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

2. 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

3. 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
DHHS guidelines for the use of antiretroviral agents in HIV-infected adults and adolescents, February 4,

4. 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

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

8. 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?

9. 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?

10. 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?

15. Oral HPV

16. Oral HPV (Concerning for immunosuppression)

17. Anal Warts (Condyloma)

18. Penile Warts (hyperpigmented)

19. 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

20. Anal Cancer

21. 46 year old patient with AIDS presents with a severe rash

23. 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?

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

28. 48 year old HIV+ pt with CD4 480 is being treated with mupirocin ointment for impetigo. Why is it not getter better?

31. 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

32. Patient presents with stye; what else could it be?

33. HIV+ patient presents with a bruise on his leg.

34. AIDS patient is being treated for a keloid with intralesional steriods

35. Kaposi’s Sarcoma

36. AIDS patient with CD4 count 40 presents with nonhealing ulcer.

42. Patient with a severe rash
HIV antibody negative
HIV PCR (viral load negative)
What next?

44. How do you measure the size of a TST reaction?

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

56. 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

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

60. 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

61. 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

62. 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).

63. 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.

65. 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?