in diameter -resemble molluscum contagiosum

8.  MOLLUSCUM CONTAGIOSUM
More common in young women
Occurs in 8-15% of AIDS patients
2 to 3 pearly flesh colored papules often with central
umbilication on the face, anogenital region, as disseminated
cryptococcosis

9.  HISTOPLASMOSIS
Slightly pink 2-6mm cutaneous papules to larger reddish
plaques and multiple shallow crusted ulcerative usually in
febrile patients
 MYCOBACTERIUM INFECTION (MTb, MAC, Myco bacterium
avium)
Vary from acne, plaques, pustules or indurated verrucous
plaques to ulcerative nodular lesion eg lupus vulgaris from
mycobacterium tuberculosis
 HUMAN PAPILLOMA VIRUS WARTS, Condyloma Acuminata
Diffuse flat filiform lesion, often in usual sites eg Genital tract
 KAPOSI SARCOMA (CD4 of mean 87cells/ul and 77cells/ul

10.  KAPOSI SARCOMA (CD4 of mean 87cells/ul and 77cells/ul
Early lesions are round or irregular pinkish red to violaceous
macules to papules. Usually nontender, often symmetrical
along skin tension lines

11. , NODULAR VERRUCOUS /OR ULCERATIVE LESIONS
A,
a. Mycobacterium
b. Cryptococcosis
c. Histoplasmosis
d. Furunculosis. Mostly due to MRSA. Contagion with
household partners
e. Bacillary angiomatosis, Friable vascular papules , cellulitis,
plaques and sub cutaneous nodules usually tender. Patient
maybe febrile. Maybe confused with Kaposi sarcoma.
Etiology is Bortonella henselae , B quintans which may be
isolated from blood 5-15 days incubation of lysis
centrifugation or blood agar in 5% CO2

12.  Eosinophilic folliculitis associated with a low CD4 count and
mark pruritus, discrete, erythematous urticaria, follicular
painless, papules on the trunk, head, neck, proximal
extremities, 90% above the nipple line, increase eosinophils,
increase IgE, CD4 usually <250 cell/ul, difficult to
differentiate from infective folliculitis
•

13.  KAPOSI SARCOMA.Kaposi associated herpes virus (KSHV)
now called HHV8 is found in biopsy samples and blood
mononuclear cells of the patient with aids related or classic
KS. The skin is the first presentation lesion, palpable, firm,
nontender, nodules. Early lesions may resemble
ecchymoses. Typically violaceus, hyperpigmented, involving
head , neck, later become confluent, from large tumor
masses and occur throughout the body. Up to 40% GI
involvement and oral lesion may precede skin lesions
responding to HAART
 NON HODGKINS LYMPHOMA. The skin in 15% of
patients with non Hodgkin's lymphoma lesions are usually
papules or nodules

14.  Mycobacterium Avium Intracellular. This is associated with fever and extensive cutaneous
nodular (granulomas or focal necrosis). It has been reported in patients infected with MAC
who respond to ART with immune reconstitution (increased CD4 and decreased viral load)
steroids may be useful
 Leishmaniasis. May produce a wide spectrum of localized or disseminated cutaneous,
mucosal or diffuse lesion. Most lesions are small, popular with ulceration but HIV may
widely disseminate with hundreds of lesions. (common in the middle east)

15. VESICULAR BULLOU OR PUSTULAR LESIONS
 Herpes simplex virus
Grouped vesicles on erythematous base rapidly evolve into ulceration or fissure. May persist
as chronic large ulcerative lesions especially in the perianal area

16.  VARICELLA ZOSTER VIRUS.
Common in HIV positive patients and frequently precedes AIDS 10-20% frequency
overall
Grouped vesicles on erythematous base and may be verrucous. In chronic form may
persist as hyperkeratotic lesions
 Dermatological distribution maybe multidermatomal
 Cytomegalovirus. Rare . small reddish papules that ulcerate. May present with
nonhealing or serpentine perianal ulceration

17.  Staphylococci impetigo. Fragile bullae that rupture easily with no specific distribution
of atypical scabies. Extremely pruritic, popular and vesicular lesions, characterized linear
or serpentine burrows. Most commonly on hands wrists elbows ankles. Average number
of mites =11
 Steven Johnson syndrome .Most often drug related (TOM/SMX, fluconazole, ddl, and
anti Tb drugs).
 Porphyria cutanea tarda. Associated HIV described, but the co-occurrence may reflect
co-existence of risk factors especially alcohol use Hep C rather than the causal association
lesion especially over sun exposed areas

18. ,PAPULOSQUAMOUS LESIONS
 Seboborrheic dermatitis. Occurs in 20 to 80% of HIV pos individuals as dandruff, patches and
plaques of erythema with indistinct margins and yellowish scale on hairy areas. Malessezia
furfur maybe the causative agent
 Xerotic Eczema(dry skin syndrome with a decrease in the CD4 count. Occurs in 5-20% of HIV
pos individuals often severely pruritic and resistant to antihistamine
 Dermatophytes: Occurs in 20 to 30% of HIV individuals , widespread and often severe with
scaly red pruritic papules or plaques

19.  CRUSTED SCABIES.
 occurs in 3 to5% of HIV individuals , highly contagious and usually occurs in patients with
severe immunodeficiency, characterized by erythema, hyperkeratosis and crusting
differentiated from psoriasis, lichen planus and secondary Syphillis
Pruritus is typical but hyperkeratotic and burrows not seen. Gross nail thickening and sub
lingual debris/ alopecia, hyperpigmentation pyoderma and eosinophilia. Diagnoses is based
on scrapping vs a few typical scabies. A heavy mite burden. Its resistant to therapy and
treatment failure is common. Treatment is effective with permethrin 5% cream plus oral
ivermectin or topical benzyl benzoate emulsion with ivermectin

20.  Splenomegaly. 23 to 70% of consecutive HIV patients were
found with splenomegaly on physical examination and 66%
by ultra sound in a 6 years longitudinal follow up of HIV
patients
 Systemic wasting syndrome. Weight loss is common, 20% in
one series. Caused by opportunistic infections, with chronic
dermatitis