HIV-Related Dermatoses — MCQs
A man presents with a rash on his flank with itching for the past 2 weeks. The patient has tried several over-the-counter medications, including lotrimin and hydrocortisone, without any improvement. In physical examination, the rash is seen on his palms and the sole of one foot, but no oral lesions are found. What is the likely diagnosis?
A 45 year-old HIV-positive male presented with multiple red hemangioma-like lesions. Biopsy specimens show clusters of bacilli that stain positively with the Warthin-Starry stain. Which of the following could be the causative organism?
Which of the following is not considered an opportunistic infection in AIDS?
Itchy, polygonal, violaceous papules are seen in
Perivascular lymphocytes & microglial nodules are seen in -
Which drug regimen is given to a pregnant woman with HIV infection?
Eosinophilic pustular folliculitis is a rare form of folliculitis that is seen with increased frequency in patients with what?
A patient diagnosed to be HIV-positive was started on highly active antiretroviral therapy (HAART). Which of the following can be used to monitor treatment efficacy?
A term infant is born to a known HIV-positive mother. She has been taking antiretroviral medications for the weeks prior to the delivery of her infant. Routine management of the healthy infant should include which of the following?
Best method to diagnose HIV in infancy is:
HIV-Related Dermatoses Indian Medical PG Practice Questions and MCQs
Question 1: A man presents with a rash on his flank with itching for the past 2 weeks. The patient has tried several over-the-counter medications, including lotrimin and hydrocortisone, without any improvement. In physical examination, the rash is seen on his palms and the sole of one foot, but no oral lesions are found. What is the likely diagnosis?
- A. Tinea corporis
- B. Pityriasis rosea
- C. Secondary syphilis (Correct Answer)
- D. Contact dermatitis
Explanation: ***Secondary syphilis*** - The rash presenting on the **palms and soles** is highly characteristic of **secondary syphilis**, which helps differentiate it from many other dermatological conditions. - The lack of improvement with antifungal (Lotrimin) and corticosteroid (hydrocortisone) treatments further supports a diagnosis other than a fungal infection or inflammatory dermatitis. *Tinea corporis* - This fungal infection typically presents as an **annular (ring-shaped) rash** with central clearing and well-demarcated borders, often on the trunk or limbs. - It would likely show some improvement, even if partial, with **Lotrimin (an antifungal medication)**, which is not the case here. *Pityriasis rosea* - This condition is characterized by an initial **"herald patch"** followed by smaller, oval, pinkish-red patches that often align along skin cleavage lines in a **"Christmas tree" pattern** on the trunk. - It typically spares the palms and soles, which are involved in this patient's presentation. *Contact dermatitis* - This is an inflammatory skin reaction due to contact with an allergen or irritant, presenting as **pruritic (itchy) erythematous (red) patches, possibly with vesicles or bullae**, limited to exposed areas. - While hydrocortisone might offer some relief, the presentation on palms and soles without clear exposure and the lack of response to treatment make it less likely.
Question 2: A 45 year-old HIV-positive male presented with multiple red hemangioma-like lesions. Biopsy specimens show clusters of bacilli that stain positively with the Warthin-Starry stain. Which of the following could be the causative organism?
- A. Bartonella quintana
- B. HHV8
- C. Bartonella henselae (Correct Answer)
- D. EBV
Explanation: ***Bartonella henselae*** - This clinical presentation of **red hemangioma-like lesions** (bacillary angiomatosis) in an **HIV-positive** individual, coupled with **Warthin-Starry stain positive bacilli** on biopsy, is highly characteristic of infection with *Bartonella henselae*. - *Bartonella henselae* is associated with **cat scratch disease** and bacillary angiomatosis, particularly in immunocompromised patients. *Bartonella quintana* - While *Bartonella quintana* can also cause **bacillary angiomatosis**, it is classically associated with **trench fever** and **endocarditis** more frequently than *Bartonella henselae*. - The clinical picture of typical "cat-scratch-like" lesions (hemangioma-like) more strongly points to *B. henselae*. *HHV8* - **Human Herpesvirus 8 (HHV8)** is the causative agent of **Kaposi's sarcoma**, which can also present with purple-red skin lesions in HIV-positive patients. - However, Kaposi's sarcoma lesions are typically **spindle cell proliferations** and would not show **clusters of bacilli** on Warthin-Starry stain. *EBV* - **Epstein-Barr Virus (EBV)** is associated with various lymphoproliferative disorders and **oral hairy leukoplakia** in HIV-positive individuals. - It does not cause **bacillary angiomatosis** or present with Warthin-Starry positive bacilli.
Question 3: Which of the following is not considered an opportunistic infection in AIDS?
- A. Candidiasis
- B. Kaposi's sarcoma
- C. Rubella (Correct Answer)
- D. Cytomegalovirus infection
Explanation: ***Rubella*** - Rubella, or **German measles**, is a relatively mild viral infection that typically affects children and is not considered an **opportunistic infection** in immunocompromised individuals like those with AIDS [1]. - While it can cause congenital rubella syndrome in infants whose mothers are infected during pregnancy, it does not disproportionately affect or cause severe disease in AIDS patients due to their compromised immunity [1]. *Candidiasis* - **Oropharyngeal** and **esophageal candidiasis** are common opportunistic infections in AIDS patients, often indicating significant immune suppression [2,3]. - The fungus *Candida albicans* can proliferate unchecked when the **CD4 count** is low [2]. *Kaposi's sarcoma* - This is a **cancer** caused by the **human herpesvirus 8 (HHV-8)**, which is a classic AIDS-defining illness [3]. - Its presence indicates severe immunodeficiency and was a hallmark of the early AIDS epidemic [3]. *Cytomegalovirus infection* - **Cytomegalovirus (CMV)** can cause severe and widespread disease in AIDS patients, including **retinitis**, **colitis**, and **encephalitis** [2]. - It becomes a significant risk when the **CD4 count** drops below 100 cells/mm³ [2].
Question 4: Itchy, polygonal, violaceous papules are seen in
- A. Psoriasis
- B. Pemphigus
- C. Lichen planus (Correct Answer)
- D. Pityriasis rosea
Explanation: ***Lichen planus*** - This condition is clinically characterized by the "6 P's": **pruritic**, **polygonal**, **planar**, **purple**, **papules**, and **plaques**. The description fits perfectly. - Microscopic findings often include a **saw-tooth rete ridge pattern** and a dense lymphocytic infiltrate at the dermoepidermal junction. *Psoriasis* - Characterized by **well-demarcated erythematous plaques** with **silvery scales**, often found on extensor surfaces. - Histologically, it shows **acanthosis** with elongated rete ridges, parakeratosis, and neutrophilic infiltrates (Munro microabscesses). *Pemphigus* - An autoimmune blistering disease characterized by **flaccid bullae** and erosions, often affecting the skin and mucous membranes. - Caused by autoantibodies against **desmogleins**, leading to intraepidermal blistering (acantholysis). *Pityriasis rosea* - Presents with a **herald patch** followed by smaller, oval-shaped, pinkish-red lesions with fine scales, typically in a "Christmas tree" pattern on the trunk. - It is often associated with a preceding viral infection and is generally **self-resolving**.
Question 5: Perivascular lymphocytes & microglial nodules are seen in -
- A. HIV encephalitis (Correct Answer)
- B. CMV meningitis
- C. Bacterial meningitis
- D. Multiple sclerosis
Explanation: ***HIV encephalitis*** - **Perivascular lymphocytes** and **microglial nodules** are the characteristic histopathological hallmarks of **HIV encephalitis (HIV-associated dementia complex)** [1][2]. - Microglial nodules are formed by activated microglia and macrophages, often accompanied by **multinucleated giant cells** (the classic triad) [2]. - These features reflect chronic CNS inflammation and neuronal damage caused by HIV infection. *CMV meningitis* - Cytomegalovirus (CMV) infection in immunocompromised patients causes meningoencephalitis with characteristic **intranuclear ("owl's eye") inclusion bodies** and necrotizing inflammation. - The histological pattern differs from the microglial nodules and perivascular lymphocytes seen in HIV encephalitis. *Bacterial meningitis* - Characterized by prominent **neutrophilic infiltrate** in the subarachnoid space, fibrinopurulent exudate, and potential vasculitis. - Acute bacterial meningitis does not show the lymphocytic and microglial nodular pattern characteristic of viral encephalitis. *Multiple sclerosis* - An autoimmune demyelinating disease with **perivenular demyelinating plaques** containing lymphocytes and macrophages. - While perivascular inflammation occurs, **microglial nodules** are not a characteristic feature; instead, MS shows demyelination with reactive gliosis. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Central Nervous System, p. 1278. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Manifestations Of Central And Peripheral Nervous System Disease, pp. 711-712.
Question 6: Which drug regimen is given to a pregnant woman with HIV infection?
- A. Tenofovir disoproxil fumarate with emtricitabine
- B. Tenofovir disoproxil fumarate with lamivudine
- C. Abacavir with lamivudine
- D. All of the options (Correct Answer)
Explanation: ***All of the options*** - All listed regimens—**Tenofovir disoproxil fumarate (TDF) with emtricitabine (FTC)**, **TDF with lamivudine (3TC)**, and **Abacavir (ABC) with lamivudine (3TC)**—are commonly used and generally safe combinations of **nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs)** in pregnant women with HIV. - The choice of regimen depends on factors such as individual patient characteristics, viral resistance patterns, and potential side effects, but all mentioned regimens are considered **first-line options** in various guidelines for preventing mother-to-child transmission (PMTCT). *Tenofovir disoproxil fumarate with emtricitabine* - This combination is a common and effective **NRTI backbone** for HIV treatment, including in pregnancy, offering good efficacy and a generally favorable safety profile. - It is frequently paired with a third agent (e.g., a **non-nucleoside reverse transcriptase inhibitor (NNRTI)** or an **integrase strand transfer inhibitor (INSTI)**) as part of a highly active antiretroviral therapy (HAART) regimen. *Tenofovir disoproxil fumarate with lamivudine* - This is another widely used and effective **NRTI combination** and is also a recommended backbone for pregnant women with HIV. - While similar to TDF/FTC, some guidelines might prefer one over the other based on specific regional recommendations or drug availability. *Abacavir with lamivudine* - **Abacavir/lamivudine** is a well-established NRTI combination that is safe and effective in pregnancy, provided the mother is **HLA-B*5701 negative** to avoid hypersensitivity reactions. - It is considered a suitable alternative to TDF-containing regimens, especially when there are contraindications or intolerances to TDF.
Question 7: Eosinophilic pustular folliculitis is a rare form of folliculitis that is seen with increased frequency in patients with what?
- A. ABPA
- B. Asthma
- C. Leukemia cutis
- D. HIV infection (Correct Answer)
Explanation: ***HIV infection*** - Eosinophilic pustular folliculitis, also known as **Ofuji's disease**, is a pruritic skin condition commonly seen in patients with **advanced HIV disease**. - Its exact pathogenesis is unknown, but it is thought to be an immune dysregulation phenomenon related to the **CD4 count decline** seen in HIV. - The condition presents as recurrent crops of sterile, pruritic follicular papules and pustules, particularly on the face, trunk, and extremities. *ABPA* - **Allergic bronchopulmonary aspergillosis (ABPA)** is a hypersensitivity reaction to *Aspergillus* species, primarily affecting the lungs. - It is characterized by **eosinophilia**, but it does not cause eosinophilic pustular folliculitis. - ABPA is associated with asthma and cystic fibrosis. *Asthma* - **Asthma** is a chronic inflammatory disease of the airways, characterized by **bronchial hyperresponsiveness** and reversible airflow obstruction. - While asthma can involve eosinophilic inflammation of the airways, it is not directly associated with eosinophilic pustular folliculitis. *Leukemia cutis* - **Leukemia cutis** refers to the infiltration of the skin by leukemic cells, often presenting as nodules, plaques, or papules. - This condition is a direct manifestation of leukemia and is biologically distinct from eosinophilic pustular folliculitis.
Question 8: A patient diagnosed to be HIV-positive was started on highly active antiretroviral therapy (HAART). Which of the following can be used to monitor treatment efficacy?
- A. CD4+ T cell count
- B. Viral load (Correct Answer)
- C. p24 antigen
- D. Viral serotype
Explanation: ***Viral load*** - **Viral load** (HIV RNA copies per milliliter of plasma) is the most direct and sensitive measure of HAART efficacy, as it indicates the amount of actively replicating virus [1]. - A successful HAART regimen aims to reduce the **viral load** to undetectable levels, signaling effective suppression of viral replication [1]. *CD4+ T cell count* - While important for monitoring immune status and disease progression, **CD4+ T cell count** changes more slowly than viral load [1]. - An increase in **CD4+ T cell count** is a positive sign of immune reconstitution but is a lagging indicator of immediate treatment efficacy [1]. *p24 antigen* - **p24 antigen** is a core structural protein of HIV, primarily detectable early in acute infection and in advanced stages when viral replication is very high. - It is generally not used for routine monitoring of HAART efficacy in chronic HIV infection because its levels fluctuate and become undetectable as the immune system produces antibodies. *Viral serotype* - **Viral serotype** refers to the specific strain or subtype of HIV (e.g., HIV-1 vs. HIV-2, or different clades within HIV-1). - It is determined at diagnosis to understand the specific virus but does not change significantly during the course of treatment and is not used to monitor HAART efficacy.
Question 9: A term infant is born to a known HIV-positive mother. She has been taking antiretroviral medications for the weeks prior to the delivery of her infant. Routine management of the healthy infant should include which of the following?
- A. HIV ELISA on the infant to determine if congenital infection has occurred
- B. Admission to the neonatal intensive care unit for close cardiovascular monitoring
- C. Chest radiographs to evaluate for congenital Pneumocystis carinii
- D. A course of zidovudine for the infant (Correct Answer)
Explanation: ***A course of zidovudine for the infant*** - This is the standard of care for newborns exposed to HIV prenatally, even if the mother received **antiretroviral therapy (ART)**. - **Zidovudine (AZT)** prophylaxis significantly reduces the risk of **perinatal HIV transmission**. *HIV ELISA on the infant to determine if congenital infection has occurred* - **HIV ELISA** tests detect **maternal antibodies** passed to the infant, which can persist for up to 18 months, leading to **false positive results**. - **HIV DNA PCR** or **RNA assays** are used to diagnose HIV infection in infants. *Admission to the neonatal intensive care unit for close cardiovascular monitoring* - Admission to the **NICU** is generally reserved for **premature** or **symptomatic infants**, or those with specific complications. - A **healthy, term infant** born to an HIV-positive mother on ART does not routinely require NICU admission. *Chest radiographs to evaluate for congenital Pneumocystis carinii* - **Pneumocystis jirovecii pneumonia (PJP)** typically presents in HIV-infected infants between **3 to 6 months of age**, not at birth. - Prophylaxis with **trimethoprim-sulfamethoxazole (TMP-SMX)** is initiated at 4-6 weeks of age for HIV-exposed infants.
Question 10: Best method to diagnose HIV in infancy is:
- A. PCR (Correct Answer)
- B. All of the options
- C. Western blot
- D. ELISA
Explanation: ***PCR*** - **Polymerase Chain Reaction (PCR)** detects **viral DNA or RNA**, not antibodies, making it the most suitable method for diagnosing HIV in infants. - Infants born to HIV-positive mothers will have **maternal antibodies** (detectable by ELISA or Western blot) regardless of their own infection status, necessitating direct viral detection. *All of the options* - This option is incorrect because **ELISA and Western blot** (antibody-based tests) are not suitable for diagnosing HIV in infancy due to the presence of maternal antibodies. - Only **PCR** can distinguish between maternal antibody transfer and actual infant infection. *Western blot* - **Western blot** detects **HIV antibodies**, which are passively transferred from mother to infant, making it unreliable for diagnosing HIV in infants before 18 months of age. - It is used for **confirmatory testing** in older children and adults but not for initial infant diagnosis. *ELISA* - **ELISA** (Enzyme-Linked Immunosorbent Assay) detects **HIV antibodies**, which can be present in infants due to **maternal transfer**. - A positive ELISA in an infant under 18 months does not confirm HIV infection but indicates exposure to maternal antibodies.
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