Cutaneous Manifestations of HIV Disease

Clay Cockerell, Antoanella Calame

• Publisher: CRC Press
• Year: 2012
• ISBN:
  9781482261318
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Dermatologists are often the first medical professionals to see patients with HIV infection, as skin diseases are common in acquired immunodeficiency syndrome. This book aims to help dermatologists recognize the cutaneous manifestations of HIV infection and AIDS, so that diagnosis can be made quickly and therapy begun as soon as possible. The book

Chapter 1

Introduction

Antoanella Calame and Clay J. Cockerell

The world became aware of a new epidemic almost three decades ago, largely a consequence of cutaneous manifestations which were among the first to be recognized. Reports of Kaposi’s sarcoma occurring in association with Pneumocystis carinii pneumonia in select subpopulations, especially homosexual men, ushered in a new era in infectious diseases, eventually leading to the definition of the condition now known as the acquired immunodeficiency syndrome (AIDS) and subsequently to the discovery of the human immunodeficiency virus (HIV). The first reports of this new syndrome were made in the United States (US) in 1981 in the Morbidity and Mortality Weekly Report from the Centers for Disease Control, and in a preliminary report by Gottlieb et al. describing widely disseminated Kaposi’s sarcoma in young homosexual men.^1,2 In the following months, a number of other reports published in prominent journals described other signs and symptoms associated with severe immuno­deficiency, including many of the now well-recognized cutaneous manifestations of HIV infection.^{3,4,5,6,7,8,9,10,11,12}

As the severity of the disease began to be understood and it became apparent that a worldwide pandemic was underway, our resourcefulness in the face of a new infectious agent was soon to be tested. In the early years following its description, AIDS was universally fatal and there seemed to be no cure in sight. Even after discovery of HIV, the causative agent of AIDS, treatment was primarily supportive and mortality rates continued to be high. While initially hopes for development of more effective therapy and an effective vaccine were high, progress remained slow. Furthermore, biased and negative public perceptions about AIDS and HIV infection as well as lack of political interest delayed much needed research funding. The first antiretroviral medication, azidothymidine (AZT), was approved in 1987, 6 years after the first reports of AIDS. Over the next 10 years, better understanding of the disease, both scientifically and publicly, led to greater funding and accelerated research. Multiple new medications were approved by the Food and Drug Administration (FDA) in the US, and by 1997, regimens known as highly active antiretroviral therapy (HAART) gave new hope of transforming HIV infection from a death sentence to a chronic, manageable disease. With more effective long-term treatment and the ability to prevent or reduce transmission of HIV via early treatment after exposure and prenatal prophylaxis for affected mothers, a more optimistic view has arisen in the fight against HIV. Although development of an effective HIV vaccine remains elusive, worldwide focus on prevention, early diagnosis, and treatment have made significant impacts on the HIV pandemic, especially in developed countries. However, significant challenges remain, especially in developing countries that are often fraught with problems of political unrest, general lack of education regarding HIV/AIDS, and social and cultural stigmata that hinder safe sex practices. Furthermore, side-effects of HAART, many of which are addressed in other chapters in this book, may cause individuals with HIV infection to discontinue taking medications, which can result in a recrudescence of immunodeficiency. Finally, and potentially most disheartening, recent data show that many men who have sex with men have begun practicing unsafe sex with the erroneous idea that they can use HAART as a foolproof way to prevent infection if they are exposed. Thus, it behoves physicians and caretakers to maintain a high degree of vigilance about the possibility of HIV/AIDS in their patients as the virus continues to maintain a high degree of prevalence in many countries, including the US.

Skin diseases are extremely common in HIV-infected individuals and, as noted above, are often the first sign of infection. The correct diagnosis of a cutaneous disease is, therefore, often instrumental in early detection and treatment of HIV infection. Skin diseases continue to be among the most recognizable signs of HIV infection, although the types of dermatologic problems observed in these individuals have changed over the years. HAART-compliant patients have significantly reduced incidence of many skin diseases although they may develop medication-related side-effects which may affect the skin (Chapters 6 and 11). Skin diseases almost exclusively seen in HIV-infected patients such as Kaposi’s sarcoma and eosinophilic folliculitis were seen much more frequently before the advent of HAART (Chapters 9 and 12). While other sexually transmissible diseases (STDs) have been associated with HIV/AIDS since its description, recently, a resurgence of STDs in the HIV-infected population has been observed. As HIV/AIDS changed from a virtually universally fatal illness to a chronic disease following the development of HAART, fear of acquiring HIV infection through unsafe sexual practices has decreased in certain groups as noted above, leading to new epidemics of diseases such as syphilis and gonorrhea (Chapter 13).

The ensuing chapters in this book review the spectrum of dermatologic manifestations associated with HIV/AIDS ranging from infectious and neoplastic conditions considered pathognomonic for HIV/AIDS, to skin diseases seen in the general population but which often present atypically in this group. It is our hope that caregivers will learn to diagnose skin diseases correctly in these individuals and by so doing, especially in early stages, help decrease rates of transmission, improve treatment, and increase the quality of life for these patients.

Chapter 2

Viral Infections in HIV Disease

Wei Su, Cindy Berthelot, and Clay J. Cockerell

Acute HIV Syndrome

DEFINITION/OVERVIEW

Acute HIV infection, also known as acute retroviral syndrome (ARS) and seroconversion illness, is the period from the initial infection with HIV to complete seroconversion. It is often subclinical and asymptomatic, and therefore may escape diagnosis. Symptomatic ARS is a transient illness that is associated with robust HIV replication followed by an expansive immunologic response to the virus.¹ The estimated incidence of symptomatic primary HIV infection ranges from 25% to 75%.^2,3 ARS has been described in all populations at risk for HIV infection: homosexual men, heterosexual men and women, recipients of contaminated blood, recipients of organs from infected donors, and those acquiring HIV from accidental occupational exposure and contaminated body fluids.⁴ Acute HIV infection is a period of extreme infectiousness, and the occurrence and severity of symptoms during ARS may correlate with the severity of clinical decline. It has been shown that early identification and treatment of patients with ARS may preserve immune function. Therefore, timely recognition of the ARS is imperative for patients and for public health as it allows for early initiation of antiviral therapy and prevention of subsequent transmission.

Pathogenesis/pathophysiology

HIV primarily infects CD4+ T-lymphocytes and, soon after primary infection, the virus rapidly concentrates in lymphoid tissue. During primary HIV infection, billions of virions are produced and destroyed each day. CD4+ lymphopenia ensues and T-lymphocyte function is diminished. There is also an expansion of CD8+ T-lymphocytes resulting in a reversal of the CD4:CD8 ratio. Decreased viremia and p24 antigenemia seen during primary infection is thought to be the consequence of the development of cellular and humoral immune responses combined with virus sequestration in lymphoid tissue. The rapid decline in HIV viremia is temporarily correlated with the development of HIV-specific CD8+ cytotoxic T-lymphocyte (CTL) responses. HIV infection is unique among human viral infections in that, despite robust cellular and immune responses that are mounted after primary infection, the virus is not completely cleared from the body. One of the most important reasons for this is thought to be antigenic exhaustion of the HIV-specific CTL responses. Chronic infection develops that persists with varying degrees of virus replication for a median of 10 years before an individual becomes clinically ill. Most adults and adolescents infected with HIV remain symptom free for long periods although viral replication continues to occur at a high pace.

Clinical Features

When primary HIV infection is symptomatic, the clinical manifestation resembles an acute nonspecific viral infection with fever, lethargy, malaise, arthralgias, myalgias, headache, sore throat, night sweats, anorexia, and lymphadenopathy.^5,6 These symptoms, thought to be related to the immune response to HIV, peak at the same time as the viremia and develop days to weeks after the virus has been acquired. Some patients may experience weight loss, retro-orbital pain and/or depression.^7,8 Less common complaints include gastrointestinal problems such as nausea, vomiting, and/or diarrhea, or neurologic symptoms such as headache. The duration of symptoms typically is less than 2 weeks; however, in rare instances it may persist for as long as 10 weeks.⁹

Cutaneous manifestations are seen in up to 75% of symptomatic patients and usually appear several days a...

Table of contents

• Cover
• Title Page
• Copyright Page
• Table of Contents
• Preface
• Contributors
• Abbreviations
• Chapter 1 Introduction
• Chapter 2 Viral Infections in HIV Disease
• Chapter 3 Bacterial and Atypical Mycobacterial Infections
• Chapter 4 Cutaneous Manifestations of Deep Fungal Infections in HIV Disease
• Chapter 5 Cutaneous Manifestations of Parasitic Infections in HIV/AIDS
• Chapter 6 Cutaneous Manifestations of Highly Active Antiretroviral Therapy
• Chapter 7 Papulosquamous Skin Disorders in HIV Infection
• Chapter 8 Non-Neoplastic Disorders of Vasculature in HIV Infection
• Chapter 9 Papulopruritic Skin Disorders
• Chapter 10 Cutaneous Manifestations of Nonantiretroviral Therapy
• Chapter 11 Photosensitive Manifestations of HIV Disease
• Chapter 12 Cutaneous Neoplastic Manifestations of HIV Disease
• Chapter 13 Cutaneous Manifestations of Sexually Transmitted Disease in the HIV-Positive Patient
• Chapter 14 Oral and Ocular Manifestations of HIV Infection
• Chapter 15 Hair and Nail Manifestations of HIV Infection
• References
• Index