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Skin and Oral Manifestations of HIV Infection. Stephen Tabet, MD, MPH University of Washington HIV Vaccine Trials Network (HVTN) Seattle, Washington [email protected] Flags: The HIV Iceberg. Evidence of End-Organ Disease. Identification Factors Present. Identification Factors Absent.

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Skin and oral manifestations of hiv infection

Skin and Oral Manifestations of HIV Infection

Stephen Tabet, MD, MPH

University of WashingtonHIV Vaccine Trials Network (HVTN)

Seattle, Washington

[email protected]


Flags the hiv iceberg
Flags: The HIV Iceberg

Evidence of End-Organ Disease

Identification Factors Present

Identification Factors Absent


Flags the goal is early hiv detection
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 


Flags identification of hiv
Flags: Identification of HIV

  • Medical and risk behavior history

  • Physical exam features

  • Identifying flags

    • Photo case examples

  • Recognizing acute HIV infection

  • Laboratory features


Patient
Patient

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


Patient presentation
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 presentation1
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 presentation2
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?






What is one of the greatest concerns for warts especially in hiv patients
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
Anal Cancer HIV+ patients?



Itchy patient
Itchy Patient HIV+ patients?

  • 32 year old new patient is in clinic complaining of itchiness since being incarcerated for the past month.

  • What would you do next?



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


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





Kaposi s sarcoma
Kaposi’s Sarcoma intralesional steriods



Patient with a severe rash
Patient with a severe rash ulcer.

  • HIV antibody negative

  • HIV PCR (viral load negative)

  • What next?




Patient Presentation ulcer.

  • 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 presentation3
Patient Presentation ulcer.

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


Differential Diagnosis ulcer.

  • 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 ulcer.

  • 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 ulcer.

  • 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 ulcer.

  • 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
Psychological Issues ulcer.

  • 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?


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