Acquired Immunodeficiency Syndrome; what can skin tell?

1. Acquired Immunodeficiency Syndrome;
what skin can tell?
Almansouri Daifallah MD

2. AIDS
– Acquired Immunodeficiency Syndrome
– An acquired defect of cellular immunity associated
with infection by the human immunodeficiency
virus (HIV), a CD4-positive T-lymphocyte count
under 200 cells/microliter or less than 14% of
total lymphocytes, and increased susceptibility to
opportunistic infections.

4. -One of the commonest AIDS
manifestation 90%

5. -One of the earlist signs

6. - Prognostic marker

7. Objectives

8. Classification of skin diseases in AIDS
1- The disease itself; malignancy (6%).
– A) AIDS-defining cutaneous cancers e.g. KS
(5%), BCNHL.
– B) non-AIDS-defining cutaneous cancers e.g.
SCC(anal), BCC, melanoma ( bad prognosis) HPV
tumor (anal or cervical).
2- Oppurtunistic infection;
viral, bact, fungal, parasitic.

9. Skin condition reflects AIDS progression
• Early stage; morbilliform eruption, condylomata
acuminata and verrucae.
• The immune system is compormised; recurrent
varicella zoster, treatment-resistant seborrheic
dermatitis, numerous hyperkeratotic warts, and
oral hairy leukoplakia.
• Late stage; 73% have CMV and HSV
• Advanced; Leishmaniasis and miliary
TB, PPE, Photosensitivity

12. 34% has KAPOSI sarcoma
• Difinition; KSHV/HHV8 induced prolifiration of
endothelials > chronic inflammation >
angiogenesis.
• DP: prolifration of infected endothelial cells and
presence of immune cells.
• 3 sites; skin, lymphnodes, and viscera.
• Homosexual men; majority.
• Pink>palpable>brown> painful.
• Recover immunity> KAPOSI remission.

13. KAPOSI SA

14. Opportunistic infection: viral
1- Herpesviridae:
A) HSV> peri-oral/anal ulcer (necrosis),
B) HZV > typical + atypical.
C) CMV > commonest cause of perineal ulcer.
Tx: acyclovir.
2- EBV: hairy leukoplakia (non-malignant).
3- HPV-66: recurrent, widely spreaded warts.
4- MC: papule ē umbilication.
Tx: imiquimod is curative.
NB. perineal ulcer/CMV infection > bad overall patient
prognosis.

15. Herpitic ulcers

16. MC

17. CMV perineal ulcer

18. Fungal infection
• Superficial: oral/viginal* candidiasis. Tx: oral
azole.
• Deep: cryptococcosis
(cellulitis, ulcers), histoplasmosis, blastomycos
is.
NB:.
*viginal candidiasis is commonest AIDS
presentation in US.

19. Bacterial infection
1 - M avium-intracellulare complex (MAC):
MOSTLY disseminated from else where.
2 - Syphlis: coinfection, ?diagnosis, presentation; typ vs
atypical.
3 - Staph. aureus is the commonest
(impetigo, cellulitis), also MRSA is higher in
HIV.

20. Parasitic
1 - Scabies: hyperkeratotic, scaly maculopapular
eruptions or crusted plaques.
2 - leshminiasis: atypical disseminated.

21. Papulosquamous Dermatoses
•
•
•
•
Seborrheic dermatitis: 83% Tx: SA, coal tar, Tacrolimus,
Xerosis: 4.5% Tx: emollients.
Psoriasis: trigger or bad prognosis.
ichthyosis: new onset+ HIV+ Drug abuse = human
lymphotropic virus II > profound helper T-cell
depletion.
• Pruritic papular eruption (PPE): 81% have advanced
HIV.
– Tx: steroids, UV-B, PUVA, and pentoxifylline

22. Hair and nails
• Alopecia; HIV itself or indinavir.
• Onychomycosis: common.
• Nail pegmentation: HIV itself or Zidovudine

23. Drug eruption
• SJS/TEN: higher rate than general papulation - reported for: Fluconazole, Clindamycin and
other
antibiotics, Phenobarbital, Chlormezanone
• Trimethoprim-sulfamethoxazole for
Pneumocystis: mostly results in morbilliform
eruption.

24. Home message
• Rull out AIDS in any pt ē resistant, generalised
or atypical fungal infection.
• Examine AIDS patient always for drug
eruption.
• Staph. A is commenest bacterial infection.
• Vaginal candidiasis is commonest
presentation.
• Kaposi sa is commonest malignancy and
improved when immunity recovered.

25. NIH guidlines
http://aidsinfo.nih.gov/guidelines

26. 2013WHO
guidlines
http://apps.who.int/iris/bitstream/
10665/94334/1/9789241506168_en
g.pdf

27. Thank you
• This presentation is on my
slideshare.net/daveallah

28. References