Cutaneous manifestations of HIV

Question 1

What is the incidence of herpes zoster outbreak in HIV+ patients compared to the general population?

Answer 1

7-15 fold increase in risk

Question 2

What are some differences noted in the lesions of molluscum contagiosum on someone with HIV-related immunosuppression as compared to what is normally seen?

Answer 2

• Larger lesions (>1cm)
• Coalescent lesions, verrucous lesions and more widespread distribution

Question 3

Treatment for molluscum contagiosum in HIV+ patients?

Answer 3

Topical cidofovir is an option

Also may spontaneously resolve after starting ART

Question 4

What is the prevalence of HPV in the HIV+ population as compared to the general population?

Answer 4

Prevalence of HPV much higher in HIV-infected patients and correlates with decreasing CD4 counts.

Question 5

What differences are seen in HPV infection among patients with HIV than the general population?

Answer 5

There is reduced HPV clearance, more treatment-resistant lesions and accelerated development of HPV-associated carcinomas.

• Anal HPV is present in >90% of HIV+ MSM patients, most with at least one high-risk type

50% prevalence of high-grade anal intraepithelial neoplasia and 30-50 fold higher risk of anal cancer than the general population

Question 6

What is oral hairy leukoplakia and at what CD4 counts does it occur at most commonly?

Answer 6

This results from EBV infection of the oral mucosa and presents as a hyperkeratotic, corrugated white plaque with hair-like projections on the lateral aspect of the tongue. Does not scrape off with tongue depressor

• More prevalent when CD4 <200/mm³

Question 7

What does oral hairy leukoplakia mean in regards to HIV disease prognosis?

Answer 7

Predictor of rapid disease progression if ART is not initiated

It may go away with ART therapy

Question 8

What is a likely etiology for an HIV+ who presents with new-onset horizontal band melanonychia?

Answer 8

Check the medication list, this may be from Zidovudine

• Zidovudine-associated melanonychia can develop longitudinal, horizontal bands or diffuse hyperpigmentation in the nails.

Question 9

What inflammatory conditions, when seen alone, suggest an underlying dx of HIV?

Answer 9

1. Eosinophilic folliculitis (unless known cause of immunosuppression otherwise)
2. Pityriasis Rubra Pilaris type VI, with follicular spines and acne conglobata

Question 10

What inflammatory conditions, when seen in a severe, recalcitrant, or sudden onset manner, would suggest HIV infection?

Answer 10

1. Seborrheic dermatitis (face/scalp)
2. Psoriasis vulgaris
3. Reactive arthritis

Question 11

What infectious diseases when seen alone raise the suspicion of HIV and justify testing?

Answer 11

Syphilis and other STD’s like chancroid, bacillary angiomatosis, botryomycosis, disseminated mycobacterial infection, chronic oral and anogenital HSV or disseminated HSV, zoster if multi-dermatomal, disseminated, verrucous or chronic, oral hairy leukoplakia, anogenital and oral ulcers, verrucous plaques or morbilliform eruption due to CMV, Kaposi sarcoma due to HHV-8 infection, oropharyngeal candidiasis, proximal subungual onychomycosis, disseminated cryptococcosis, disseminated dimorphic fungal infections, crusted scabies, disseminated or necrotic cutaneous leishmaniasis

Question 12

Which HIV test will detect the virus soonest after infection and what is the timeline?

Answer 12

Quantitative PCR for HIV-1 viral load = 6-10 days

The screening tests (HIV1/2 anitgen/antibody EIA) take 16-20 days

Question 13

What cutaneous findings can occur when starting ART therapy?

Answer 13

Flairs of cutaneous disease can occur in many types of disease with immune reconstitution. These include infections, inflammatory conditions like psoriasis, seb derm, PRP, eczema, Kaposi, non-Hodgkin lymphoma, multiple eruptive dermatofibromas, etc.

Question 14

What are patients with HIV at increased risk to get with medications?

Answer 14

Drug rashes such as drug-induced morbilliform eruptions and SJS/TEN

Question 15

What must be tested before starting the NRTI abacavir and why?

Answer 15

Must test for HLA-B*5701, this puts patients a very increased risk of morbilliform drug rash and DRESS

Question 16

What other HIV medications are commonly associated with DRESS?

Answer 16

Abacavir, Nevirapine, protease inhibitors (Atazanavir, darunavir, fosamprenavir, itpranavir, lopinavir)

Question 17

What ART therapy medications are known to cause lipodystrophy?

Answer 17

NRTIs (d4t, ddl), protease inhibitors

Question 18

What ART therapy medications cause excessive periungual granulation tissue?

Answer 18

Lamivudine and indinavir

Question 19

What is the acute exanthem of primary HIV infection and how common is it?

Answer 19

Occurs is <50%of newly infected patients as part of the acute HIV infection. Mononucelosis-like syndrome that occurs in ~80% of those with HIV to one degree or another. Typically occurs within 6 weeks of infection

Question 20

What is the clinical description of eosinophilic folliculitis?

Answer 20

Characterized by an eosinophil-rich inflammatory infiltrate in or around hair follicles. Presents as intensely pruritic, erythematous and follicular-based papules located distributed on the upper trunk, face, neck and scalp

Question 21

In HIV, what is erythema elevatum diutinum associated with?

Answer 21

Beta-hemolytic strep infection

Question 22

What is the treatment of erythema elevatum diutinum in patients with HIV?

Answer 22

Dapsone 50-100mg daily

Question 23

What is pruritic papular eruption in HIV?

Answer 23

An intensely pruritic condition commonly seen in patients with advanced HIV in the developing world. It is thought that it may be caused by an aberrant and exaggerated response to bug bites. Clinically it presents with numerous/extensive, skin-colored to hyperpigmented papules with excoriations

Question 24

What is HIV photodermatitis?

Answer 24

This is a group of photodistributed rashes with many different clinical presentations that can include lichenoid, eczematous, vitilagenous and hyperpigmented. They can be caused by exposure to certain photosensitizing mediations, especially Bactrim (trimethoprim-sulfamethoxazole). Treatment is difficult and topical steroids, strict photoprotection, thalidomide could be considered in difficult cases.

Question 25

How can anogenital HSV be clinically different in HIV+ patients?

Answer 25

Can present in the anogenital as verrucous lesions (herpes vegetans) or hypertrophic HSV.

• Can also be associated with longstanding, ulcerative lesions that are refractory to treatment in patients with profoundly low CD4+ cell counts.

Question 26

What is the treatment for herpes vegetans?

Answer 26

This is often acyclovir-resistant, intralesional cidofovir has been used for refractory cases

Question 27

When should you test someone presenting with herpes zoster lesions for HIV?

Answer 27

When they are <50 y/o

Question 28

When do CMV related ulcers occur in HIV+ patients?

Answer 28

CMV can colonize HSV-related lesions when the CD4+ counts go <50 cells/mm³

• If the HSV is treated the CMV will usually be cleared as well.

Question 29

What type of white subungual onychomycosis is suggestive of HIV+ status?

Answer 29

Proximal white subungal onychomycosis. The distal form is the more common form associated with normal onychomycosis

Question 30

What type of bx should be done in an HIV+ patient present with molluscum appearing lesions?

Answer 30

Need to do H&E and culture. These lesions can be caused by cryptococcus neoformins, coccidiodes immitus, histoplasmosis capsulatum, or penicillium marneffei.

Question 31

What does HIV due to risk of getting skin cancers?

Answer 31

Risk is increased, most for NMSC but also for melanoma (BCC>SCC>melanoma)

Question 32

What areas are more often involved in HIV-associated Kaposi sarcoma?

Answer 32

Oral mucosa and genitals

Question 33

Is HIV-associated Kaposi sarcoma only seen in patients with AIDS?

Answer 33

No, can be seen in longstanding well-controlled disease as well

Question 34

What are some treatment options for Kaposi sarcoma?

Answer 34

ART therapy, intralesional chemotherapy (vinblastine), radiation, cryotherapy, excision, and topical retinoids (alitretinoin)

Question 35

What HIV-related dermatoses are most common in patients with >500 CD4+ cells/mm³?

Answer 35

Acute exanthema of primary HIV infection, seborrheic dermatitis, oral hairy leukoplakia, vaginal candidiasis

Question 36

What HIV-related dermatoses are most common in patients with <500 CD4+ cells/mm3?

Answer 36

Psoriasis, herpes zoster, HPV, HSV, staph infections, oropharyngeal candidiasis

Question 37

What HIV-related dermatoses are most common in patients with <200 CD4+ cells/mm³?

Answer 37

Kaposi sarcoma, eosinophilic folliculitis, molluscum contagiosum, major aphthae (<100), bacillary angiomatosis, disseminated coccidiomycosis, histoplasmosis, cryptococcus (<100), xerosis, eczematous dermatitis, acquired ichthyoisis, crusted scabies

Question 38

What HIV-related dermatoses are most common in patients with <50 CD4+ cells/mm3?

Answer 38

Large, non-healing HSV ulcers, giant molluscum, pruritic papular eruption, HIV photodermatitis

Question 39

When do the findings of IRIS generally occur after starting ART?

Answer 39

2 weeks to 3 months

Question 40

Which ART therapy is associated with pigmentary changes?

Answer 40

Zidovudine: nail and mucocutaneous hyperpigmentation

Question 41

If a patient is on a NRTI and they get a morbilliform rash, can they continue treatment?

Answer 41

Yes, the NRTI’s are a common cause of morbilliform rash but in most cases, it is pruritic but does not progress to worse reaction, it will resolve over several weeks

Question 42

Aside from abacavir, what other medications commonly cause DRESS in patients with HIV?

Answer 42

Bactrim (trimethoprim-sulfamethoxazole) and dapsone

Question 43

What medication can have retinoid-like effects in patients with HIV and what are some of these effects?

Answer 43

Protease inhibitors like indinavir. Clinical manifestations include chronic paronychia, periungual pyogenic granulomas, alopecia, cheilitis, and xerosis

Question 44

What ART medication is most commonly associated with injection site reactions adn what are some of these injection-site reactions?

Answer 44

Fusion inhibitors like enfuvirtide. Clinical manifestations include erythema, ecchymosis, induration, nodules, cysts, and localized sclerosis