Stage One

A 35 year old man consulted a dermatologist for facial warts around the eyes. He had a few 2-3 mm umbilicated papules in the left periorbital region.

With a diagnosis of molluscum contagiosum, the lesions were treated with liquid nitrogen.

The outcome was satisfactory.

Facial Molluscum Contagiosum

Facial Verruca Vulgaris (Henry de Vries)

Stage Two

A year later he saw his dermatologist again, this time for papules at the corners of his mouth. He had 2-4 mm long filliform and verrucous papules, partly eroded due to shaving trauma.

A diagnosis of verruca vulgaris was made and the lesions were again treated with liquid nitrogen.

The outcome was satisfactory.

At no point in the consultation was he asked about his sexual history.

Stage Three

Two years later the man visited the venereology clinic with complaints of itchy perianal papules and a recurrent buttock rash.

The history revealed multiple male sexual partners since age 22, a few episodes of urethritis and recurrences of sacral blistering lesions with localised parasthesiae 2-3 times a year, which had increased in frequency and severity over the last 6 months. Genital herpes (HSV2) was diagnosed at a subsequent recurrence.

Atypical Sacral Herpes (Peter Greenhouse)

Florid perianal warts (Peter Greenhouse)

Stage Four

Additionally, florid verrucous papules were seen perianally and in the penile sulcus. Anogenital warts were diagnosed.

An immediate point of care HIV test was positive for HIV antibodies, confirmed with a laboratory test (Western blot).

The patient was referred to the HIV treatment specialist – ‘his CD4 count was 130 cells/ml3. Antiretroviral treatment was immediately started.

Lessons

  1. Several indicator conditions were missed that could have led to an earlier HIV diagnosis. Molluscum contagiosum and verrucae on the face are classic indicators of low immunity in HIV (and other causes of immunosuppression), as are florid anogenital warts and the atypical presentation of genital herpes shown here.
  2. If you consider that HIV may enter the differential diagnosis, you should offer an HIV test.
  3. You may wish to consider the benefits of having point of care HIV tests in your dermatology practice.
  4. A simply taken sexual history would have given clues to the HIV diagnosis at the first visit.

Indicator conditions which could have led to an earlier HIV diagnosis