An overview of sexually transmitted diseases. Part III ... - Dermatology

More documents

Recommendations

Info

420 Czelusta, Yen-Moore, and Tyring J AM ACAD DERMATOL SEPTEMBER 2000 Fig 9. HIV-positive patient. Molluscum contagiosum. by the MCV-2 virus than control patients. 187 The presence of MCV-2 in these patients may suggest that HIV-positive patients are manifesting an adult acquired infection because young and healthy patients are more commonly infected with MCV-1. 187 Clinically, molluscum contagiosum in HIV-positive persons appears to be transmitted in both sexual and nonsexual patterns. Lesions in healthy, sexually active adults commonly occur on the lower abdomen, inner thighs, and genitalia. HIV-infected patients may have lesions with this distribution, but lesions on the face and neck are more common (Fig 9). In one study of mostly homosexual HIV-positive men, 14 of 27 patients had lesions on the face and neck, whereas only 7 patients had lesions in locations associated with sexual transmission. 188 Ophthalmologists have described many cases of complicated eyelid mollusca in HIV-infected patients. 189,190 The lesions can become quite large (up to 2 cm) 191 and numerous (numbering up to the hundreds). 192 They are prone to autoinoculation, and in male patients, shaving the beard area has been reported to cause particularly severe infections, with lesions encompassing their entire face. 184,193,194 Certainly, numerous lesions on a patient who is not yet diagnosed with HIV disease should prompt discussion of an HIV test. 195 Atypical molluscum contagiosum is common in HIV patients. Lesions may resemble comedones, abscesses, furuncles, condylomas, syringomas, keratoacanthomas, basal cell carcinomas, ecthyma, a sebaceous nevus of Jadassohn, and a cutaneous horn. 196-201 Importantly, disseminated fungal infections, specifically cryptococcosis, 202,203 Penicillium marneffei infection, and histoplasmosis, 204 are reported to clinically mimic molluscum contagiosum and should be included in the differential diagnosis for these patients. Because of the atypical nature of mollusca in the HIV-positive patient, diagnosis is in large part dependent on biopsy. Studies evaluating the microscopic and ultrastructural (electron microscopic) features of mollusca identified no major differences between samples taken from healthy patients as compared with patients with AIDS. 184,205 One possible exception to this might be that AIDS patients are less likely to have the inflammation and lymphocytic infiltrates associated with mollusca regression in their tissue. Interestingly, Smith et al 206 noted ultrastructural evidence for the presence of viral particles in “immunocompetent” skin adjacent to mollusca in HIV-infected patients. This was thought to help explain the high recurrence rates of lesions after treatment. 206,207 Molluscum contagiosum in HIV-positive patients is notoriously difficult to treat, 208 and unlike otherwise healthy hosts, there is no evidence that lesions spontaneously resolve. Most available evidence regarding the management of molluscum contagiosum in HIV-infected patients is anecdotal. Some potential treatment modalities are listed in Table III. Perhaps the most widely used methods are curettage 209 and cryosurgery. Tretinoin may serve as a helpful adjunct to any locally destructive therapy through daily applications. 192 Although this medicine does appear to diminish the appearance of new lesions and help eliminate old lesions, its use is limited by local irritation. Nonetheless, some researchers have reported success in AIDS patients by using nightly tretinoin as an adjunct to cantharidin (applied for up to 24 hours) on body and facial lesions followed by curettage for recalcitrant lesions. 192 One study using trichloroacetic acid peels yielded an average reduction in molluscum contagiosum lesion counts of 40.5% in 7 HIV-seropositive patients. 210 Intralesional 211 and systemic interferon 212 have been used with minimal to moderate success in treating AIDS patients with mollusca.
J AM ACAD DERMATOL VOLUME 43, NUMBER 3 Imiquimod has been studied in AIDS patients and certainly deserves consideration as a potential therapy. 213 Crude podophyllin extract might be a poor choice in an HIV-infected patient, given the predisposition for the development of cancer in these patients and podophyllin’s link to the mutagens quercetin and kaempherol. 165 Cidofovir is a nucleotide analog that is used most commonly for the treatment of cytomegalovirus retinitis in AIDS patients. 214 Because of its activity against DNA viruses, it may be effective as either an intravenous or topical therapy for recalcitrant mollusca. A recent case report describes resolution of extensive facial lesions in 3 AIDS patients after beginning either intravenous or topical cidofovir therapy. 215 The authors of this report point out that the patients’ improvement most closely correlates with the use of cidofovir, but that it is impossible to exclude the possible immune system–enhancing effects of antiretroviral therapy. At least 3 case reports describe the reduction in number of patients’ extensive mollusca after beginning potent combination antiretroviral treatment. 190,216,217 In one early case, a patient improved after initiation of zidovudine, 190 and in a more recent case, a patient improved after starting ritonavir. 216 This highlights an important point: every attempt should be made to optimize treatment of the HIV infection in patients afflicted with molluscum contagiosum because this will make treatment of the molluscum contagiosum infection more feasible. 218 HUMAN HERPESVIRUS 8 Human herpesvirus 8 (HHV-8), formerly known as Kaposi’s sarcoma–associated herpesvirus, was originally identified in Kaposi’s sarcoma (KS) from AIDS patients. 221 It has been linked with all other forms of KS as well. 222-226 HHV-8 is also associated with a rare type of non-Hodgkin’s lymphoma, termed primary effusion lymphoma, 227,228 and with the plasma cell variant of Castleman’s disease. 229,230 Furthermore, patients with HIV-associated KS are at a significantly greater risk for the development of non-Hodgkin’s lymphoma than their unaffected counterparts. 231-234 Schwartz 235 discussed the major issues relating to KS in a comprehensive review, and a similar discussion would be inappropriate here. Although the biology of HHV-8 is not entirely understood, it appears to be a sexually transmitted infection in the United States and Western Europe. Most cases of AIDS-associated KS have appeared in men who participated in promiscuous homosexual activities or had a history of STDs. 236-244 Furthermore, homosexual men whose partners live in areas of high HHV-8 prevalence, such as San Francisco or New York City, appear to be at an Czelusta, Yen-Moore, and Tyring 421 Table III. Treatment modalities for molluscum contagiosum Surgical Curettage 192,209 Electrodesiccation 192,218 Cryotherapy 219 Laser surgery 220 Cytodestructive Cantharadin 192 Iodine 192,218 Lactic acid 207 Phenol 192,207 Salicylic acid 207 Silver nitrate 192 Tretinoin 192 Trichloroacetic acid 210 Chemotherapeutic/antiviral Cidofovir 215 Interferon 211,212 Imiquimod 213 increased risk of acquiring the virus. Those persons who acquired HIV nonsexually (eg, hemophiliacs or intravenous drug abusers) have much lower rates of KS than those people who contracted HIV from homosexual or bisexual contacts. Many studies have focused on shedding of HHV-8 into semen with variable results. Most studies were unable to detect HHV-8 in either the semen of healthy patients or HIV patients, 245-249 and detection of HHV-8 in the semen of patients with KS proved similarly difficult. However, two controversial studies reported high rates of HHV-8 in the semen of healthy patients. 250,251 Oral secretions in patients with KS appear to consistently shed HHV-8 virions. 252,253 Other suggested, but less investigated methods of transmission, include oral-anal contacts or exposure to feces. 254-256 Further investigation regarding this virus, its transmission, and its relationship to HIV is indicated. KS was originally described in HIV-seronegative persons (ie, classic KS). This form usually presents as purple plaques or papules on the lower extremities of elderly men of Mediterranean and/or Jewish decent. Patients with classic KS may die with this sarcoma but rarely die from it. In HIV-positive persons, however, a much wider variety of lesions (eg, patches, plaques, papules, nodules, ulcers) may appear anywhere on the skin or mucous membranes (Fig 10). Visceral involvement of KS is common in HIVseropositive persons and is associated with significant morbidity and mortality. KS has been much less common in the past 3 years since the availability of highly active antiretroviral therapy (HAART), which
Page 1 and 2: The HIV epidemic has drastically al
Page 3 and 4: J AM ACAD DERMATOL VOLUME 43, NUMBE
Page 11: J AM ACAD DERMATOL VOLUME 43, NUMBE
Page 25 and 26: Directions for questions 1-16: Give

An overview of sexually transmitted diseases. Part III ... - Dermatology

Create successful ePaper yourself

Delete template?

Save as template?