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105: HIV & Things That Make You Itch and Burn

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Varicella Zoster (Chickenpox)

  • Human herpesvirus 3
  • Primary Infection – Chickenpox
  • Incubation period of 10-21 days
  • Infectious from a few days before rash appears until lesions are completely dry
  • Transmitted through droplet or direct contact with lesions
  • Herpes Zoster Shingles – Recurrent Disease – about 15% reactivation

Clinical Presentation

  • Fever
  • Loss of appetite
  • Headache
  • General malaise
  • Rash
    • Papule —> vesicle —> pustule —> crust
    • Dew drop on a rose petal – irregular papule with clear vesicle on top
    • Form in crops of lesions
    • Lasts 7-10 days

Physical exam findings

  • Rash
  • Fever

Diagnosis

  • Primarily clinical
    • Presence of typical characteristic rash and oral sore
    • Prodromal symptoms
  • Tzanck Smear
    • Scraping of an ulcer base to look for Tzanck cells – Large multi nucleated cells
    • Tzanck cells may be found in
      • Herpes simplex
      • Varicella and herpes zoster
      • Pemphigus vulgaris
      • Cytomegalovirus
  • Direct Fluorescent antibody
  • Blood test – to identify a response to acute infection (IgM) or previous infection and subsequent immunity (IgG)

Treatment

  • Acetaminophen
  • Calamine lotion
  • Oral antihistamine
  • Hydration
  • Cool loose fitting clothing
  • Regular bathing
  • Keep nails short and clean especially in young kids
  • Complications include pneumonia, skin infection and CNS involvement
  • Oral antivirals
  • Chickenpox vaccine (live attenuated)
    • Pre-exposure prevention
    • Post exposure and having the vaccine in 3 days will result to being immune to chickenpox or have mild symptoms
  • Immunoglobulins VZIG
    • Can be used in pregnant women, newborns or others who are at high risk for getting chickenpox complications

Varicella Zoster (Shingles)

  • Human herpesvirus 3
  • Shingles
  • Recurrent Disease

Clinical Presentation

  • Burning and itching sensation along one dermatome
  • Several days later a rash appears along the same dermatome
    • Red fluid filled blisters
  • Hyperesthesia – “Even using a sheet to sleep at night hurts”
  • Paresthesia
  • Fever
  • Chills
  • Headache

Physical exam findings

  • Characteristic rash

Diagnosis

  • Clinical diagnosis
  • Direct fluorescent antibody staining of varicella-zoster virus (VZV)
    • infected cells in a scraping of cells from the base of a lesion is rapid, specific, and sensitive, but it is substantially less sensitive than polymerase chain reaction (PCR)
  • Polymerase chain reaction (PCR)
    • Used to detect VZV DNA rapidly and sensitively in properly collected skin lesion specimens
  • Tzanck smears

Treatment

  • Shingles vaccination is recommended for people over age 50
  • Medications
    • Antiviral
      • Acyclovir, Valacyclovir, and Famciclovir
      • Reduce pain and speed recovery
    • Anti-inflammatory
    • Narcotic medications or analgesics
    • Antihistamines
    • Numbing creams, gels, or patches
    • Zostrix cream – helps reduce the risk of postherpetic neuralgia
    • Calamine Lotion
  • Application of cold wet compresses to the rash to reduce pain

Human Papillomavirus

  • The most common sexual transmitted infection
  • Transmission is through direct contact, most commonly sexual contact
  • Low risk types of HPV generally cause warts and do not lead to cancer
  • High risk types of HPV may cause abnormal cell changes and eventually lead to cancer.
    • HPV 16, 18, 31 and 45 are present in 90% of cervical cancer patients
    • HPV 16 and 18 are found in over 70% of cervical cancer cases

Clinical Presentation

  • Common warts & Plantar warts
  • Genital warts (HPV 6 & 11)
    • Flat, cauliflower lesions
    • Women – Most commonly found on the vulva but may be near anus, in the vagina or on the cervix
    • Men – On the Penis, scrotum or near the anus

Labs, Studies and Physical Exam Findings

  • Visible warts
  • Vinegar (acetic acid) solution test
    • A vinegar solution is applied that turns HPV-infected genital areas white which helps in identifying difficult-to-see flat lesions
  • Nucleic acid amplification test for HPV DNA
    • Check for high risk types of HPV that have been linked to genital cancers.
    • Does not change management of the patient
  • Papanicolaou test (Pap)
    • Cervical swab and microscopic examination of the cells looking for abnormalities which may represent cancerous precancerous cells.
    • Recommended every 3-5 years for screening in female patients from age 21

Treatment

  • HPV vaccination is currently recommended for children before they become sexually active.
  • Treating warts
    • Salicylic Acid
    • Freezing with liquid nitrogen (cryotherapy)
    • Electrocautery
    • Laser surgery
    • Scalpel
  • Treating cervical cancer
    • Surgery is generally the first line treatment
      • Ranges from cone biopsy to radical hysterectomy with lymph nodes
    • Chemotherapy and radiation may also be necessary

HIV / AIDS

  • Retrovirus requiring reverse transcriptase
  • HIV primarily affects CD4 lymphocytes causing the destruction of these immune cells
  • Transmitted through direct contact with body fluids including
    • Blood
    • Semen
    • Rectal fluids
    • Vaginal fluids
    • Breast milk
  • Staging of HIV/AIDS
    • Stage 1: Acute Infection
      • High levels of HIV virus and HIV antibodies in the blood
      • May initially have flu or mono like symptoms –
    • Stage 2: Clinical Latency – Minor symptoms
      • Moderate unexplained weight loss – under 10% of measured body weight
      • Recurrent respiratory tract infections – sinusitis, tonsillitis, otitis media, pharyngitis
      • Herpes zoster
      • Angular cheilitis
      • Recurrent oral ulceration
      • Seborrhoeic dermatitis
      • Fungal nail infections
    • Stage 3: HIV disease or AIDs related complex (ARC) – Moderate symptoms
      • Unexplained severe weight loss – over 10% of measured body weight
      • Unexplained chronic diarrhea for longer than one month
      • Unexplained persistent, intermittent fever
      • Persistent oral candidiasis
      • Oral hairy leukoplakia
      • Pulmonary tuberculosis
      • Severe bacterial infections, such as pneumonia, empyema, pyomyositis, bone or joint infection, meningitis, bacteraemia
      • Acute necrotizing ulcerative stomatitis, gingivitis or periodontitis
      • Unexplained anemia below 8, chronic thrombocytopenia 50
    • Stage 4 – AIDS
      • HIV wasting syndrome
      • Pneumocystis pneumonia
      • Recurrent severe bacterial pneumonia
      • Chronic herpes simplex infection – orolabial, genital or anorectal of more than one month’s duration or visceral at any site
      • Esophageal candidiasis
      • Extrapulmonary tuberculosis
      • Kaposi sarcoma
      • Cytomegalovirus infection
      • Central nervous system toxoplasmosis
      • HIV encephalopathy
      • Extrapulmonary cryptococcosis including meningitis
      • Disseminated non-tuberculous mycobacteria infection
      • Progressive multifocal leukoencephalopathy
      • Chronic cryptosporidiosis
      • Chronic isosporiasis
      • Disseminated mycosis
      • Recurrent septicemia
      • Lymphoma (cerebral or B cell non-Hodgkin)
      • Invasive cervical carcinoma
      • Atypical disseminated leishmaniasis
      • Symptomatic HIV-associated nephropathy or HIV-associated cardiomyopathy
  • AIDS is defined as a CD4 count below 200 or any development of an AIDS indicator
    • Severe Candidiasis
    • Extrapulmonary cryptococcosis infection
    • Significant CMV infection
    • Extrapulmonary histoplasmosis
    • Kaposi Sarcoma
    • Pneumocystis jirovecii pneumonia
    • Recurrent pneumonia
    • Toxoplasmosis
    • etc.
  • As the CD4 count drops and viral load increases opportunistic infections and malignancies become increasingly frequent

Clinical Presentation

  • Persistent lymphadenopathy
  • Fever
  • Night sweats
  • Weight loss with significant muscle wasting
  • N/V/D
  • Sore throat
  • and opportunistic infections.

Labs, Studies and Physical Exam Findings

  • 4th-generation antigen/antibody combination immunoassay is recommended
  • Two enzyme-linked immunosorbent assays (ELISA) are performed but may have false positives
  • Western blot is performed to confirm the diagnosis but is prohibitively expensive for an initial test
  • Monitor CD4
  • Monitor viral load with nucleic acid amplification assays

Treatment

  • Prevention
    • Barrier protection for sexual intercourse
    • Screening of blood products
    • Avoid used needles
  • Postexposure prophylaxis with antiretrovirals
    • Begin within 72 hours and continue for at least 4 weeks
    • Needlestick injury from known HIV positive patient has a 0.3% chance of causing disease
  • Antiretroviral Therapy (ART)
    • Nucleoside reverse transcriptase inhibitors (NRTIs)
      • Zidovudine (AZT) and Lamivudine (3TC)
    • Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
      • Efavirenz (Sustiva) and Nevirapine (Viramune).
    • Protease inhibitors (PIs)
      • Atazanavir (Reyataz) and Lopinavir (Kaletra)
    • Integrase inhibitors
      • Dolutegravir (Tivicay) and raltegravir (Isentress).
    • Entry inhibitors
      • Maraviroc (Selzentry) and enfuvirtide (Fuzeon).
  • Aggressively treat opportunistic infections