Ver: www.hivindv.org
Manifestações cutâneas de HIV
- Acute retroviral syndrome - mononucleosis like syndrome with morbilliform rash 1-3 weeks after sexual contact
- Inflammatory
- New or worsening common inflammatory skin conditions
- Psoriasis
- Lesões rupioides típicas, como se fossem antigas moedas da índia “rupia” - clássico HIV
- Psoríase inversa
- Fenómeno de Koebner
- Tratamento: optimizar tratamento HIV → acitretina (3-6 meses) → MTX, AntiTNF alfa contraindicados → IL-17, IL-23 (não há estudos, ter HIV é critério de exclusão dos estudos, existem apenas relatos de caso, candidíases podem ocorrer mais)
- Seborrheic dermatitis
- Prurigo nodular
- Fisiopatologia: desvio da imunidade
- Síndrome de Sweet
- Porfiria cutanea tarda
- Comum na co-infeção hepatite C - HIV
- Atopic dermatitis
- Ichthyosis
- Pityriasis rubra pilaris
- Often generalized, severe
- Can be explosive in onset
- Eosinophilic folliculitis
- Papular eruption of HIV - usually with improving CD4 count
- Treatment Related inflammatory disorders
- Antiretrovirals
- Abacavir - DIHS/DRESS due to HLA B5701
- Neviripine - TEN
- Indinavir - paronychia
- Zidovudine - melanonychia
- Lipodystrophy associated with HIV protease inhibitor
- Tratamento: metformina, leuprolide
- Prophylaxis
- TMP-SMX - SJS/TEN
- Drug eruptions by TMP-SMX occur in more than 50% of patients, compared with aproximately 10% in HIV-negative
- Immune reconstitution inflammatory syndrome (IRIS)
- Most common with cryptococcosis but can also be seen in Kaposi Sarcoma
- IRIS associated with pulmonary KS - usually fatal
- Ask about pulmonary symptoms and chest X ray
- Infections
- Due to immunosuppression
- Virus
- Herpes
- Zoster - múltiplos dermátomos
- Simplex - formas verrucosas, e prolongadas (>1 mês)
- HHV8 - Kaposi, Castleman disease
- Profuse Molluscum contagiosum lesions
- Molluscum like lesions in immunosuppressed patients:
- Cutaneous cryptococcosis
- Talaromyces marneffei
- HPV
- Verruca
- Condilomas
- Epidermodisplasia verruciforme adquirida
- EBV
- Hairy oral leucoplakia
- Bacteria
- Piodermites
- Foliculites, furúnculos, abcessos
- Furunculose disseminada
- Bacillary angiomatosis
- Mycobacteria
- TB
- Atypical
- Fungus
- Micoses superficiais
- Candidiasis
- Candidose oral
- Paroníquia crónica
- Candidose vaginal e balanite
- Candidose disseminada - associada a imunossupressão severa, pode ser fatal
- Onychomycosis - proximal subungueal (trichophitum rubrum) and superficial
- Pitiríase versicolor
- Pode ter foliculites associadas (≠foliculite bacterianas porque as foliculites de malassezia estão no V do decote)
- Micoses profundas (verdadeiras disseminadas ou oportunistas)
- True pathogens
- Asymptomatic primary infection
- Healed primary infections
- Acute and chronic pulmonary and disseminated infections (different sites of predilection eg lymph nodes)
- Primary cutaneous infections (rare)
- Relation to HIV and biologics
- Opportunistic pathogens
- Usually in the setting of onychomychosis with paronychia that evolves
- At the sites of dressings, previous IV access
- Purpuric or necrotic look (eschar)
- Systemic opportunistic infection with disseminated cutaneous disease
- Patients with stem cell transplant and hematologic malignancies are at highest risk
- Early tissue biopsy and culture is critical
- Phaeohyphomycosis
- Hyalohyphomycosis
- Parasites and arthropods
- Crusted scabies
- Diseases that travel with HIV
- Syphilis
- Aumenta 2-5x o risco de transmissão VIH
- Scabies
- Sarna crostosa
Clinical patterns of systemic mycoses from true pathogens
Clinical patterns
- Malignancy
- Non-melanoma skin cancer
- 2-3x higher in HIV: SCC>BCC
- Trend towards increased risk with lower CD4 counts
- Neoplasias associadas ao HPV na região genital
- Na dermatologia chamamos Queyrat, Bowenoid, outras especialidades chamam VIN, PIN, AIN. O alto e baixo grau tem mais interesse no colo do útero. Mas é tudo carcinoma intraepitelial
- HAART não restaura a resposta imune celular contra o HPV, portanto mesmo tratando o HIV, há maior probabilidade de neoplasias relacionadas com o HPV
- Eritroplasia Queyrat
- Papulose bowenoide
- Bowen anogenital
- Tumores de HPV em HIV são quimiosensíveis - por isso 5-FU, imiquimod e crioterapia responde bem, discutir em decisão multidisciplinar se envolver o esfíncter
- CEC perianal
- Quimio-radioterapia para evitar colostomia e resseção do esfíncter
- Since 1993, invasive cervical cancer has been included in the definition of AIDS
- Melanoma - unclear risk, but frequently metastatic at presentation
- Kaposi sarcoma - over 3000x higher risk
- Merkel cell carcinoma - 10x risk
- Cutaneous T-cell Lymphoma
- Unclear risk
- Benign lymphoproliferative disorders
- Eruptive tumors: nevi, dermatofibromas
Correlation of CD4 cell count with specific HIV associated disorders
>500 | <500 | <250 | <50 |
Oropharyngeal candidiasis (thrush) Herpes zoster Psoriasis, severe or refractory Eruptive atypical melanocytic nevi and melanoma Kaposi sarcoma | Eosinophilic folliculitis Seborrheic dermatitis, refractory Mollusca, extensive Bacillary angiomatosis Miliary/extrapulmonary tuberculosis Herpes simplex virus infection, disseminated Cryptococcosis; Histoplasmosis; Coccidiomycosis, disseminated Botryomycosis Non-Hodgkin lymphoma | Large, non-healing mucocutaneous herpes simplex virus infection (e.g. perianal) Papular pruritic eruption Giant mollusca Perianal ulcers due to CMV Aspergillosis Acquired icthyosis Mycobacterium Avium complex infections Major aphtae |
International classification
- Group A: asymptomatic; uncomplicated stage of HIV. Usually CD4>500
- Group B: all patients with minor clinical manifestations not included in the list of AIDS criteria C. Usually CD4 200-500
- Group C: meets the definition of AIDS. CD4<200
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