Dermatology in HIV — SAQ

Stem

A 32-year-old man presents with a three-month history of severe, treatment-resistant seborrhoeic dermatitis over the scalp, nasolabial folds and chest, recurrent oral thrush, and an enlarging cluster of painless purple-brown nodules on his hard palate and lower legs. He has also noticed a chronic, painful, non-healing ulcer in his perianal region. He is sexually active with male partners and has never been tested for HIV. On examination there are also numerous umbilicated papules on his face and neck.

Questions

a) What is the most likely unifying diagnosis, and which clinical features support it? (2 marks)

^[4]HIV infection with advanced immunosuppression. Supporting features: severe treatment-resistant seborrhoeic dermatitis (commonest early HIV dermatosis), recurrent oral candidiasis, purple-brown nodules on the hard palate (highly suggestive of Kaposi sarcoma, AIDS-defining, HHV-8), chronic perianal ulcer (chronic HSV over 1 month is AIDS-defining), and numerous umbilicated facial papules (molluscum or, critically, disseminated cryptococcosis). An HIV test with CD4 count and viral load is essential.

^[3]b) Outline your investigations. (3 marks)

• HIV serology (4th-generation Ag/Ab), CD4 count and percentage, HIV viral load (RNA PCR).
• Biopsy of a purple nodule (KS: spindle cells + slit-like vascular spaces, HHV-8 IHC) and of the perianal ulcer (HSV PCR/culture).
• Biopsy or scraping of the facial umbilicated papules — exclude disseminated cryptococcosis (PAS/GMS stain, mucicarmine; serum cryptococcal antigen; lumbar puncture if positive).
• Baseline bloods: FBC, U&E, LFTs, HBV/HCV serology, syphilis serology (RPR + TPPA), Toxoplasma IgG, TB screen (IGRA + chest X-ray).

^[2]c) Outline your stepwise management. (3 marks)

• Initiate ART — the single most effective treatment for all HIV skin disease ("test and treat", supported by START trial); refer to HIV physician.
• Condition-specific therapy: KS — ART often sufficient for limited disease, plus liposomal doxorubicin for extensive/visceral; HSV ulcer — valaciclovir or IV aciclovir; candidiasis — fluconazole; molluscum — cryotherapy/curettage.
• Screen for and treat STIs; cancer screening (anal Pap, cervical screening); sun protection; ophthalmology if any ocular symptoms (CMV retinitis).
• Warn the patient about IRIS — paradoxical worsening in the first weeks of ART; do not stop ART; corticosteroids if severe.

^[1]d) What are the key complications and prognostic factors? (2 marks)

• Complications: IRIS (especially KS-IRIS); drug eruptions (10 to 100x more common; cotrimoxazole, abacavir with HLA-B*5701, nevirapine SJS); visceral KS (GI bleeding, pulmonary); secondary infection of ulcers; dissemination of cryptococcosis to meningitis.
• Prognosis: transformed by effective ART — most dermatoses resolve with immune restoration; KS frequently regresses; prognosis worst with late presentation, untreated virus, disseminated fungal disease, or SJS/TEN.

References4ShowHide

1. [1]Jacobson JM, Spritzler J, Fox L, et al. Thalidomide for the treatment of esophageal aphthous ulcers in patients with human immunodeficiency virus infection J Infect Dis, 1999.PMID 10353862
2. [2]Sirka CS Clinical features of a large chronic ulcer on the genital and perianal region in HIV-infected patients can be a strong clinical clue for the diagnosis of herpes simplex infection Indian J Sex Transm Dis AIDS, 2020.PMID 33817593
3. [3]Sirka CS Clinical features of a large chronic ulcer on the genital and perianal region in HIV-infected patients can be a strong clinical clue for the diagnosis of herpes simplex infection Indian J Sex Transm Dis AIDS, 2020.PMID 33817593
4. [4]Sirka CS Clinical features of a large chronic ulcer on the genital and perianal region in HIV-infected patients can be a strong clinical clue for the diagnosis of herpes simplex infection Indian J Sex Transm Dis AIDS, 2020.PMID 33817593