SKIN MANIFESTATIONS IN AIDS Pornchai Chirachanakul M.D. Bamrasnaradura Institute
SKIN MANIFESTATIONS IN AIDS Pornchai Chirachanakul M.D. Bamrasnaradura Institute Classification Infection Non-specific dermatitis Neoplasm Bacterial infection Pyogenic diseases Mycobacterial diseases Nocardiosis Bacillary angiomatosis Pyogenic disease Impetigo Hemorrhagic ecthyma Ecthyma gangrenosum Folliculitis Furuncle Pyogenic disease Abscess Carbuncle Cellulitis Pyomyositis Pyoderma Secondary infection of scabies, eczematous dermatitis & intravenous catheter site Pyogenic diseases -staphylococcus aureus* -pseudomonas aeruginosa Pathogenesis: -B-cell defect -neutropenia -defective chemotaxis of neutrophil Pathogen: Pyogenic disease Diagnosis: clinical features Gram stain & culture blood culture skin biopsy 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 Treatment of pyogenic disease (Pseudomonas aeruginosa) debridement compress with 5% acetic acid oral ciprofloxacin i.v.imipenem 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 Treatment of M. tuberculosis Standard short course regimen: 2HRZE/4HR for 6 months Nocardiosis Low incidence (0.2-1.8%) Pathogen: Nocardia species Nocardiosis Clinical features: fever productive hemoptysis chest pain dyspnea weight loss cough Nocardiosis Clinical features: subcutaneous cellulitis pustules pyoderma paronychia ulcer abscess Nocardiosis Diagnosis: clinical features Gram stain modified acid fast stain culture Nocardiosis Treatment: TMP-SMZ (2.5-10 mg/kg of TMP) twice a day Sulfadiazine 4-6 g/d Ceftriaxone 2 g/d Amikacin 1 g/d Minocycline 200 mg/d >6-12 months duration Bacillary angiomatosis Clinical features: Elevated friable bright red granulation tissue like papules 1-1,000 lesions Subcutaneous nodules Ulcerating tumor Cellulitic plaque Pathogen: Bartonella quintana (or B. henselae) Bacillary angiomatosis Diagnosis: Histopathology: -Warthin-Starry stain or -modified Brown-Hopp’s stain Culture: -brain heart infusion agar or -trypticase soy agar with 5% sheep blood Treatment of Bacillary angiomatosis Erythromycin 250-500 mg qid for 6 weeks or until lesions cleared Doxycycline, minocycline, tetracycline Co-trimoxazole Rifampicin, isoniazid Azithromycin, roxithromycin Norfloxacin, ciprofloxacin Viral infection Herpes simplex virus infection Varicella-Zoster virus infection Cytomegalovirus infection Epstein-Barr virus infection Human papillomavirus infection Poxvirus infection Herpes simplex virus infection Clinical features: Deep seated (hemorrhagic) vesicles Chronic ulcerative mucocutaneous lesion Exophytic lesion Ulcerated tumor like lesion Herpes simplex virus infection Diagnosis: Clinical feature Tzanck smear Histopathology Viral culture Herpes simplex virus infection Diagnosis: Direct fluorescent Ab staining Polymerase chain reaction Electron microscopy Treatment of HSV infection 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) Treatment of HSV infection Oral valaciclovir 1,000 mg two times daily for 7-10 days Oral famciclovir 250 mg three times daily for 7-10 days Varicella-Zoster virus infection Varicella: Clinical features (Monomorphism) # hemorrhagic infarcted vesicles # clear vesicles Herpes zoster: Clinical features # groups of vesicles in dermatomal distribution # ecthymatous crusted punch out ulcer Varicella-Zoster virus infection 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) Varicella-Zoster virus infection post-herpetic neuralgia is uncommon may be disseminated infection more skin necrosis high risk cases have 73% positive anti-HIV Ab Varicella-Zoster virus infection Diagnosis: clinical features Tzanck smears Histopathology Viral culture Varicella-Zoster virus infection Diagnosis: Direct fluorescent Ab staining Polymerase chain reaction Electron microscopy Varicella-Zoster virus infection Treatment Oral acyclovir 800 mg five times daily for 7-10 days Oral famciclovir 500 mg three times daily for 710 days Oral valaciclovir 1,000 mg three times daily for 7-10 days I.V. acyclovir 10 mg/kg/dose three times daily Foscarnet (resistance to ACV) Molluscum contagiosum Incidence 10-20% common at genitalia, face(periorbital area),axilla,groin & buttock ่ may be larger than 1 cm. CD4+ count <250 cells/cu.mm. Diagnosis: clinical feature Histopathology Treatment of molluscum contagiosum Curettage Electrocoaggulation Cryosurgery Carbon dioxide LASER vaporization Treatment of molluscum contagiosum Topical wart agents Topical retinoic acid Highly active antiretroviral therapy Cidofovir 5% Imiquimod cream Systemic fungal infection Penicilliosis Cryptococcosis Histoplasmosis Penicilliosis Pathogen: - Penicillium marneffei, a dimorphic fungi - endemic in Southeast Asia Reservoirs: - bamboo rat Penicilliosis Clinical features: skin lesions ~ 71.2% Molluscum-like Crusted papulonecrotic lesions plaque Pustulo-nodular lesions Ulcer (oral or extraoral lesion) Penicilliosis Clinical features: Erythema nodosum-like lesions Subcutaneous nodule (lymphadenopathy) Illusion of vesiculation Penicilliosis Diagnosis: Skin scraping Skin biopsy touch smear Skin biopsy (histopathology) Culture:-blood sensitivity ~ 76% -skin sensitivity ~90% -bone marrow sensitivity ~100% Treatment of penicilliosis Initial therapy: Amphotericin-B 0.6-1.0 mg/kg/d (~2 weeks) & follow with itraconazole 400 mg/d (~10 weeks) Suppressive therapy: Itraconazole 200 mg/d HAART-induced penicilliosis Pathogenesis: restoration of CD4+ and CD8+ T lymphocyte may be cytokine-mediated reaction HAART-induced penicilliosis Clinical feature: shiny erythematous papulo-nodular plaques non pruritic lesions occur within the first 2 months after HAART HAART-induced penicilliosis Diagnosis: history of previous treated penicilliosis history of HAART skin biopsy (granulomatous dermatitis with yeast cells) skin culture for fungus HAART-indued penicilliosis Treatment: Amphotericin B or itraconazole Short course systemic corticosteroid Cryptococcosis Pathogen: Cryptococcus neoformans Clinical features: skin lesions ~ 10-20% Molluscum-like papulonecrotic lesion Subcutaneous nodule Oral nodule Oral ulcer Verrucous tumor Localized cellulitis Cryptococcosis Diagnosis: Skin scraping Skin biopsy touch smear Histopathology Culture: -skin -CSF -blood 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 Histoplasmosis Pathogen: Histoplasma capsulatum Clinical features: skin lesions ~ 10-20% exanthema-like maculopapular eruption molluscum-like papulonecrotic lesion oral ulcer or oral mass vegetative plaque diffuse purpura panniculitis Histoplasmosis Diagnosis: Skin scraping Skin biopsy touch smear Histopathology Culture: -skin -blood -bone marrow 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 Crusted (Norwegian) scabies Pathogen: Sarcoptes scabiei Clinical features: generalized scaly hyperkeratotic nonpruritic plaque(bark-like appearance) subungual hyperkeratosis psoriasiform dermatitis Diagnosis: skin scraping Treatment of crusted scabies 1% gamma benzene hexachloride 5% permethrin cream (lotion) keratolytic agent (5%-6% salicylic acid oint.) oral ivermectin 200 microgram/kg as a single dose (efficacy ~ 91 %) Non-specific dermatitis Pruritic papular eruption (PPE) Seborrheic dermatitis Psoriasis Exfoliative dermatitis Drug eruption Prurigo nodularis Miscellaneous skin diseases Pruritic papular eruption (PPE) chronic recall reaction to mosquito bite excoriated hyperkeratotic hyperpigmented papules at extremities & lower back severe itch refractory to treatment Treatment of pruritic papular eruption (PPE) high potent topical corticosteroid short course systemic corticosteroid antihistamine (esp.oral doxepin HCl) antibiotic( esp. excoriation) UVB phototherapy or natural sunlight systemic PUVA Seborrheic dermatitis greasy scaly erythematous patch more severe in late stage of disease refractory to treatment Treatment of seborrheic dermatitis ketoconazole + hydrocortisone cream clotrimazole cream ketoconazole shampoo selenium sulfide shampoo zinc pyrithione shampoo ciclopirox olamine shampoo 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) 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 Treatment of psoriasis Topical tar & corticosteroid preparation Topical calcipotriol preparation UVB phototherapy Narrow-band UVB phototherapy Systemic PUVA Exfoliative dermatitis Etiology: psoriasis drug reaction cutaneous T-cell lymphoma high grade non-Hodgkin’s lymphoma unknown cause Exfoliative dermatitis Diagnosis: - skin biopsy Treatment:- eliminate the causes - if no causes, the drugs are systemic corticosteroid antihistamine emollient cream Drug eruption Incidence: ~10 times of general population Etiology: multiple drugs treatment abnormal immune response metabolic factor Drug eruption Common causative drugs: sulfonamide (TMP-SMZ, sulfadiazine) dapsone anti-tuberculous drugs(INH, RFP) ofloxacin fluconazole Drug eruption Common causative drugs: pentamidine carbamazepine foscarnet nevirapine efavirenz indinavir Drug eruption Clinical feature: Morbiliform reaction Fixed drug eruption Urticaria Photoallergic reaction Drug eruption Clinical feature: Exfoliative dermatitis Hypersensitivity syndrome Stevens-Johnson syndrome Toxic epidermal necrolysis Treatment of drug eruption Mild form: offending drug may be stopped topical corticosteroid antihistamine Treatment of drug eruption Severe form: offending drug must be stopped short course high dose systemic corticosteroid antihistamine antibiotic if necessary Prurigo nodularis Etiology: arthropod reaction (esp. Mosquito) pre-existing HIV-associated pruritic dermatosis circulating pruritogenic factor emotional stress Prurigo nodularis Etiology: malabsorption & malnutrition peripheral nerve infection with HIV immunologic abnormality Prurigo nodularis Clinical features: firm hyperkeratotic nodules & papules only 1-2 or more than 100 nodules crusting & excoriation perilesional pigmentary alteration symmetrical distribution Prurigo nodularis Diagnosis: clinical features skin biopsy (to exclude pseudocarcinomatous inflammation in cutaneous infection) Prurigo nodularis Treatment: thalidomide 50-300 mg qid high potent topical corticosteroid antihistamine (e.g. doxepin, hydroxyzine) Miscellaneous skin diseases Recurrent Apthous Ulcer (RAU) Xerostomia & exfoliative cheilitis Pigmentary skin change Patchy depapillation of the tongue Xerosis Miscellaneous skin disease Chronic actinic dermatitis Vitiligo Alopecia areata Necrotizing vasculitis Recurrent apthous ulcer CD4+ cell count: <50 cells/cu.mm. Etiology: - unknown Diagnosis: clinical feature ulcer smear ulcer biopsy Recurrent apthous ulcer Differential diagnosis: histoplasmosis cryptococcosis herpes simplex virus cytomegalovirus mycobacterium avium complex klebsiella pneumoniae enterobacter cloacae Recurrent apthous ulcer Treatment: thalidomide 50 -300 mg/d topical steroid in orabase intralesional injection of triamcinolone colchicine 1.5 mg/d prednisolone 30 -70 mg/d G-CSF (neutropenic patient) Xerostomia & exfoliative cheilitis Etiology: - salivary gland disease (parotid gland - pathology look like Sjogren’s syndrome Xerostomia & exfoliative cheilitis Treatment: topical fluoride topical glycerine topical white petrolatum HIV-related vasculitis Incidence: low Etiology: drug-induced hypersensitivity infectious process (HIV,HBV,HCV & systemic fungus) immunological disorder HIV-related vasculitis Clinical features: palpable purpura digital necrotic ulcers swelling of hands & feet arthralgia fever HIV-related vasculitis Diagnosis: clinical features histopathology HIV-related vasculitis Treatment: bed rest antihistamine NSAID colchicine avoid immunosuppressive agent eliminate the etiologic agent Chronic actinic dermatitis Prevalence: common in men younger than 60 years old CD4+ cell count <200 cells/cu.mm. Chronic actinic dermatitis Pathogenesis: reactive photoproduct + endogenous carrier protein photohapten photosensitivity Chronic actinic dermatitis Clinical features: hypo & hyperpigmented patches lichenified plaques fissures & erosions confine to sun exposed areas Chronic actinic dermatitis Diagnosis: clinical features phototest decreased MED of UVA & UVB Chronic actinic dermatitis Treatment: avoid sunlight sunscreen topical corticosteroid preparation systemic antihistamine HIV-associated eosinophilic folliculitis Pathogenesis: follicular hypersensitivity reaction to Pityrosporum yeast,Demodex folliculorum or Leptotricia bucalis change in cellular immune homeostasis HIV-associated eosinophilic folliculitis Clinical features: common in male patients advanced stage of HIV infection groups of edematous erythematous pruritic follicular papules at face, upper trunk, arms & (thighs) HIV-associated eosinophilic folliculitis Diagnosis: clinical features histopathology peripheral blood eosinophilia (~ 35%) elevated serum IgE CD4+ cell count < 200 cells/cu.mm. HIV-associated eosinophilic folliculitis Treatment: metronidazole 250 mg t.i.d. for 3-4 weeks itraconazole 200-300 mg/d for 4 weeks isotretinoin 0.5-1.2 mg/kg/d 5% permethrin cream apply once a day for 4 weeks HIV-associated eosinophilic folliculitis Treatment: Prednisolone 60mg/d (tapered over1-2week) or 60mg/d (one day/week) UVB phototherapy Systemic PUVA Kaposi’s sarcoma (KS) Classic KS Endemic KS KS in iatrogenically immunocompromised patients HIV-associated KS HIV-associated KS Epidemiology: 95% in homosexual or bisexual men low incidence in thailand Etiology: genetic marker immune dysregulation retrovirus HHV-8 (Human Herpes Virus-8) HIV-associated KS Clinical features: common at nose,eyelids & pinna skin lesions may be numerous & disseminated bleeding ulcers symptom & sign of respiratory & gastrointestinal tract Diagnosis: histopathology & immunopathology HIV-associated KS Treatment: simple excision Cryotherapy, Radiotherapy Carbondioxide or Argon LASER Photodynamic therapy,Chemotherpy Interferon alpha & beta Highly active antiretroviral therapy Merkel cell carcinoma originate from cutaneous Merkel cell (neuroendocrine cell) no reported case until now clinical features: - raised reddish blue nodule - occur at any site Merkel cell carcinoma Diagnosis: histopathology electron microscopy (specific dense core granule) special stain Treatment: - surgical excision Prognosis: - poor Lymphoma Non-Hodgkin Lymphoma Hodgkin’s disease Cutaneous T-Cell Lymphoma (CTCL) Cause of HIV-related Lymphoma Polyclonal proliferation & lymph node follicular hyperplasia Chromosomal abnormalities Epstein-Barr Virus (EBV) infection Treatment of lymphoma chemotherapy immunostimulator antiviral agent
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