Transcript
Slide 1
From TA Maurer, MD, at 11th RW Program Clinical Update, IAS–USA.
HIV Dermatology: Case-based Presentation
Toby A. Maurer, MDAssociate Professor
University of California San Francisco
The International AIDS Society–USA
Slide 2
From TA Maurer, MD, at 11th RW Program Clinical Update, IAS–USA.
• 38 y.o. male has been on and off ARVs for 2 yrs, secondary to substance abuse
• New lesions on legs
• CD4 80, VL 80,000
• Restart Antiretrovirals (ARVs)
• Special clinical features: – edema lower legs/ groin region– woody feeling to upper legs
Slide 3
From TA Maurer, MD, at 11th RW Program Clinical Update, IAS–USA.
• If lymphedema, ARVs may not be enough
• For those who need chemotherapy, liposomal doxorubicin is first line chemotherapy in this country
Slide 4
From TA Maurer, MD, at 11th RW Program Clinical Update, IAS–USA.
• Pt does not have swelling-so you convince him to get back on ARVs
• He is anxious-how long will it take to get rid of these?
• Ave: 9 months
• Doesn’t want to live with lesion on his face– intralesional vinblastine– radiation therapy
Slide 5
From TA Maurer, MD, at 11th RW Program Clinical Update, IAS–USA.
• He tolerates his ARVs and is adherent to regimen
• Notes abdominal pain and bloody stools
• Old cutaneous lesions popping out/enlarging
• Still no swelling in ankles
Slide 6
From TA Maurer, MD, at 11th RW Program Clinical Update, IAS–USA.
• You suspect KS immune reconstitution (IRIS)-just skin and tolerable– Continue ARVs; will stabilize in 16 weeks
• Systemic involvement-GI, pulmonary-start liposomal doxorubicin
• Do we have labs that indicate IRIS?
• Do we have a way to work up pts with KS to predict systemic involvement?
Slide 7
From TA Maurer, MD, at 11th RW Program Clinical Update, IAS–USA.
Did you biopsy?
Biopsy of KS is always useful1) Early detection is the name of the game- if you
don’t start ARVs within a year of KS presentation, mortality is the same as in the pre-ARV era
2) Several skin conditions mimic KS. A real diagnosis is useful
3) Pt may fail ARVs or need adjunctive therapy with chemotherapy or radiation therapy-need tissue
Slide 8
From TA Maurer, MD, at 11th RW Program Clinical Update, IAS–USA.
• Abolulafia DM et al. Regression of AIDS KS after HAART. Mayo Clin Proc. 1998 May.
• Udharain A et al. Pegyalted liposomal doxorubicin in treatment of AIDS. KS Int J Nonomed. 2008.
• Nguyen HQ et al. Persistent KS in HAART era. AIDS. 2008 May.
• El Amari EB et al. Predicting evolution of KS in HAART era. AIDS. 2008 May.
Slide 9
From TA Maurer, MD, at 11th RW Program Clinical Update, IAS–USA.
Kaposi’s Sarcoma
• Majority of KS seen with CD4 <200 and VLs that are mounting
• Your pt has CD4 of 450, VL 8000-do you start ARVs?
• Yes-we have found that within months CD4 declines and VL starts mounting
Slide 10
From TA Maurer, MD, at 11th RW Program Clinical Update, IAS–USA.
Kaposi’s Sarcoma-new group
• 17 patients with CD4 over 300 and VL<75 for more than 2 years with new or persistent KS
• All on ARVs and doing well• Ave age 51 (range: 41-74 yrs)• Ave duration of HIV: 18 years• Ave length of time on ARVs: 7years (1-
19 yrs)
Slide 11
From TA Maurer, MD, at 11th RW Program Clinical Update, IAS–USA.
What is going on?
• HHV8 virus-unusual type or unusual behavior
• Functionally abnormal T cell response to HHV8
• Immunosenescence-the aging immune system of HIV-infected, treated individuals
Slide 12
From TA Maurer, MD, at 11th RW Program Clinical Update, IAS–USA.
How do you manage these individuals?
1) To date, they have not had systemic involvement or eruptive KS-reassure
2) Local therapy to include radiotherapy and intralesional therapy
3) Monitor closely re: HIV status (no change to date) and other co-morbidities of the aging immune system
4) Let us know- maurert@derm.ucsf.edu or 415-206-8680
Slide 13
From TA Maurer, MD, at 11th RW Program Clinical Update, IAS–USA.
• Maurer T et al. NEJM. May 2007, Sept 2007.
• Dittmer DP et al. NEJM. Sept 2007.
Slide 14
From TA Maurer, MD, at 11th RW Program Clinical Update, IAS–USA.
The skin as a window to the immune system
• Pt known to you to have psoriasis. Walks into ER with thick, oozing plaques
• Could this really be psoriasis?
• Is this infected psoriasis?
• Suspect change in pt’s CD4 count, VL
• Look for resistance
Slide 15
From TA Maurer, MD, at 11th RW Program Clinical Update, IAS–USA.
• First line therapy: ARVs
• ARVs turn off psoriaisis before CD4 count increases or VL declines
• ? Anti-inflammatory mechanism??
Slide 16
From TA Maurer, MD, at 11th RW Program Clinical Update, IAS–USA.
• Pt also has pulmonary TB-can’t start ARVs yet until his TB is treated
• What about his psoriasis? Start acitretin 25 mg qd-this is a retinoid designed specifically for psoriasis
• TB under control-start protease inhibitor regimen-acitretin still on board-watch for retinoid toxicity-monitor cholesterol, TG, painful red skin-can probably discontinue acitretin
• Tx with topical steroids
Slide 17
From TA Maurer, MD, at 11th RW Program Clinical Update, IAS–USA.
Other Markers of Poor Immune Status
• Prurigo nodularis
• Pruritic papular eruption of HIV
• Molluscum
Slide 18
From TA Maurer, MD, at 11th RW Program Clinical Update, IAS–USA.
• Prurigo nodularis-pts consumed by itch• CD4 under 100 with VL• You start new ARV regimen in this patient-
can’t get the CD4 count above 60 but VL is low
• Topicals include clobetasol oint (class 1 steroid) and doxepin 50 mg qhs
• Thinking about adding thalidomide• Is pt a candidate for raltegravir?
Slide 19
From TA Maurer, MD, at 11th RW Program Clinical Update, IAS–USA.
Pruritic Papular Eruption
86/102 biopsies showed evidence for arthropod assault in Ugandan study (Resneck J. JAMA. 2004)
• The more severe the eruption, the lower the CD4 count (p< 0.001)
• Persons on ARVs improve with 16 wks of therapy (Castelnuovo B. AIDS. 2008 Jan)
• Hypersensitivity to bug bites may be secondary to T cell dysregulation
Resneck J, et al. JAMA. DEC 1, 2004
Slide 20
From TA Maurer, MD, at 11th RW Program Clinical Update, IAS–USA.
Molluscum
• 1st line therapy is ARVs• Liquid nitrogen only temporary• Curretage of large molluscum• Cryptococcus can mimic molluscum but
lesions develop quickly over days
Slide 21
From TA Maurer, MD, at 11th RW Program Clinical Update, IAS–USA.
New Directions
• Can we use these skin diseases as markers for virologic response?
• If these recur on treatment, does it indicate drug resistance or non-adherence?
• Particular importance in resource poor settings/children with HIV/as a clue to look for resistance-obtain CD4 count, VL
Slide 22
From TA Maurer, MD, at 11th RW Program Clinical Update, IAS–USA.
• CD4 250, VL < 50, admitted for IV vancomycin for cellulitis
• Blister on back-is this a new area of methicillin resistant staphylococcus?
• Call dermatology-consider toxic epidermal necrolysis
Slide 23
From TA Maurer, MD, at 11th RW Program Clinical Update, IAS–USA.
Toxic epidermal necrolysis
• Complete separation of epidermis
• Watch for triangular blisters
• Higher incidence in HIV
• Higher mortalitiy in HIV
• TMP-SMX/vancomycin
• Intravenous immunoglobulin (IVIG)???
Slide 24
From TA Maurer, MD, at 11th RW Program Clinical Update, IAS–USA.
Drug Reactions
• NNRTIs-redness-treat through
• NNRTIs- erythema mutiforme-discontinue drug and don’t rechallenge; change class of drug
• Abacavir-5-8% develop hypersensitivity rxns-HLA B*5701+ higher risk
Slide 25
From TA Maurer, MD, at 11th RW Program Clinical Update, IAS–USA.
• 2 cases of erythema multiforme to raltegravir
• Fixed drug reactions to darunavir• Do not give prednisone unless
hypersensitivity marked by transaminase or creatinine elevation
• Syphilis-widespread erythematous maculopapular eruption-check RPR-usually does not itch
Slide 26
From TA Maurer, MD, at 11th RW Program Clinical Update, IAS–USA.
• Pt with CD4 140, VL 100,000-starts ARVs
• New pruritic bumps on face, scalp, chest, back (within 3 weeks of starting ARVs)
• He felt it was a drug eruption and so discontinued his ARVs
Slide 27
From TA Maurer, MD, at 11th RW Program Clinical Update, IAS–USA.
Eosinophilic folliculitis
• CD4 counts under 200
• Develops within 3-6 months of initiating ARVs-immune reconstitution
• Itraconazole 200-400 mg /day
• Permethrin from waist up
• UVB
• Wait for immune reconstitution to settle (3-6 months after starting ARVs)
Slide 28
From TA Maurer, MD, at 11th RW Program Clinical Update, IAS–USA.
Differential diagnosis
• Acne-seeing lots of it as a result of normalized immune systems and drug induced acne (testosterone, INH, lithium)
• Doesn’t itch and not on scalp
• Staphyloccocal folliculitis-increased incidence in HIV infection-easily denuded pustules (not on scalp)
Slide 29
From TA Maurer, MD, at 11th RW Program Clinical Update, IAS–USA.
• Pt admitted with painful leg with erythema-admitting diagnosis = cellulitis
• Developed pustules
• Discharged on antibiotics-now pustules all over body
Slide 30
From TA Maurer, MD, at 11th RW Program Clinical Update, IAS–USA.
Herpes zoster
• CD4 between 200-400, VL 70-100,000
• Disseminated zoster-seeing it more often in pts on and off ARVs
• Recurrent zoster with high CD4 counts-would that lead you to place pts on ARVs?
Glesby MJ et al. JAIDS. 2004 Dec.
Abbas V et al. Am J Med Sci. 2001.
Slide 31
From TA Maurer, MD, at 11th RW Program Clinical Update, IAS–USA.
Herpes simplex
• Have never seen disseminated herpes simplex in HIV
• Pt presents with large hypertrophic and painful lesion perianally
• Must rule out squamous cell carcinoma
Slide 32
From TA Maurer, MD, at 11th RW Program Clinical Update, IAS–USA.
• Diagnosis-herpes simplex
• Send for acyclovir resistance testing
• Pt will need foscarnet/cidofovir +/- topical cidofovir
Levin et al. Clin Inf Dis. 2004.
Slide 33
From TA Maurer, MD, at 11th RW Program Clinical Update, IAS–USA.
Squamous Cell Carcinoma
• Several cohort studies have now documented that there is a higher incidence of SCC and BCC in HIV
• Risk factors: being white, increasing age, longer duration of HIV infection
• Low CD4 counts not a significant variable for tumor initiation
• Sun and smoking
Slide 34
From TA Maurer, MD, at 11th RW Program Clinical Update, IAS–USA.
Melanoma
• Melanoma in HIV may be more aggressive when compared by tumor thickness
• Sentinel node biopsy recommended at shallower thickness-usually do sentinel node if melanoma is 1mm or more in thickness
• Recurrent melanoma more frequent
• Max out the immune system-start ARVs
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