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10/05/2016
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HIV and the skin - workshopDr Alexis Lara Rivero, MD MAIMS
Skin and Cancer Foundation
Australia
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Case 1
• Male
• 42 y/o
• Sep 2008: 4 mo itchy skin rash – Trunk, face, upper limbs and palms
• HIV Dx 2000– ART (changed 7 mo before): zidovudine, lamivudine, saquinavir,
nelfinavir
– CD4: 333 cell x mm3
– HIV viral load: <50 copies/mL
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Case 1
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DIAGNOSIS…?
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Case 1
• Provisional diagnosis
– Folliculitis
• Bacterial and/or fungal
• Differential Dx
– Eosinophilic folliculitis
– Pruritic Papular Eruption in HIV
– Drug reaction
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PLAN / MANAGEMENT…?
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Case 1
• Laboratory tests
– Pustule swab
• Gram: +ve cocci 2+
• MB: budding yeasts 1+
• Culture: S. epidermidis
– FBC
• Leucopenia 3500 cell x mm3 / 18% eosinophils
– LFT, Bio, UEC normal
• Skin biopsy
– Diffuse and nodular inflammatory infiltrate constituted bylymphocytes, histiocytes and rich in eosinophils, surrounding hair follicles and forming granulomas and pustules. Fungal and AFB stainings negative.
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Case 1
Final diagnosis
Eosinophilic folliculitis in an HIV-positive man
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Case 1
• Treatment
– Topical pimecrolimus x 12 wk
– Marked reduction in number of lesions and symptoms
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Case 1: Eosinophilic folliculitis
• EF: three forms– Classic, childhood, immunosuppression
– IRIS phenomenon
• Dysregulation of immune system and skin Ag
• No systemic symptoms
• Recurrence of skin lesions– Irregular response to treatment
• Laboratory– High HIV VL, CD4 <300 cell x mm3
– Peripheral eosinophilia
Ise S, et al. Arch Dermatol 1965; 92: 169-71Nervi S, et al. J Am Acad Dermatol 2006; 55: 285-9.Ellis E, et al. Am J Clin Dermatol 2004; 5: 189-97.Toutous-Trellu L, et al. Arch Dermatol 2005; 141: 1203-8.
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Case 2
• Female
• 38 y/o
• 5 wk skin rash (asymptomatic)
– Trunk, face, upper limbs and palms
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Case 2
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DIAGNOSIS…?
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Case 2
• Provisional diagnosis
– R/O HIV infection
– Secondary Syphilis
• Differential Dx
– Disseminated cryptococcosis
– Disseminated MC
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PLAN / MANAGEMENT…?
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Case 2
• Laboratory tests
– VDRL x 2: negative
– FTA-Abs x 2: negative
– ELISA-HIV positive
– Western Blot-HIV positive
– CD4+ lymphocyte count: 302 cells x mm3
– Viral Load RNA-HIV: 48020 copies/ml
• Cultures
– Bacterial, fungal and MB: negative
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Case 2
• Skin biopsy
– Nodular and diffuse inflammatory infiltrate constituted by
lymphocytes and numerous plasmacytes. AFB and fungal
stainings negative. Spirochaete staining (W-S) equivocal.
– PCR T. pallidum not available
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ANY IDEAS…?
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Case 2
Final diagnosis
Seronegative secondary syphilis in an HIV-positive
woman
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Case 2
• Treatment
– Therapeutic trial with Benzathine Penicillin
– Complete resolution of the lesions
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Case 2: Seronegative Syphilis
• Seronegative cases of SS are very rare
• Frequency unknown
• Alternative methods to increase sensitivity and specificity
– PCR: inconclusive results?
• Therapeutic test effective for the confirmation of this STI
– Therapeutic failure reported
• Epidemiology + clinical picture: essentials in the diagnosis
McKenne J, et al. Med Hypotheses 1986: 21: 421 – 430Fowler V Jr, et al. Arch Dermatol 2001; 137: 1374 – 1376Smith G, et al. South Med J 2004; 97: 379 – 382Kingston J, et al. Arch Dermatol 2005; 141: 431 – 433
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Case 2 a
• 14 year old male
• Cd4 150
• Before Viral loads
• Rash on the hands
• Treated with steroids
• No help Photo m whitfeld
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Case 3
• 28 year old vietnamese man, generally well,
• but a bit of lethargy,
• still working in construction
• Presents with painful rash on the perianal area and buttock
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What is the diagnosis
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What to do next
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What to do next
• What treatment would you use?
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What to do next
• What treatment would you use?
• Valtrex 1 gm tds
• Famcyclovir 500mg tds
• Acyclovir 800 mg 5 times daily
• Stool softener
• Topical betadine or salt water bathing
• 1/2 - 1 tsp salt in 1 cup water
• Check renal function
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What else to do
• HIV positive
• CD4 150 VL 178,000
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What else to do
• HIV positive
• CD4 150 VL 178,000
• Started on Tenofovir, 3TC and efavirenz
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What else to do
• HIV positive
• CD4 150 VL 178,000
• Tenofovir, 3TC and efavirenz
• Represents 6 months later with
• Painful masses on the upper chest
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description
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What is your diagnosis
• What is your
differential diagnosis
• would you do next
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What is your diagnosis
• What would you do
next
• What is this a sign
of?
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How would you treat this?
• Acid fast bacilli seen
on FNA /incision and
drainage
• TB isolated on PCR
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Immune restoration inflammatory
syndrome
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How would you treat this?
• Triple therapy
• Rifampicin,
ethambutol
pyrazinamide
isoniazid
+/- prednisone
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Case 4
• 38 year old man
• Long history of
perianal itching
• HIV positive 10 years,
• Stable HIV on HAART
• CD4 380 V/L ND
• Unsuccessful
treatment with
canesten
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Case 3
• What is your
differential
diagnosis.
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Case 3
• How would you
investigate it
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Case 3
• How would you treat
it
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PAPILLOMAVIRUS AND HIV
• HPV 16 and 18 associated with
cervical carcinoma. Perianal,
penile carcinoma
• Increased anal dyslasia
,carcinoma-in-situ and invasive
anal carcinoma
• Increased bowenoid papulosis,
(carcinoma in situ with wart
changes producing pigmented
plaques)
• Needs anoscopy or high
resolution anoscopy
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Often velvetyPink colourRash that doesn’t go awayOften irritated
In situ carcinoma of the anus and perianal areaAKA AIN III or AIN II-III
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How to treat
• Surgery- traditional
• Cautery
• Liquid nitrogen
• Now aldara
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AIN II AND CARCINOMA
IN-SITU
It is important to biopsy if you are unsure of the diagnosis as steroids makes, otherwise recogniseuu
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BOWENOID PAPULOSIS
Bowenoid papulosisHPV 16 associated In situ carcinomaDebate about whether to call it High grade dysplasia or in situ carcinoma
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How I use aldara for AINAldara™ (imiquimod 5%) cream is an immune response modifier
Topical administration
Chemically, imiquimod is 1-(2-methylpropyl)-1H-imidazo[4,5-c]quinolin-4-amine
Stimulates the innate & adaptive arms of the immune system
Aldara is used to treat solar keratoses, bowensdisease and superficial BCC.
Also used for genital warts, so it seemed logical to treat perianal warts with in -situ carcinoma.
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Aldara
• How to use
• Initially 3 times weekly and aim for mild irritation
• Can increase to 5 times weekly
• Minimum of 6 weeks
• Will not work of low CD4 count > 200 essential but need to
produce immune reponse
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Case 5
• Male
• 35 y/o
• HIV Dx 2005
– ART (2007): CD4 180
– 3TC abacavir ritonavir /atazanavir
– Noticed the development of a pustular rash on the face a few months into treatment
– CD4: 333 cell x mm3
– HIV viral load: <50 copies/mL
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DIAGNOSIS…?
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Case 1
• Provisional diagnosis
– Rosacea
• Differential Diagnosis
- Eosinophilic folliculitis
– Acne
– Drug eruption
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Treatment
• Doxycycline 50 mg daily
• Topical Rozex gel
• Improvement and subsequently able to come off meds
• Diagnosis
• Rosacea as an IRIS
• Exacerbation of mild pre- existing condition
• What is the antigenic trigger
• ? Demodex ? Staph epidermidis
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Case 6
• Female
• 63 y/o
• 3 mo asymptomatic tumour on hard palate
– Slow grow
• HIV Dx 2006
– ART (2009): zidovudine, lamivudine, abacavir
– CD4: 664 cell x mm3
– HIV viral load: <50 copies/mL
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Case 6
Photos courtesy Dr Elda de Marinucci
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DIAGNOSIS…?
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Case 6
• Provisional diagnosis
– Malignant oral tumour UE: ?SCC ?Salivary gland tumor
?KS
• Differential Dx
– Benign oral tumours
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PLAN / MANAGEMENT…?
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Case 6
• Oral lesion biopsy
– Pseudocarcinomatous hyperplasia of the mucosa.
Submucosal islets of squamous cells, without atypical
cells, forming salivary ducts with metaplasia
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Case 6
Final diagnosis
Necrotising sialometaplasia on the hard palate
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Case 6
• Treatment
– Stop wearing denture until refitting the old one or making a
new one
– Complete disappearing of the tumour in two months
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Case 6: Necrotising sialometaplasia
• Few cases reported in HIV patients
• Local trauma
– Minor salivary glands ischemia
• Bizarre clinical presentations
– Solitary plaques, ulcers, nodules or tumours
• No specific treatment
– Remove causing agent
Femopase F, et al. Med Oral 2004; 9: 304-8.Farthing P, et al. Curr Diag Pathol 2003; 12: 66-74.Silva A, et al. Spec Care Dentist. 2010; 30: 160-2.Fowler C, et al. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000; 89: 600-9.
