TRIPE PALMS ACANTHOSIS PALMARIS, PACHYDERMATOGLYPHY

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HIV / AIDS Sexually Transmitted
Infections SKIN MANIFESTATIONS

• Dr. P.S.Mathew
• Associate Professor
• Dept. of Dermatology Venereology
• Medical College, Trivandrum.

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Major headings

• Introduction
• Pretest - Quiz Photo Quiz
• Current Scenario of HIV/AIDS
• Origin spread of HIV
• Common STDS their diagnosis and Management in
  HIV co-infected
• Dermatological manifestations in HIV/AIDS
• Conclusion

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HIV/AIDSSEXUALLY TRANSMITTED INFECTIONS SKIN
MANIFESTATIONS

• PRE TEST
• Quiz Photoquiz
• 20 questions 20 marks

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1

• Which is the Kaposis Sarcoma associated herpes
  virus ?
• Human Herpes Virus 8
• Herpes Simplex Virus 2
• Epstein Barr Virus

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2

• During secondary stage of syphilis, VDRL test is
  usually
• Positive in 100 of cases
• Positive in 50 of cases
• Negative

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3

• Bartonella henselae and Bartonella
• quintana are the organisms causing -----
• Kaposis Sarcoma
• Bacillary Angiomatosis
• Eosinophilic folliculitis

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4

• An antiretroviral agent which may induce skin
  rash frequently
• Lamivudine
• Nevirapine
• Efavirenz

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5

• In patients with AIDS, the usual course of
  psoriasis is -------
• Becomes aggravated
• Gets resolved
• No change

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6

• Which is the characteristic oral lesion in AIDS ?
• Candidiasis
• Kaposis Sarcoma
• Hairy Leukoplakia

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7

• A very common dermatological non -infectious
  manifestation in HIV/AIDS is -------
• Lichen planus
• Acne vulgaris
• Seborrhoeic dermatitis

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8

• Scabies in the immunosuppressed patient presents
  as --------
• Scabies Incognito
• Nodular scabies
• Crusted scabies

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9

• Grouped vesicular lesions on the genitals 2 to 5
  days after sexual contact suggests -----
• Chancroid
• Herpes genitalis
• Condyloma acuminata

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10

• Which of the following are the cutaneous
• lesions in AIDS patients resembling
• Molluscum contagiosum?
• Kaposis Sarcoma Bacillary Angiomatosis
• Cutaneous cryptococcosis Penicillium
• 
  marneffei infection
• Sporotrichosis Histoplasmosis

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PHOTO QUIZ
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11. Can you identify these scientists ?
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11

• Schaudin Hoffman
• Montagnier Galo
• Fleming Florey

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12. Who was this Hollywood actor who died of
AIDS in the late 1980s ?
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12

• Rock Hudson
• Magic Johnson
• Arthur Ashe

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13. Which is this animal which is considered
to be important in the origin of AIDS ?
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13

• Chimpanzee
• African Green Monkey
• Asian Macaque monkey

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14. Can you diagnose this lesion on the tounge
in this HIV positive individual ?
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14

• Cadidiasis
• Snail track ulcer
• Hairy Leukoplakia

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15. What is your diagnosis in this HIV
positive person ?
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15

• Cutaneous Cryptococcosis
• Molluscum contagiosum
• Verruca Vulgaris

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16. What is your diagnosis in this HIV
positive person ?
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16

• Bacillary Angiomatosis
• Extensive Warts
• Itchy Folliculitis

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17. What is your diagnosis in this HIV positive
person
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17

• Bacillary Angiomatosis
• Eosinophilic Folliculitis
• Kaposis Sarcoma

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18. What is your diagnosis in this HIV positive
person ?
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18

• Eosinophilic Folliculitis
• Kaposis Sarcoma
• Bacillary Angiomatosis

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19. Can you spot the diagnosis in this HIV
positive man ?
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19

• Seborrhoeic dermatitis
• Kaposis Sarcoma
• Giant Molluscum Contagiosum

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20. What is your diagnosis of the skin lesions
in this HIV positive homosexual man ?
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20

• Kaposis Sarcoma
• Bacillary Angiomatosis
• Eosinophilic Folliculitis

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GRADING

• 15 or more correct - Excellent knowledge
• 10 to 14 correct - Good performance
• 5 to 9 correct - Average performance
• Less than 5 - Can score more at the
• end of session
  

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Adults and children estimated to be living with
HIV/AIDS as of end 2003
Eastern Europe Central Asia 1.5 million
Western Europe 600 000
North America 1 million
East Asia Pacific 1 million
North Africa Middle East 600 000
South South-East Asia 6.4 million
Caribbean 470 000
Sub-Saharan Africa 26.6 million
Latin America 1.6 million
Australia New Zealand 15 000
Total 40 million
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Number of adults and children newly infected with
HIV during 2003
Eastern Europe Central Asia 230 000
Western Europe 35 000
North America 45 000
East Asia Pacific 210 000
North Africa Middle East 55 000
South South-East Asia 850 000
Caribbean 60 000
Sub-Saharan Africa 3.2 million
Latin America 150 000
Australia New Zealand 850
Total 5 million
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Estimated adult and child deaths from HIV/AIDS
during 2003
Eastern Europe Central Asia 30 000
Western Europe 3 000
North America 15 000
East Asia Pacific 45 000
North Africa Middle East 45 000
South South-East Asia 460 000
Caribbean 40 000
Sub-Saharan Africa 2.3 million
Latin America 60 000
Australia New Zealand lt100
Total 3 million
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About 14 000 new HIV infections a day in 2003

• More than 95 are in developing countries
• 2000 are in children under 15 years of age
• about 12000 are in persons aged 15 to 49 years,
  of whom
• - almost 50 are women
• - about 50 are 15-24 year olds

UNAIDS
WHO
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GLOBAL SUMMARY
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BEGINNING OF A NEW EPIDEMIC

• 1981 JUNE
• LOS ANGELES NEW YORK

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Opportunistic infections in male
homosexuals

• Pneumocystis Carinii pneumonia
• Kaposis Sarcoma

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The New Disease -Terminology

• GRID Gay Related Immune Deficiency
• AIDS Acquired Immuno DeficiencySyndrome

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LUC MONTAGNIER 1983 ROBERT GALO 1984
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VIRUS TERMINOLOGY

• LAV Lymphadenopathy Associated Virus
• HTLV III Human T Lymphotropic Virus type III
• ARV Aids Related Virus
• HIV-1 Human Immunodeficiency Virus type1
• HIV-2 Human Immunodeficiency Virus type2

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The Origin and Spread of AIDS
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THE DECADE OF DEATH

• Rock Hudson
• Halston
• Robert Reed
• Arthur Ashe

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ROCK HUDSON
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ARTHUR ASHE
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MAGIC JOHNSON
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INDIAN SCENARIO

• FIRST HIV INFECTION CHENNAI 1986 April
• FIRST AIDS CASE MUMBAI 1986 May
• CURRENT STATUS 4.78 million 2003 End

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UNAIDS / WHO HIV Epidemic definitions

• Generalised
• gt 1 in the general population.
• Concentrated
• lt 1 in the general population, over 5 in high
  risk groups
• Low-level
• lt1 in the general population, lt 5 in
  high-risk groups

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Transition Map of HIV prevalenceEvolution of HIV
from 1986 to 2002
4.78 Million Indians Living with HIV/AIDS
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Expanding Disease Burden 1986 to 2002
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Distribution of Reported AIDS Cases by State
through August,2003
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Share of Reported AIDS Cases among
High-prevalence States through August,2003
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HIV Prevalence in STD Clinics
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PREVALENCE OF HIV AMONG STD PATIENTS STATEWISE
2002

• Stat e Highest
  Prevalence
• Manipur 9.60
• Rajasthan 6.00
• Gujarat 6.17
• Kerala 2.45
• Bihar 1.20
• Nagaland 1.60

• State Highest Prevalence
• Mumbai 14.84
• Tamil Nadu 14.7
• Maharashtra 7.60
• Andhra Pradesh 30.40
• Karnataka 13.60

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HIV TRANSMISSION IN SOUTH-EAST ASIA
ROUTE EFFICIENCY OF
TOTAL SEXUAL INTERCOURSE 0.1-1.0
80-90 BLOOD TRANSFUSION gt
90 3 - 5 INTRAVENOUS DRUG USE
0.5-1.0 5-10 EQUIPMENT/NEEDLES
lt 0.5 lt 0.1 PERINATAL 15-45
lt 0.1
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Probable source of infection among AIDS cases in
India (n16722, May 1986 to Dec. 2000)
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HIV Infectious Fluids

• Blood
• Fluids containing blood
• Potentially infectious fluid / tissue
• Semen
• Vaginal Secretions
• Human Breast milk
• CSF
• Synovial
• Pleural
• Peritoneal
• Pericardial
• Amniotic

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Not considered potentially infectious

• Saliva
• Sweat
• Nasal Secretions
• Sputum
• Tears
• Faeces
• Urine
• Vomitus

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Natural history of HIV infection
Infection by HIV Acute Retroviral
Syndrome Asymptomatic Phase Symptomatic
Infection/ AIDS Death
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How HIV Infects the Body

• HIV infects the CD 4 cells in the body
• CD4 lymphocytes
• macrophages
• follicular dendritic cells
• Langerhans cells
• Binding of HIV to the CD4 molecule takes place by
  the gp120

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How HIV Infects the Body

• Entry into the cell needs gp41 and co-receptors
• CCR5 on macrophages
• CXCR4 on lymphocytes

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Natural History of HIV Infection Without the Use
of AntiretroviralTherapy
Primary Infection
Death
Acute HIV syndrome Wide dissemination of
virus Seeding of lymphoid organs
1200 1100 1000 900 800 700 600 500 400 30
0 200 100 0
OpportunisticDiseases
Clinical latency
HIV/RNA Copies per ml Plasma
Constitutional Symptoms
CD4 T Lymphocyte Count (cells/mmm3)
0 3 6 9 12
1 2 3 4 5
6 7 8 9 10
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Years
Weeks
Source Fauci et al 1996.
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ART works Progression to AIDS/Death
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Dual Therapy
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No Therapy
Mono-Therapy
20
Patients Progressing
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10
Triple Therapy
5
0
1 2 3 4 5 6 7 8
9 10 11 12 13 14 15
Months
JAMA 1998, CMAJ 1999
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Three patterns of CD4 depletion

• Rapid progressors ("CD4 crash") 50 cell drop per
  month after seroconversion
• Moderate decliners 35-50 cell drop per year.
• Slow or Non-decliners stable at baseline

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Currently Available Antiretrovirals
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Nucleoside Reverse Transcriptase
Inhibitors(NRTIs)

• NRTI's or "nukes" block reverse transcriptase,
  preventing the transformation from RNA to DNA.
• Without the DNA, HIV is unable to make functional
  copies of itself and its proliferation in the
  body is halted

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Protease Inhibitors

• block the functioning of the enzyme protease
• without functioning protease, HIV is unable to
  mature and therefore can not make more copies of
  itself.

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Major Targets of Antiretroviral Agents
Protease Inhibitors NFV LPV/rtv SQV,RTV, IDV,
AMV,
RT Inhibitors NRTI AZT, ddI, d4T, 3TC,
ABC NNRTI NVP, EFV NTRTI Tenofovir
6
ds DNA
Integrase
Genomic RNA
vpr
Protease
HIV
5
DNA
3
Proviral DNA
2
RT
1
Transcription
4
RNA
mRNA
Polyprotein Protein
Spliced mRNA
Entry Inhibitors CXCR4 AMD3100, T22 CCR5 SCH-C,
D TAK779 Fusion gp41 T20 (Fuzeon)
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CD4 Cell Counts and Opportunistic Infections
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Opportunistic Infections in AIDS cases in
India (n5145)
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57.5
Percentage
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8
3.8
0.6
TB
Candidiasis
Cryptpspori..
PCP
Kaposi
Others
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HIV/AIDS STDS
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HIV/AIDS and SexuallyTransmitted Infections

• 1 Rate of HIV acqisition and
• transmission increased
• 2 Accelerate the natural progression of HIV
  infection
• 3 Alter critical clinical and
• serological parameters used
• to diagnose and treat STD

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GENITAL ULCERATIVE DISEASES

• SYPHILIS
• CHANCROID
• HERPES GENITALIS
• DONOVANOSIS
• LYMPHO GRANULOMA VENEREUM

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SYPHILIS HIV

• PRIMARY SYPHILIS
• SECONDARY SYPHILIS
• EARLY LATE LATENT SYPHILIS
• BENIGN TERTIARY SYPHILIS
• CARDIOVASCULAR SYPHILIS
• NEURO SYPHILIS

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Treponema Pallidum under Dark ground Microscope
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1905FRITZ SCHAUDINN
ERIC HOFFMANN
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PRIMARY SYPHILIS

• Incubation period 9 to 90 days
• Primary Chancre Painful in HIV infected
• Multiple primary in HIV infected

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EXTRA GENITAL PRIMARY CHANCRE
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SECONDARY SYPHILIS

• 6 to 8 weeks after primary
• Macules, papules, nodules, condyloma lata
• Pustular necrotic lesions in HIV infected- Lues
  maligna
• Constitutional features fever,malaise,
  arthralgia, bone pain
• Generalised lymphadenopathy
• Serology- VDRL reactivity- variation in HIV
  infected

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SECONDARY SYPHILIS MACULO
PAPULAR RASH
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Secondary Syphilis
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Secondary Syphilis
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Secondary Syphilis
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Secondary Syphilis Mucous
patches
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SECONDARY SYPHILIS
POLYCYCLIC PATTERN IN HIV
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NODULAR SYPHILIDE IN HIV
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NODULAR SYPHILIDE IN HIV
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ANNULAR SYPHILIDE IN HIV
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ULCERATIVE SYPHILIDE IN HIV
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CONGENITAL SYPHILIS
SYPHILITIC RHINITIS
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CONGENITAL SYPHILIS BULLOUS RASH
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LATENT SYPHILIS

• No signs or symptoms of syphilis but
  serology positive
• Early Latent Syphilis less than 2 years after
  infection
• Late Latent Syphilis more than 2 years after
  infection

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GUMMATOUS SYPHILIS

• BENIGN TERTIARY SYPHILIS
• Gummas of the skin,mucous membranes,
  subcutaneous and submucous tissues and internal
  organs

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CARDIOVASCULAR SYPHILIS

• AORTITIS
• AORTIC REGURGITATION
• AORTIC ANEURYSM

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NEURO SYPHILIS

• ASYMPTOMATIC NEUROSYPHILIS
• TABES DORSALIS
• GENERAL PARALYSIS OF THE INSANE
• PRECOCIOUS TERTIARY IN HIV INFECTED

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TREATMENT OF SYPHILIS

• Early syphilis
• Late syphilis
• CVS and Neurosyphilis
• Syphilis in HIV infected

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EARLY SYPHILIS primary, secondary and early
latent

• Procain Penicillin PP12 L i/m daily ATD x 10
  days
• Benzathene penicillin 24 L as a single inj. ATD
• Tetracycline 500 mg qid x 15 days
• Erythromycin 500 mg qid x15 days

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LATE LATENT SYPHILIS

• Inj. PP12 I/m daily ATD x 21 days
• Tetracycline or Erythromycin 500 qid x 30 days

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CVS and NEUROSYPHILIS with HIV

• Inj. CP 40 L I/v 4 hourly atd x 14 days
• Inj. PP24 L X 21 days

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CHANCROID

• Caused by Haemophilus ducreyi
• Incubation period 2 to 5 days
• Multiple superficial ulcers
• Painful and tender
• Bleeds to touch
• Erythematous halo
• Inguinal inflammatory bubo
• Variation in HIV

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Treatment of Chancroid

• Erythromycin 500 qid x7 days
• Ciprofloxacin 500 single dose
• Inj. Ceftriaxone 250 mg I/m single dose
• Azithromycin 1 gm single dose
• Septran 2 bd x 7 days

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HERPES GENITALIS

• Caused by Herpes simplex virus type 2
• Incubation period 2 to 5 days
• Grouped vesicles and erosions
• Frequent recurrences
• Extensive lesions lasting longer periods in HIV
  infected

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HERPES GENITALIS IN HIV
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HERPES GENITALIS IN HIV
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Treatment of Herpes genitalis

• Primary episode
• Recurrent episodes
• Acyclovir / Famciclovir / Valaciclovir
• Acyclovir 200 mg 5 times daily x 7-10
  days
• Famciclovir 250 mg bd
• Valaciclovir 1 gm bd

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GRANULOMA INGUINALE

• Also calleed Donovanosis
• Caused by Calymmatobacterium granulomatis
• Beefy red granulomatous ulcers
• Pseudobubo

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GRANULOMA INGUINALE IN HIV
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DONOVANOSIS IN HIV
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DONOVAN BODIES
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Treatment of Granuloma Inguinale

• Septran 2 bd x 14 days
• Inj. Streptomycin 1 gm bd x 10 days
• Tetracycline 500 mg x 14 days
• Azithromycin 1 gm oral per week x 3 weeks

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LYMPHOGRANULOMA VENEREUM

• CHLAMYDIA TRACHOMATIS
• TRANSIENT ULCER
• INGUINAL SYNDROME
• GROOVE SIGN
• GENITAL SYNDROME-ESTHIOMENE

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LGV
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LGV - GROOVE SIGN
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Chlamydia trachomatis
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Treatment of LGV

• Tetracycline 500 mg x 21 days
• Erythromycin 500 mg qid x 21 days
• Doxycycline 100 mg bd x 21days

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DERMATOLOGICAL MANIFESTATIONS OF AIDS

• INFECTIOUS AETIOLOGY
• NON INFECTIOUS AETIOLOGY

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INFECTIOUS AETIOLOGY

• VIRAL
• BACTERIAL
• FUNGAL
• PARASITIC INFESTATIONS

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NON-INFECTIOUS AETIOLOGY

• SEBORRHOEIC DERMATITIS
• PSORIASIS
• REITERS SYNDROME
• EOSINOFILIC FOLLICULITIS
• CUTANEOUS DRUG ERUPTIONS
• NEOPLASTIC DISORDERS

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VIRAL DISEASES

• ACUTE RETROVIRAL SYNDROME
• HERPES SIMPLEX VIRUS
• VARICELLA-ZOSTER VIRUS
• EPSTEIN-BARR VIRUS
• CYTOMEGALO VIRUS
• HUMAN PAPILLOMA VIRUS
• POX VIRUSES

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ACUTE RETROVIRAL SYNDROME

• 2 TO 6 WEEKS AFTER EXPOSURE
• SEEN IN ABOUT 50
• FEVER, FATIGUE, HEADACHE
• LYMPHADENOPATHY, PHARYNGITIS
• MYALGIA, ARTHRALGIA
• WEIGHT LOSS, DIARRHOEA
• MORBILLIFOPRM RASH
• MUCO CUTANEOUS ULCERATION

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MACULO PAPULAR RASH OF ACUTE
RETROVIRAL SYNDROME
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HERPES SIMPLEX VIRUS INFECTION
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HERPES SIMPLEX VIRUS INFECTION IN HIV
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VARICELLA-ZOSTER INFECTION
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HERPES ZOSTER
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HERPES ZOSTER OPHTHALMICUS
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KAPOSIS SARCOMA HUMAN
HERPES VIRUS 8
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Kaposis Sarcoma
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ORAL HAIRY LEUKOPLAKIA

• EPSTEIN BARR VIRUS
• SEEN IN 25
• WHITE, CORRUGATED, HAIRY APPEARANCE
• LATERAL SURFACE OF TONGUE
• DO NOT PROGRESS TO MALIGNANCY
• TOPICAL PODOPHYLLIN, ISOTRETINOIN
• SYSTEMIC ACYCLOVIR
• DESTRUCTIVE MEASURES

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ORAL HAIRY LEUKOPLAKIA
EPSTEIN- BARR VIRUS
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ORAL HAIRY LEUKOPLAKIA
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PERIANAL ULCERATION CYTOMEGALO
VIRUS
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CYTOMEGALO VIRUS INFECTION
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EXTENSIVE VERRUCA VULGARIS
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CANDIDIASIS
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Molluscum Contagiosum

• Caused by DNA pox virus
• Firm, transluscent papules
• Central umblication

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MOLLUSCUM CONTAGIOSUM
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MOLLUSCUM CONTAGIOSUM
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MOLLUSCUM CONTAGIOSUM
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CRYPTOCOCCOSIS
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CRYPTOCOCCOSIS
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Cutaneous Cryptococcosis
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Cryptococcus neoformans
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CRYPTOCOCCUS
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PENICILLIUM MARNEFFEI

• Endemic disease in Asia
• Reported in Thailand and India
• 70 develop skin lesions
• Umbilicated papules, folliculitis, subcutaneous
  nodules and morbilliform eruptions
• Skin biopsy Culture
• Fluconazole, Itraconazole, Terbinafine

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BACILLARY ANGIOMATOSIS

• BARTONELLA HENSELAE B.QUINTANA
• RED TO VIOLACEOUS DOME SHAPED PAPULES
• FEVER, LYMPHADENOPATHY
• PELIOSIS HEPATITIS
• SOLITARY TO 100s
• ERYTHROMYCIN OR DOXYCYCLINE

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Bacillary Angiomatosis
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BACILLARY ANGIOMATOSIS
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BARTONELLA HENSELAE WARTHIN
STARRY STAIN
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PSEUDOMONAS INFECTION
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NON-INFECTIOUS AETIOLOGY

• SEBORRHOEIC DERMATITIS
• PSORIASIS
• REITERS SYNDROME
• DRUG REACTION
• EOSINOPHILIC FOLLICULITIS
• NEOPLASTIC DISORDERS

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Seborrhoeic Dermatitis
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PSORIASIS
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REITERS DISEASE
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NECROTIC VASCULITIC ULCER IN A PATIENT
WITH AIDS
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STEVENS JOHNSON SYNDROME
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STEVENS JOHNSON SYNDROME
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Cheilitis due to Indinavir
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CONCLUSION
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LET US JOIN
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THANK YOU
HAVE A NICE DAY