Didactic Series - PAETCpaetc.org/wp-content/uploads/2018/05/DermHIV2018-3.pdf · • A. Prescribe...
Transcript of Didactic Series - PAETCpaetc.org/wp-content/uploads/2018/05/DermHIV2018-3.pdf · • A. Prescribe...
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Didactic Series
HIV related Dermatologic Manifestations
Ankita Kadakia, MD UC San Diego, Owen Clinic
April 26, 2018
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Learning Objectives
1) Recognize common dermatologic manifestations associated with HIV and underlying disorders
2) Understand diagnosis and treatment of dermatologic manifestations
3) Review immunologic factors related to skin manifestations
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HIV Dermatology • Presenting sign of HIV infection is skin
manifestations • HIV positive individuals due to defects in
cell immunity are predisposed to certain bacterial, fungal, viral, and mycobacterial disease with skin manifestations
• Skin diseases which are common in general population are exacerbated in HIV with increased prevalence 3
American Academy of Dermatology
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Classifications Infectious Dermatoses • Bacterial • Mycobacterial • Fungal • Viral • Parasitic
Noninfectious Dermatoses • Systemic and Cutaneous Malignancy • Drug reactions • Epidermal disorders • Papular and follicular eruptions • Pigment disorders
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https://www.aids.gov.hk/pdf/g190htm/21.htm
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Infectious Dermatoses
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Bacterial
Fungal
Viral
Parasitic
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Case Presentation
• 50 y homeless M, CD4 22, VL 110K, not on ARVs, living in a tent under a bridge, recently took in a female cat and her kittens. He presents to the ER 3 months later with fever, weight loss, and dark red papules on his arms and trunk.
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9 Left: P. Volberding, MD, UCSF Center for HIV Information Image Library Right: G. Beatty, MD; A. Lukusa, MD, HIV InSite
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Poll Question
• What could the lesions be due to?
• A. Syphilis • B. Kaposi’s sarcoma • C. Sporotrichosis • D. Bacillary angiomatosis (Bartonellosis)
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Bacillary Angiomatosis • CD4 <50 • Bartonella henselae / Bartonella quintana • kitten scratches and fleas • Systemic lesions in Liver, spleen, bone,
lymph nodes • Bartonella PCR or blood culture • Doxycyline, macrolides have activity • MAC prophylaxis is protective 11
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Bacterial Dermatoses
• Staph aureus (skin abscess,folliculitis, carbuncles)
• Syphilis ( secondary syphilis, gumma, chancre)
• Bacillary angiomatosis • Nocardia • Mycobacterial – TB and NTM
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• 52 participants, HIV +/-, MRSA+/-,measured MRSA-specific CD4 T-cell responses including IFN-gamma in skin biopsies and blood
• Lower frequency of IFNγ+ producing CD4 memory T cells compared to HIV-uninfected participants with MRSA SSTIs
• Increasing CA-MRSA causing skin and soft tissue infections • MRSA colonizes 8.8% PLWHIV in North America • PLWHIV were 18-fold more likely to have CA-MRSA infections than
uninfected and twice as likely to have recurrences • Lower CD4 counts and low nadir CD4 • Higher peak RNA levels • Not on ART • Close contact in MSM and multiple sex partners
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Fungal Dermatoses • Primary Cutaneous
– Seborrheic dermatitis of scalp and face – Tinea/onychomycosis
• Muco-cutaneous – Oropharyngeal candidiasis
• Invasive Fungal with cutaneous lesions – Cryptococcus – Histoplasma – Penicillium – Cocci – Blastomycosis – Sporotrix
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Candidiasis
• Acute pseudomembranous candidiasis (thrush): The classic multiple white-flecks on the tongue, buccal mucosa, and palate
• Chronic hyperplastic candidiasis: Thick white plaques on the buccal mucosa
• Acute atrophic (erythematous) candidiasis: Erythematous patches on the palate
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Courtesy of Dr.Stephen Raffanti
Pearly flesh colored papules indicate disseminated cryptococcosis
Raised red papules of disseminated Histoplasmosis
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Poll Question • 35y M with HIV, CD4 250, VL ND, on ART c/o of
recurrent painful ulcerations in the anal cleft. Took acyclovir 5x’s/day for 10 days with no relief. Similarly 3 months ago did not respond to acyclovir. You confirm HSV by PCR of a lesion. What should you do next?
• A. Test for Thymidine Kinase mutation and empirically start Valganciclovir
• B. Test for VZV Ab and give IVIG • C. Start Foscarnet immediately
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Viral Dermatoses
• HSV • VZV/Herpes Zoster • Molluscum
contagiosum • CMV • HPV
• Vesicles- grouped in HSV and VZV
• Umbilicated in Molluscum
• Ulcerations in HSV, CMV
• Verrucous growth in HPV
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Scabies
webmd.com
Norwegian (Crusted) Scabies
Parasitic Dermatoses
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Scabies
• Superinfestation in Norwegian scabies occurs in advanced AIDS, HTLV co-infection
• Permethrin 5% cream once, can reapply after 14 days
• Need to treat household contacts • Ivermectin 200 mcg/kg oral, at least 2
doses taken 7 days apart
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Non-Infectious Dermatoses
Systemic and Cutaneous Malignancy
Drug Reactions
Epidermal Disorders
Papular and Follicular Eruptions
Pigment Disorders
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Most Common Non-infectious Dermatoses
• Psoriasis • Eosinophilic Folliculitis • Seborrheic Dermatitis • Atopic Dermatitis • Xerosis • Prurigo nodularis • Drug reaction
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22 Cedeno-Laurent et al. Journal of the International AIDS Society 2011, 14:5
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Systemic and Cutaneous Malignancy
• Kaposi’s sarcoma • Lymphoma • Melanoma • Basal cell carcinoma • Squamous cell Carcinoma
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Kaposi’s Sarcoma
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http://visualsonline.cancer.gov
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Kaposi’s Sarcoma • Decreased prevalence with more ART • Associated with HHV-8 • More extensive disease at low CD4 counts • ART can prevent / regress lesions unless
extensive cutaneous disease • Extensive cutaneous disease requires
adjunct chemo with Doxorubicin • Radiation therapy for localized lesions
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Kaposi’s Sarcoma • Have to look for mucocutaneous lesions-
Oral and rectal exam • MC visceral site is GI tract followed by
pulmonary • Workup for visceral lesions includes
EGD/Colonoscopy , CT Chest • Steroids worsen KS so avoid systemic
steroids including steroid inhalers and topical
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Poll Question • 45 y M, new HIV diagnosis, CD4 255, VL 55K, starts
Triumeq. 3 days later he develops painful blisters on his arms and trunk, 5 days later the skin starts to peel near the blisters and he feels like he has a bad sunburn. What do you do?
• A. Prescribe Acyclovir for Herpes Zoster since he is likely reconstituting his immune system
• B. Test for HLA B5701, if negative then continue Triumeq
• C. Stop Triumeq immediately and give fluids and steroids
• D. Treat for MRSA skin infection with Bactrim
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Drug Eruption • Increased due to ART, 20 to 100 times
more common • Can occur with any ART or OI prophylaxis
( Nevirapine/sulfa) • Mild form: Maculopapular exanthem or
morbiliform rash • Toxic epidermal necrolysis • Stevens Johnson syndrome • DRESS ( drug reaction with eosinophilia
and systemic symptoms) 28 Dermatol Res Pract. 2017; 2017: 6216193.
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Dermnet NZ
• SJS <10% BSA • TEN >30% BSA • HLA types like B5701 with abacavir hypersensitiviy syndrome • Drug specific CD8+ cytotoxic lymphocytes can be detected in the early
blister fluid. They have some natural killer cell activity and can probably kill keratinocytes by direct contact. Cytokines implicated include perforin/granzyme, Fas-L and tumour necrosis factor alpha (TNFα).
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Epidermal Disorders
• Psoriasis • Xerosis ( severe generalized itching and
dryness) • Seborrheic dermatitis
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Psoriasis
• Any CD4 count • Worsening of psoriasis with HIV • Increase prevalence of psoriatic arthritis • Inverse psoriasis occurs in body folds,
smooth shiny red lesions • Topical steroids, retinoids, vitamin D
replacement not as effective in HIV • Responsive to ART
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34 Cedeno-Laurent et al. Journal of the International AIDS Society 2011, 14:5
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Inverse Psoriasis
http://psoriasismedication.org/flexural-or-inverse-psoriasis/
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Classic Psoriasis
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American Academy of Dermatology
Well circumscribed erythematous plaques with silver scaling
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Papular and Follicular Eruptions
• Eosinophilic folliculitis • Prurigo nodularis- pruritic nodules on
extremities • Pruritic Papular Eruption- papular and
pustular eruptions on extensor surfaces and dorsum of hands
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Courtesy of Dr.Stephen Raffanti
Raised pruritic nodules with pustular head on erythematous base
Eosinophilic Folliculitis
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Eosinophilic Folliculitis • Elevated IgE, peripheral eosinophilia • CD4 < 300 • Inflammatory condition and often diffuse • Th2 cytokine response to an unknown
antigen (Pityrosporum ovale or Demodex folliculorum)
• elevation of IL-4, IL-5 and chemokines that mediates chemotaxis, recruits eosinophils in the allergic late phase reaction
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Eosinophilic Folliculitis
• Skin biopsy: Intense infiltration of eosinophils around sebaceous glands/hair follicles, no PMNS or organisms
• Improves with ART • Topical steroid creams,oral antihistamines
for mild disease • Isotretinoin, Itraconazole, Phototherapy,
moderate to severe disease
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Prurigo nodularis
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http://bestpractice.bmj.com/topics/en-gb/855
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Pigment Disorders
• Hyperpigmentation ( Zidovudine) • Vitiligo- unknown pathogenesis but
thought to be autoimmune and possibly viral trigger to melanocytes
• Vitiligo treatment: topical corticosteroids, vitamin-D derivatives, calcineurin inhibitors, photochemotherapy
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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4360494/
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Vitiligo
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https://en.wikipedia.org/wiki/Vitiligo#/media/File:Vitiligo2.JPG
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References
• American Academy of Derm- HIV module • Mandel, Douglas and Bennet’s Principles
and Practice of Infectious Disease ed.2011
• aidsetc.org • Cedano et.al, New Insights into HIV-1
Primary Skin Disorders; Journal of the International AIDS Society 2011, 14:5
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