CUTANEOUS MANIFESTATIONS OF HIV Dr.Kalyani PG (DVL) Kamineni Institute of Medical Sciences

LEARNING OBJECTIVES • Describe the significance of cutaneous manifestations in HIV. • List /classify the cutaneous manifestations in HIV. • Discuss the atypical presentations of cutaneous diseases in HIV. • Discuss the treatment modalities of these manifestations in HIV setting.

SIGNIFICANCE OF SKIN IN HIV/AIDS • Skin diseases are the first to appear in majority of HIV patients. • Recognizing HIV-related skin changes may lead to the diagnosis of HIV infection in the early stages.

• Skin manifestations occur in almost all patients. • Some skin conditions are pathognomonic of HIV. • They are prognostic indicators- more severe skin manifestations are a sign of progression of the disease, correlates with CD4.

• Concomitant STIs increase HIV transmission, have atypical manifestations & add to the morbidity. • Management differs in HIV setting.

WHY SKIN IS AFFECTED ? • Antigen presenting cells of skin – Langerhan s cells & dermal dendritic cells are also attacked by HIV in addition to CD4 lymphocytes. • Cutaneous immunodeficiency develops earlier than systemic immunodeficiency. • Patients with decreased cutaneous CMI (anergy) develop end stage disease at substantially higher rates.

WHO Clinical Staging of HIV/AIDS Clinical Stage 1 • Asymptomatic • Persistant generalised lymphadenopathy Clinical Stage 2 • Moderate unexplained weight loss(10%) Unexplained chronic diarrhoea (>1 month) Unexplained persistant fever (>1 month) Oral candidiasis Oral hairy leukoplakia Pulmonary TB within last 2 years Severe presumed bacterial infections (Pneumonia, empyema, pyomyositis, bone and joint infection, meningitis, bacteremia) • Acute necrotizing ulcerative stomatitis, gingivitis or peridontitis

Clinical Stage 4 • HIV wasting syndrome • PCP pneumonia • Recurrent severe or radiologic bacterial pneumonia • Chronic herpes simplex infection (oral or genital or anorectal site) for >1 month • Esophageal candidiasis • Extra pulmonary TB

• • • • • •

Kaposi sarcoma CNS toxoplasmosis HIV encephalopathy Cryptococcosis, extrapulmonary Disseminated non TB Mycobacterial infection Progressive multifocal, leukoencephelopathy

• • • • • •

Candida of the trachea, bronchi or lungs Cyptosporidiosis Isosporiasis Visceral HSV infection, CMV infection Any disseminated mycosis Recurrent non typhoidal Salmonella septicemia • Lymphoma • Invasive cervical carcinoma • Visceral leishmaniasis

DERMATOSES IN HIV/AIDS Acute exanthem of HIV Infections/Infestations

Non-infectious disorders

• Viral infections

• Papulosquamous disorders

• Bacterial infections

• Pigmentary disorders

• Fungal infections

• Drug reactions

• Arthropod infestations • Protozoal infections

• Malignancies • Hair & nail changes

ACUTE EXANTHEM OF HIV DISEASE • Occurs in about 70% patients; within 2-6 weeks after the infection. • Febrile illness with fever, malaise & lymphadenopathy.

Pruritic, erythematous, maculopapular rash over trunk & extremities (morbilliform).

• Rarely urticaria, enanthemata, perleche, oral ulcers. • Resolution occurs within a week followed by a period of latency; some progress rapidly with early death. • ELISA negative; PCR positive. • Early institution of HAART is helpful.

VIRAL INFECTIONS

HERPES SIMPLEX VIRUS (HSV)

• HSV 1- H. labialis & HSV 2 – H. Genitalis.

• They present with grouped vesicles which rupture to form superficial erosions.

In advanced HIV:

• Large confluent erosions, chronic ulcers, hemorrhagic lesions, widespread varicelliform eruption. • More frequent recurrences are also observed when the CD4+count falls to