Professional Documents
Culture Documents
1. INFECTIOUS DERMATOSES
(a) VIRAL INFECTIONS
(a) Disorders of epidermal cell kinetics ------ Seborrhoeic dermatitis, Psoriasis, Reiter’s disease, Ichthyosiform dermatoses.
(e) Cutaneous & systemic vasculitis of many etiologies has been reported to occur in HIV including ADR, CMV infection, PAN,
Lymphomatoid granulomatosis, Kawasaki’s disease and possibly HIV infection itself.
(f) ADR
The I.P. (from presumed exposure to development of acute febrile illness) ranges from 3-6 weeks (average = 14
days)varying with the route of infection and size of the viral inoculum. Commonly reported clinical manifestations include ------
fever
fatigue
rash
myalgia arthralgia
pharyngitis
night sweats
N/V/ Diarrhoea
Less common manifestations include ---------- decreased TC/platelet count, weight loss, aseptic meningitis, encephalitis,
neuritis, myelitis, oral ulcers and/or genital ulcers. RESOLVES IN 2 WEEKS.
The laboratory diagnosis of HIV-1 infection is made by 3 methods:
detection of p24 antigen
detection of viral nucleic acids
viral culture.
A DELAY OF 3-4 WEEKS EXISTS BETWEEN NEWLY ACQUIRED HIV-1 INFECTION AND DEVELOPMENT OF ANTIBODIES ---- CALLED
WINDOW PERIOD
BACTERIAL INFECTIONS:
Ecthyma like lesions occur due to M. marinum
Draining matted L.N with overlying erythema is caused by MAI.
BCG vaccine may cause local and systemic infection in HIV patients.
The INCIDENCE OF MAC INFECTTIONS HAS FALLEN NOW A DAYS DUE TO PRIMARY PROPHYLAXIS WITH AZITHROMYCIN AND MORE
RECENTLY HAART.
3. HELICOBACTER CINEADI
It causes a syndrome characterized by FEVER, BACTEREMIA AND RECURRENT AND/OR CHRONIC CELLULITIS (resembling
erythema nodosum) in compromised. The organism is carried as bowel flora in 10% of homosexual men.
Treatment is difficult and prolonged. CLARITHROMYCN, CIPRO OR DOXYCYCLIN are the possible initial treatments.
4. PSEUDOMONAS AERUGINOSA
FUNGAL INFECTIONS:
Cutaneous fungal infections in HIV infection occur as
Superficial infections
Invasive cutaneous infections or
Systemic infections with hematogenous dissemination to the skin.
RINGWORM INFECTIONS:
Onethird of HIV patients have superficial infections with ringworm. May be >Typical
Extensive
Altered morphology due to enhancement or diminution of inflammatory component.
Involvement of soles to give rise to diffuse hyperkeratosis or keratoderma blenorrhagica like picture
Proximal subungual onychomycosis is the CHARACTERISTIC NAIL INVOLVEMENT IN HIV. Other types of nail involvement can
also occur.
Relapses are common.
MUCOCUTANEOUS CANDIDIASIS:
Cutaneous candida infections of intertriginous areas and moist keratinized cutaneous sites like anogenital area are
relatively uncommon in AIDS. Occur with equal frequency in AIDS and NON AIDS individuals.
Candidial colonization of the oropharynx is common in HIV even in the absence of clinical findings. C. albicans is the main
pathogen. Non albicans species are found in ADVANCED HIV INFECTION WITH VERY LOW CD4 CELL COUNT.
ESOPHAGEAL CANDIDIASIS, an AIDS defining condition, occurs only in advanced immunosuppression (CD4 count < 100
cells/microlitre).
Disseminated candidiasis is uncommon in HIV because of B cell activation and the presence of anti candidial protective
antibody.
Vaginal candidiasis is commoner in HIV infected females.
Children with HIV infection commonly experience candidiasis in the diaper area and intertrigo in the axilla and neck folds.
Fingernail chronic candida paronychia with secondary nail dystrophy (onychia) also is common in HIV infected children.
VIRAL INFECTIONS:
The incidence of viral OIs has decreased after the institution of HAART except the manifestations of HPV.
Viruses are major pathogens causing OIs in HIV disease many of which are manifested at the mucocutaneous sites.
1. HSV:
With more advanced immunosuppression, lesions tend to be
SUBACUTE OR CHRONIC
INDOLENT.
ATYPICAL
RESPONDING LESS PROMPTLY TO TREATMENT
2. VZV:
In a compromised host, can present as -----
SEVERE VARICELLA
PERSISTENT VARICELLA
DERMATOMAL HERPES ZOSTER
DISSEMINATED HZ ---- defined as cutaneous involvement greater than 3 contiguous dermatomes, more than 20 lesions
scattered outside the initial dermatome or systemic infection (hepatitis, pneumonitis, encephalitis.
CHRONIC OR RECURRENT HZ.
3. MC
The clinical course of MCV infection in HIV disease differs significantly from that in the normal host and is an excellent
clinical marker of the degree of immunosuppression.
WIDESPREAD infection of face is common and highly characteristic of HIV.
Progressive & Recurrent after
treatment unless the immune
status improves with HAART.
Large numbers
Gaint MC
Extensive molluscum of more than one anatomic region (eg. face & groin) is highly suggestive of a CD4 count less than
50/c.mm.
4. HPV
Infections by HPV occur commonly during the course of HIV disease and their occurrence is NOT INFLUENCED BY HAART.
Intraepithelial carcinomas can develop even without the usual HPV types A/W malignancy.
Common warts:
Become numerous, confluent
Refractory to usual treatment modalities.
Precancerous lesions identical to mucosal lesions (SIL & SCCIS) can occur periungually and on the nail bed epidermis
(usually fingers) and may progress to invasive SCC.
Genital warts:
HPV 6 and 11 cause genital warts whereas HPV 16 and 18 cause precancerous lesions, low grade SIL, high grade SIL and
invasive SCC.
Oral warts:
Resemble genital warts. Extensive intraoral condyloma acuminata (oral florid papillomatosis) presents as multiple large
plaques that can transform to verrucous carcinoma.
Management of external anogenital HPV infection is directed at identifying these dysplasia and SCC. All HIV infected
individuals should be examined annually for evidence of HPV infection, especially those with prior HPV infection. Cervix and anal
canal must also be seen. If SIL is found, examination should be more frequent --------- 4-6 monthly. Biopsy is indicated. For minimally
invasive SCC in anal verge or on external anogenital sites, surgical excision is needed with adequate borders around the lesion.
Invasive SCC of the anus is treated by radiation therapy and chemotherapy is given.
PARASITIC INFECTIONS:
1. Scab
ies:
In individuals with advanced immunosuppression, scabies can occur with minimal or no pruritus but an
extensive papulosquamous eruption, i.e. hyperkeratotic crusted scabies or Norwegian scabies. Secondary Staph aureus infection
can occur rarely complicated by bacteremia.
Oral ivermectin (200 microgram/kg weekly) is the most effective therapy.
2. Demodicid
osis: Causes itchy papular lesions in HIV patients. Affected areas are the head, neck, trunk and arms.
Scrapings show numerous mites. It rapidly relapses with gamma benzene hexachloride.
3. Acanthameb
iasis
It is a rare form of encephalitis that may occur in immunocompetant and immunosuppressed hosts. It may occur in
ADVANCED AIDS (CD4 T cell count< 50/c.mm). In AIDS patients, skin lesions are the most common presentation (75% cases).
Lesions occur as deep seated nodules that suppurate, crust or weep serosanguinous fluid occurring mostly in extremities.
Sinusitis is commonly present and the palate or nasal septum may be perforated. The diagnosis is based on the biopsy of the
ulcer which will show suppurative and granulomatous inflammation WITH VASCULITIS. The vasculitis is uncommon in other
infectious granulomas and should alert the pathologists to search acanthamoeba.
STDs:
OPORTUNISTIC NEOPLASMS:
The prevalence of ONs including KS, HPV induced neoplasia, undifferentiated non Hodgkin’s B cell lymphoma (NHL) and
primary CNS lymphoma is increased in HIV disease. The incidence of melanoma and non melanoma skin cancer, Merkel cell
carcinoma, HL, T cell lymphomas and seminoma also may be increased.
Many of these OIs are associated with oncogenic human viruses and diminished immune surveillance.
PAPULOSQUAMOUS DISORDERS:
3 dermatologic disorders characterized by scaling patches and plaques are seen in HIV infected persons: SEBORRHOEIC
DERMATITIS, PSORIASIS AND REITER’S DISEASE.
It is one of the early signs of immunosuppression and is seen in over 50% AIDS patients.
WIDESPREAD
ATYPICAL --------- nummular eczematous.
HISTOLOGICALLY, there is keratinocyte necrosis and inflammatory obliterative changes at the DEJ.
2. Psoriasis
: see notes.
3. Reiter’s disease
Pruritus is a common complaint in patients with late symptomatic and advanced HIV disease occurring commonly in
patients with CD4 counts of less than 50 cells per microlitre compared to those of counts > 250 cells per microlitre.
Causes are:
1. Eosinophilic folliculitis
2. ADR
3. Atopic dermatitis (flares in AIDS)
4. XEROSIS
5. Urticaria
6. Scabies
7. Insect bites
8. Demodicidosis
9. Allergic contact dermatitis.
10. Lymphoma
11. Renal faiure
12. Viral hepatitis
13. Obstructive liver disease.
Eosinophilic folliculitis:
It is the most common non staphylococcal folliculitis in HIV infected persons. It occurs in
patients with CD4 T cell counts less than 200/c.mm.
Characteristically is a chronic, waxing and waning eruption with moderate to severe pruritus. The etiology and
pathogenesis is unknown but may be associated with a th2 response to unknown antigen.
Lesions are in the form of pink to red edematous folliculocentric papules that occur symmetrically above the
nipple line.
Secondary changes include ---- excoriations, excoriated papules, LSC and prurigo nodularis as well as secondary S. aureus
infection.
Skin biopsy reveals inflammation containing eosinophils surrounding and involving the hair follicle.
Peripheral eosinophilia is common.
The most effective treatment for EF is prednisolone starting with 70 mg PO and tapered at weekly intervals by 5-10 mg.
Other drugs are ----
Isotretinoin
PUVA
Topical tacrolimus.
Sedating antihistaminics.
Lipodystrophy syndrome ---- with PIs. Discontinuation or replacement of PI therapy does not result in reversal of
dysmorphic changes in most patients.
Drug interactions: mainly with PIs.
Pigmentation: Zidovudine treated individuals experience longitudinal melanonychia with brown black longitudinal streaks
in the nail plate. The pigmentary changes are usually noted in the finger and / or toe nails within 4-8 weeks after initiation
of ZVD therapy. Pigmentation also occurs in the mucous membranes. Diffuse hyperpigmentation mimicking primary
adrenal insufficiency has been reported.
Other ZVD ADRs include ------- hypertrichosis, hypersensitivity, leucocytoclastic vasculitis and paronychia.
Zalcitabine can cause apthous like ulceration of the oropharynx and esophagus.
INTERFACE DERMATITIS:
A histological entity showing basal keratinocyte vacuolation and necrosis and dense inflammatory infiltrate in the DEJ
appears to be specific to HIV. Such changes may be superimposed on well recognized conditions like seborrhoeic eczema and
psoriasis occurring in AIDS.
HAIR DISORDERS:
Diffuse alopecia.
Telogen effluvium.
Alopecia areata.
Vertical thinning.
Fungal Scalp disease.
Localized loss around scalp margin.
Hair loss From Syphilis.
Premature graying.
NAIL DISORDERS:
Beau’s lines
Pallor of nail beds
Yellow nail syndrome --------- this occurs mainly in A/W pneumocyctis pneumonia.