Skin and Oral Manifestations of HIV Infection Stephen Tabet, MD, MPH University of Washington HIV Vaccine Trials Network (HVTN) Seattle, Washington [email protected].

Skin and Oral Manifestations of HIV Infection

Stephen Tabet, MD, MPH

University of WashingtonHIV Vaccine Trials Network (HVTN)

Seattle, Washington

[email protected]

Flags: The HIV IcebergEvidence of Evidence of End-Organ End-Organ

DiseaseDisease

Identification Factors Present

Identification Factors Absent

Flags: The Goal is Early HIV Detection

• Initiate appropriate preventive therapy

– Generally inexpensive

• Prophylaxis for opportunistic infections

• Vaccinations (HBV, influenza, Pneumovax®, tetanus)

• Initiate appropriate antiretroviral therapy

– Use CD4+ and HIV-1 RNA thresholds

• Reduce HIV transmission to others

– After diagnosis of HIV, risk behavior

Flags: Identification of HIV

• Medical and risk behavior history

• Physical exam features

• Identifying flags

– Photo case examples

• Recognizing acute HIV infection

• Laboratory features

Patient

• Patient presents with what he describes as facial dandruff for the past several weeks.

Patient Presentation

• The patient is seen by you and the doctor and he diagnoses him with seborrheic dermatitis.

• The patient reports that he is bisexual.

• Would you recommend an HIV antibody test?

Patient Presentation

• The patient is treated with topical ketoconazole and hydrocortisone, and ketoconazole shampoo.

• The patient tests HIV positive, but does not return back to clinic for his results.

• How might you have gotten better success with getting him to come back for his results?

Patient Presentation

• HIV+ patient reports to you that he has had these strange warts in his pubic area for the past several months.

• Wants to know what he should do?

Oral HPV

Oral HPV (Concerning for immunosuppression)

Anal Warts (Condyloma)

Penile Warts (hyperpigmented)

What is one of the greatest concerns for warts especially in

HIV+ patients?• 1. That it can be spread to other parts of the

body

• 2. That is can turn into ulcers

• 3. That is can progress to cancer

Anal Cancer

46 year old patient with AIDS presents with a severe rash

Itchy Patient

• 32 year old new patient is in clinic complaining of itchiness since being incarcerated for the past month.

• What would you do next?

What is the most common cause of lip and mouth ulcers is HIV+ patient?

48 year old HIV+ pt with CD4 480 is being treated with mupirocin ointment for impetigo.

Why is it not getter better?

You get the patient Ophthalmologic consultation and Slit lamp examination is normal.

Which of the following is likely to reduce the duration of the patient’s herpes zoster rash?

• 1. Acyclovir

• 2. Zostrix cream

• 3. Prednisone

• 4. Fluconazole

Patient presents with stye; what else could it be?

HIV+ patient presents with a bruise on his leg.

AIDS patient is being treated for a keloid with intralesional steriods

Kaposi’s Sarcoma

AIDS patient with CD4 count 40 presents with nonhealing ulcer.

Patient with a severe rash

• HIV antibody negative

• HIV PCR (viral load negative)

• What next?

How do you measure the size of a TST reaction?

Patient with CD4 180 and sore, red mouth. Diagnosis?

Patient Presentation

32 year old married male presents with one week of fatigue, night sweats, sore throat, and rash. He reports not knowing his HIV serostatus.

Examination shows a healthy appearing male with T 38.9 C, a rash and 1/2 – 1 cm bilateral occipital, cervical and axillary lymphadenopathy

Patient Presentation

• You suspect primary HIV infection. What are some important clues in this patient’s history to help you obtain the clinical diagnosis?

Differential Diagnosis

Acute HIV Secondary syphilis ‘Flu’ or non-specific viral syndrome Drug Reaction Epstein-Barr virus (EBV) mononucleosis Primary cytomegalovirus (CMV) infection Toxoplasmosis Primary herpes simplex virus infection Rubella

Patient Presentation

Patient reports being married and monogamous for the past 3 years

He denies sex with men, but does report ‘occasional’ heroin IVDU for the past 8 yrs

HIV antibody test is ordered and returns negative by ELISA and WB

Patient Presentation

What would you do next? 1) Don’t overly alarm him. Tell him that while

he currently tested HIV-negative, he still needs follow up HIV testing in another month.

2) Tell him you suspect he is in the very early stages of HIV infection and is very infectious. Then repeat HIV Ab.

3) Tell him you suspect he is in the very early stages of HIV infection and is very infectious. Then do an HIV RNA (viral load).

Patient Presentation

Laboratory data» HIV RNA by PCR 1.8 million copies/ml» CD4+ T-cells 640 /microliter» platelet count 104,000/microliter

Rash, sore throat, and fatigue all resolve within 1 week. Night sweats persist for 2 weeks.

Psychological Issues

• What else would you want to talk with the patient about?

• How would you help him talk with his wife?

• How would you help him deal with this new diagnosis?