Stage One

A 64-year-old woman, married for 32 years, was seen over a three-year period by a general dermatologist for seborrheic eczema which failed to respond to standard therapy.

Treatments included: tar shampoo, ketoconazole shampoo and topical treatment with a combination of corticosteroids and ketoconazole.

Seborrheic dermatitis (Science Photo Library)

Chronic herpetic whitlow (Colm O'Mahony)

Stage Two

She also had a two-month history of chronic ulceration over the index finger which was correctly diagnosed as a herpetic whitlow (PCR-positive for HSV-1).

After each attempt at long term suppression with various doses of aciclovir, valaciclovir and famciclovir, the lesion recurred within a week or two of ceasing each therapy.

Stage Three

At the same time she was seeing her gynaecologist for increasingly troublesome night sweats: These had failed to respond to an increase in the estrogen dose of her hormone replacement therapy.

Unknown to each other, the gynaecologist and dermatologist had also both treated her for frequently recurrent vulvovaginal candidiasis, which had spread to the entire groin area and had become resistant to fluconazole and itraconazole.

Severe vulvovaginal candidiasis and tinea cruris (Peter Greenhouse)

HIV-related pruritic rash (Henry de Vries)

Stage Four

She was eventually referred to an academic dermatology outpatient clinic. A point-of-care HIV antibody test proved positive and HIV infection was later confirmed by laboratory test (immunoblot). The CD4 count was very low at 45 cells/ml3.

She had also recently developed a previously unexplained pruritic rash over the legs, which resolved shortly after starting antiretroviral therapy.

Stage Five

She had only had one sexual partner in 35 years, her husband who was 12 years younger than she was. He was also found to be HIV-positive with no clinical features of HIV infection apart from generalised lymphadenopathy, oral hairy leukoplakia on his tongue and chronic bacterial folliculitis on his buttocks and thigh.

He admitted for the first time that he had regular sexual contacts with multiple male partners. He had started having sex with men via the internet about 15 years previously, but had been unable to tell his wife and children.

Oral hairy leukoplakia (Peter Greenhouse)

Bacterial folliculitis (Henry de Vries)

HIV indicator conditions which should prompt an HIV test

Lessons

1. Seborrheic dematitis is commonly found in people with HIV and low immunity.

2. Herpetic whitlow – or any other herpes lesion – present for over one month strongly suggests HIV infection.

3. Likewise, recurrent vulvovaginal candidiasis is a common condition which worsens with any cause of immunosuppression.

4. Any dermatological condition which fails to improve with a conventional treatment regime MUST raise the possibility of hidden immunosuppression, prompting the need for an HIV test.

 

Continued below…

Lessons (continued)

5. Many men are aware of attraction to other men at an early age but – due to personal circumstances and/or societal constraint – initially follow a conventional heterosexual role model. Since the arrival of the internet, sexual contact between men has become easier to arrange.

6. Smartphone technology has greatly increased the facility for acquiring new anonymous contacts. Since apps were first developed in 2009, rates of syphilis and gonorrhoea in men who have sex with men have increased substantially in countries where these conditions are regularly reported.

7. Better communication between the dermatologist and gynaecologist might have helped in this case, but the sexual history of long-term monogamy blinded them both to the possibility of HIV as the cause of her immunosuppression. Only if HIV tests are routinely offered to women (and men) with conditions refractory to conventional treatment, will such late HIV presentation cases be prevented.

Smartphone apps for sexual contacts and increase in sexually transmitted infections (Peter Greenhouse and Public Health England)