Mucocutaneous HIV Manifestations and diagnosis

mucocutaneous hiv manifestation

1. Mucocutaneous manifestations in HIV and AIDS Dr. Ammar Sabir Siddiqui Assistant Professor, Department of Medicine IIMSR, Lucknow

2. Extensive deep ulceration of perineal area due to HSV infection

3. Herpetic ulcers on glans penis Herpetic whitlow

4. Herpes zoster with extensive ulceration

5. Clinically, they may be extensive, giant, warty and mostly extragenital. Lesions occur at atypical sites and persist for long. Extensive bilateral periorbital lesions are common. Intraoral lesions can also occur. They may mimic Warts Cutaneous aspergillosis Cryptococcosis Penicillosis Sebaceous nevi Ecthyma Condylomata In case of doubt, it is confirmed by biopsy

6. MANAGEMENT OF MOLLUSCUM CONTAGIOSUM IN HIV PATIENTS Electrofulguration and curettage are treatment of choice. In resistant cases 5% topical imiquimod In resistant cases, intralesional cidofovir can be used Starting of HAART brings about resolution of Molluscum Contagiosum Photodynamic therapy can be used

7. extensive verruca vulgaris over hands and feet

8. HPV infection in HIV + ve patients tends to be diffuse and occurs at multiple sites, the lesions may be vegetating type anal condyloma. Oral HPV may present as pink or white verrucous lesions. Extensive lesions can coalesce to form plaque, which may become malignant (oral florid papillomatosis). Epidermodysplasia verruciformis (EV) is common in these patients. It can present as pityriasis versicolor, flat warts, and lichenoid papules. EV may be associated with skin cancer or lymphoproliferative disorder and can also occur in IRIS. Extensive condyloma acuminata over the glans simulating malignancy

9. TREATMENT The lesions respond to the usual treatments but some may be resistant. Imiquimod 5% cream and Cidofovir either as 1% cream or intravenous or intralesional are effective. They can be combined with cryotherapy or surgery when resistant. HPV infection regress when immune status improves with HAART

10. CYTOMEGALOVIRUS INFECTION End organ or disseminated CMV infection occur in severely immunosuppressed patients of AIDS with CD4 count <50 cells/µl. About 90% of patients of AIDS develop CMV infection and 25% of them life threatening infection. Retinal involvement accounts for 80% cases. Though others organs like the gastrointestinal tract, brain, lungs, and the liver are commonly affected cutaneous manifestations are relatively uncommon and can be variable. When skin is involved the mortality is 85% in six months.

11. The most common manifestation is a chronic ulcer in perineal area probably extension of proctocolitis. Ulcers can also be seen on thighs, buttocks and oral cavity. The other types of lesions are pruritic maculopapular rash, prurigo nodularis , diaper dermatitis like.

12. Diagnosis Light microscopy Viral culture Immunoperoxidase test Immunohistochemistry PCR DNA hybridization Antivirals Effective against CMV Ganciclovir Valganciclovir Foscarnet Cidofovir Fomivirsen

13. Oral thrush (pseudomembranous type)

14. Oral thrush (hyperplastic type)

15. MANAGEMENT OF CANDIDIASIS Oropharyngeal candidiasis Fluconazole—100 mg or 200 mg for 7–14 days Clotrimazole troches or nystatin suspension Itraconazole solution following fluconazole failure Voriconazole Posaconazole Amphotericin-B suspension Vulvovaginal candidiasis A singe stat dose of 150 mg of fluconazole Topical azoles for 3–7 days Recurrent vulvovaginal candidiasis Fluconazole 150 mg weekly for 6 months Esophageal candidiasis 14–21 day course of 200 to 400 mg fluconazole Oral itraconazole Refractory cases Intravenous caspofungin Micafungin Anidulafungin

16. Multiple papules and nodules

17. PROTOZOAL INFECTIONS

18. Norwegian scabies.

19. Demodex: During HIV infection, democidosis occurs at the AIDS stage with a CD4 count lower than 200. A pruritic, papulonodular folliculitis eruption of the face, neck and torso occurs in an AIDS patient. Rosaceal eruption and an ivory white, poorly defined, indurated plaque on the temple and Demodex folliculitis can occur as part of IRIS. It has been shown to be responsive to ivermectin .

20. Pruritic Papular Eruptions Very common cutaneous manifestation Incidence varying from 2 to 35.8% in Indian reports Occur at a mean CD4 count of 153 Clinically present as chronic, pruritic, symmetrically distributed popular lesions Trunk and limbs are common sites It follows a waxing and waning course. Lesions may be folliculocentric and healed with marked hyperpigmentation and scarring. Antihistaminics , topical steroids and emollients are 1 st line treatment NB UVB and pentoxifylline has been found to be effective.

21. Eosinophilic Folliculitis EF occurs in late stage of HIV commonly at CD4 cell count below 250 Clinically, it presents as severely pruritic, folliculocentric , pink to red oedematous papules. Usually distributed above the nipple line on trunk, head, neck and proximal arms Secondary changes like excoriation, PIH are common and occur as part of IRIS Oral prednisolone starting at 70mg and tapered is very effective Itraconazole 200 mg daily, topical high potency steroids, NB UVB therapy are effective in management of EF

22. Oral Manifestations Highly prevalent in HIV infected persons They may also indicate failure or success of HAART Patients with CD4 count less than 200 have 4 times higher risk of developing oral lesions Presence of more than four concurrent oral lesions is a sign of deteriorating immunity They may be viral, fungal, and bacterial infections and candidiasis being the MC in oral lesions.

23. They occur on soft palate, buccal mucosa, tonsillar area, and tongue. The ulcers are deep, painful, progressive, and recurrent. Interfere with speech and swallowing leading to inadequate intake and rapid weight loss.  Parotid enlargement is common in children occurring in 10–30% patients.

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