Kaposi’s sarcoma

Kaposi’s sarcoma is an AIDS-defining condition and is strongly indicative of HIV infection. It has a predilection for the roof of the mouth as well as the skin. It can be difficult to identify on dark skin. HIV testing should be strongly recommended and referral to an HIV specialist is advised. Urgent hospital admission may be required.

Kaposi's sarcoma on dark skin (Henry de Vries)

Widespread Kaposi's sarcoma on the back (Henry de Vries)

Widespread Kaposi's sarcoma on the trunk (Henry de Vries)

Chronic herpes in a severely immunocompromised patient (Henry de Vries)

Herpetic whitlow (Colm O'Mahony)

Herpes simplex (HSV)

Herpes simplex is one of a number of viral infections which are more common in people with HIV. When ulcers are chronic (for over a month), or are found in an area other than the skin and mucosal tissue, the condition is AIDS-defining. Always offer an HIV test when ulcers in any part of the body are persistent, extensive or do not respond to antiviral therapy. Anogenital HSV is an STI and should also always prompt the offer of an HIV test.

Other AIDS-defining conditions

Other conditions which are AIDS-defining but more rarely seen in Europe are:

  • Atypical disseminated leishmaniasis
  • Disseminated penicilliosis
  • Disseminated histoplasmosis

Always offer an HIV test to patients presenting with one of these conditions.

Disseminated histoplasmosis (Henry de Vries)

Maculopapular rash of primary HIV infection (Henry de Vries)

Rash of primary HIV infection on distal limb (Henry de Vries)

Maculopapular rash of primary HIV infection (Henry de Vries)

Maculopapular rash of primary HIV infection (Henry de Vries)

Infectious mononucleosis-like syndrome

A few weeks after initial infection with HIV, most people experience a flu-like seroconversion illness (also known as primary HIV infection or acute HIV infection), when the body is developing antibodies to the infection. This illness very closely resembles infectious mononucleosis. Symptoms most specific to HIV can include a maculopapular rash on the trunk as well as oral, genital or perianal ulcers. Other possible symptoms include fever, sore throat, malaise/lethargy, arthralgia and myalgia, headache, neck stiffness, meningism, generalised lymphadenopathy, and oral, genital or perianal ulcers.

Diagnosing HIV at the time of seroconversion has particular value as it enables the patient to start treatment when they have the best prognosis. It can also prevent further HIV transmission at a stage when they are highly infectious. If not detected at this stage, HIV may stay hidden for a long period while the patient’s immunity gradually declines and the risk of transmission continues.

Recent studies 18 19 have shown an HIV prevalence between 1% and 5% in patients presenting with infectious mononucleosis-like symptoms. The presentation of the two conditions is often clinically indistinguishable. Whenever a maculopapular rash is accompanied by possible symptoms of infectious mononucleosis, you should offer an HIV test in addition to testing for syphilis. Important: An HIV test that detects only antibodies may give a false negative result at seroconversion. See Types of HIV test for more details.

Sexually transmitted infections (STIs)

Both HIV and STIs are transmitted through unprotected sexual intercourse, and people who have an STI are more likely than the general population also to have HIV. An HIV prevalence of 4% has been found in patients diagnosed with an STI. 20 The presence of an STI can increase the HIV viral load in patients who are co-infected, promoting the progression of their HIV disease and increasing the risk of HIV transmission. In addition, HIV-negative people with an STI, especially where there is ulceration or inflammation, are more likely than those without an STI to acquire HIV through sex with an HIV-positive person.

In patients with undiagnosed HIV, STIs may be more persistent or severe. Even a common condition such as genital warts, if difficult to treat, can indicate impaired immunity and underlying HIV infection.

The presence of any STI should prompt the offer of an HIV test, but this is especially the case for STIs which are more common among groups at particular risk for HIV, notably hepatitis C, syphilis, gonorrhoea and lymphogranuloma venereum, and for infections which are recalcitrant or have unusual presentations. Routine HIV testing is also recommended in European guidelines for all patients attending sexually transmitted infection (STI) clinics. 21

Bowenoid papulosis of the anus - HPV16-related (Henry de Vries)

Chronic herpes infection hypertrophied lesion (Henry de Vries)

Condylomata lata in secondary syphilis. Multiple fleshy lesions perianally in HIV-positive patient (Angela Robinson)

Condylomata on mid-line of tongue (Henry de Vries)

Confluent ulceration due to herpes in an HIV-positive patient (Henry de Vries)

Faint macular rash in patient with secondary syphilis (Peter Kohl)

Papular lesions on the mouth - HPV-related (Henry de Vries)

Primary herpes episode in an HIV-positive woman (Angela Robinson)

Primary herpes simplex on the penis (Angela Robinson)

Rash of secondary syphilis - papular (Henry de Vries)

Rash of secondary syphilis on scrotum - annular configuration (Henry de Vries)

Syphilitic balanitis (Henry de Vries)

Herpes zoster on an HIV-positive patient (Angela Robinson)

Multidermatomal herpes zoster (Colm O'Mahony)

Zoster infection (shingles) involving multiple dermatomes (Henry de Vries)

Herpes zoster

A diagnosis of herpes zoster usually means that the patient’s immunity is low, which may be due to HIV. An HIV prevalence rate of almost 3% has been found in patients with herpes zoster who are under 65 years of age. 22 Herpes zoster may be the first manifestation of HIV and it is often more severe when undiagnosed HIV is present. Multidermatomal herpes zoster is always highly suggestive of HIV. HIV increases the risk of complications from herpes zoster.

Cervical and anal dysplasia or cancer

Cervical cancer is AIDS-defining and an HIV prevalence of 1% has been found in patients with cervical or anal dysplasia or cancer. European guidance strongly recommends offering an HIV test to these patients. If individuals presenting to dermatovenereologists are found to have one of these conditions, an HIV test should be offered.

Anal intraepithelial neoplasia (Henry de Vries)

Vulval intraepithelial neoplasia (VIN3) - HPV-related in an immunosuppressed patient (Angela Robinson)

Atrophic candida oralis in HIV (Henry de Vries)

Candidiasis oralis in HIV (Henry de Vries)

Mycosis (Henry de Vries)

Candidiasis and persistent fungal infections

Candida infections can be a sign of an immune system weakened by HIV and European guidance recommends offering an HIV test to patients presenting with candidiasis. Although vaginal candida is also common in women who do not have HIV infection, you should consider making a routine offer of HIV testing to women with this condition if sexual history-taking is not part of your normal practice.

When to test for HIV / Part 2

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