Thread by @WuidQ

#IDgrandrounds 30/F, HIV (CD4 25), diffuse (>90% BSA), thick, hyperkeratotic/pigmented plaques w/ extensive flaking x 3 months. No fever/meds.

Peeling similar to this (see picture).

Differentials? @DocWoc71 @CarlosdelRio7 @Cortes_Penfield @SAIRABT @GermHunterMD @CPSolvers

@DocWoc71 @CarlosdelRio7 @Cortes_Penfield @SAIRABT @GermHunterMD @CPSolvers 1/10) #IDgrandrounds Case resolution:

Clinical/path dx: erythrodermic psoriasis @dschless @PACinTX

Patient's rash, most impressive I've ever seen. Dramatic improvement w/ infliximab.

Many thanks to our fellow @NNolanMD who did a fantastic presentation last week. @CPSolvers

2/10) % of psoriasis in people w/ and w/o HIV are similar. But people with HIV develop more severe & atypical forms of psoriasis (erythroderma, guttate, palmoplantar, +arthritis)

Psoriasis can be a presenting symptom of HIV as reported by @doktora_ging

ncbi.nlm.nih.gov/pmc/articles/P…

3/10) Severity of psoriasis in people w/ HIV is directly correlated with HIV immune suppression. Course improves with ART.

Thought to be 2/2 HIV-associated immune dysregulation (CD8 >>> CD4 response in HIV).

4/10) HIV & autoimmunity: unique relationship

Psoriasis, spondyoarthropathy, reactive arth, Sjogren, myopathies --> worsen w/ advanced HIV; improves w/ ART

RA, SLE, sarcoidosis --> maybe dampened by HIV; flares w/ HIV IRIS

ncbi.nlm.nih.gov/pmc/articles/P…

Other pearls @doktora_ging?

5/10) Erythroderma is a specific term for diffuse redness & scaling that covers >90% of body surface area (head to toe). It is a clinical sign & not a diagnosis.

There are many causes of erythroderma, ranging from infectious, inflammatory, to malignant conditions.

6/10) Important DDX to case presented:

**Norwegian/crusted scabies
Described in 1848 among Norwegian leprosy pts by Boeck/Danielssen.

Suspected in pts w/ HIV, HTLV, lymphoma, steroids, those w/ leprosy, Down sx + thick, crusted, fissured plaques. Tx: ivermectin

7/10) Important DDX to case presented:

**Cutaneous T cell lymphoma (Sezary Sx)

Can appear in many forms & mimic a lot of dermatologic conditions. Not so common in HIV (B-cell more common).

Not directly linked w/ HTLV co-infection although can happen: nejm.org/doi/full/10.10…

8/10) Important DDX to case presented:

**Adult T cell leukemia.
Can have widespread skin lesions that mimic Sezary.

This one is linked to HTLV co-infection (esp. in endemic areas: Japan, Caribbean, South America, Africa)

This was covered previously:

https://twitter.com/WuidQ/status/1071225458220515328?s=20

9/10) Other DDX:

**SJS/TEN. The lack of mucosal involvement makes this less likely. Although there are certain HIV meds that may predispose to SJS/TEN, esp nevirapine & abacavir.

10/10) Diffuse rash in a person w/ HIV opens a Pandora's box of DDX!! Ultimately, the approach requires a good H/P, pattern recognition of common/uncommon dx, & invaluable help from our Dermatology colleagues.

Review more here:
National HIV Curriculum hiv.uw.edu/go/basic-prima…