Skin and Oral Manifestations of HIV Infection Stephen Tabet, MD, MPH University of Washington HIV Vaccine Trials Network (HVTN) Seattle, Washington stabet@hvtn.org

Flags: The HIV Iceberg Identification Factors Absent Evidence of End-Organ Disease Identification Factors Present The pyramid shown on this slide represents the spectrum of identifiable and unidentifiable factors associated with HIV infection In most cases patients are asymptomatic with no identification factors present In a smaller percentage of cases (central area of pyramid), patients manifest identification factors In a very small percentage of cases (near top of pyramid), patients display evidence of end-organ disease 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  HIV testing allows clinicians to track and predict the course of the disease. It also provides a basis for initiating antiretroviral treatment Regular education and routine recommendation for HIV testing to high-risk patients can increase the number of patients that request testing Early identification of HIV infection results in more successful treatment regimens. This can prevent the occurrence of opportunistic infections and decrease the cost associated with treating them. Early treatment can also prevent transmission to uninfected inmates and prison staff Alternatives to routine blood tests, such as urine and oral fluid tests, may increase the likelihood that patients consent to be tested References Providing services to inmates living with HIV. CDC fact sheet, August 2001. http://www.cdc.gov/idu. DHHS guidelines for the use of antiretroviral agents in HIV-infected adults and adolescents, February 4, 2002. www.hivatis.org.

Flags: Identification of HIV Medical and risk behavior history Physical exam features Identifying flags Photo case examples Recognizing acute HIV infection Laboratory features This slide gives an overview of the key factors involved in identification of HIV

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?

1. Acyclovir 2. Zostrix cream 3. Prednisone 4. Fluconazole 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?