| Etiology | Clinical features |
|---|---|
| Bacterial infection | |
| Bacillary angiomatosis | Fleshy, friable, protuberant papules-to-nodules that tend to bleed very easily |
| Staphylococcus aureus | Folliculitis, ecthyma, impetigo, bullous impetigo, furuncles, and carbuncles |
| Syphilis | May occur in different forms (primary, secondary, or tertiary); chancre may become painful due to secondary infection |
| Fungal infection | |
| Candidiasis | Mucous membranes (oral, vulvovaginal), less commonly Candida intertrigo or paronychia |
| Cryptococcoses | Most common on the head and neck; typically present as pearly 2- to 5-mm translucent papules that resemble molluscum contagiosum papules; other forms include pustules, purpuric papules, and vegitating plaques |
| Seborrheic dermatitis | Poorly defined, faint pink patches, with mild-to-profuse fine, loose, waxy scales in the hair-bearing areas such as the eyebrows, scalp, chest, and pubic area |
| Arthropod infestations | |
| Scabies | Pruritus with or without rash; generalized but can be limited to a single digit, more severe in Norwegian type |
| Viral infection | |
| Herpes simplex | Painful vesicular lesion in clusters; perianal, genital, orofacial, or digital; can be disseminated |
| Herpes zoster | Painful dermatomal vesicles that may ulcerate or disseminate (polydermatomal) |
| HIV | Discrete erythematous macules and papules on the upper trunk, palms, and soles are the most characteristic cutaneous finding of acute HIV infection |
| Human papilloma virus | Genital warts (may become unusually extensive) |
| Kaposi’s sarcoma (herpesvirus) | Erythematous macule or papule, enlarge at varying rates, violaceous nodules or plaques, occasionally painful |
| Molluscum contagiosum | Discrete umbilicated papules commonly on the face, neck, and intertriginous site (axilla, groin, or buttocks) |
| Noninfectious | |
| Drug reactions | Mild rash to Stevens–Johnson syndrome |
| Nutritional deficiencies | Mainly seen in children and patients with chronic diarrhea; diffuse skin manifestations, depending on the deficiency |
| Psoriasis | Scaly lesions; diffuse or localized; can be associated with arthritis |
| Vasculitis | Palpable purpuric eruption (can resemble septic emboli) |
Abbreviation: HIV = human immunodeficiency virus.
Lymph nodes
Nonspecific small, symmetric, mobile nodes are commonly seen in patients with HIV infection; these often reflect nonspecific reactive hyperplasia. Acute generalized lymphadenopathy can be seen during seroconversion. Non-Hodgkin’s lymphoma (NHL) and infectious pathogens can present as single or multiple nodes. At each visit lymph node groups should be assessed for size, quantity, texture, and tenderness. Biopsy is usually not indicated and is not helpful, unless the etiology is unclear, the nodes are rapidly enlarging, and/or they are associated with fever and weight loss.
Head, eyes, ear, nose, and throat
Candida and herpes simplex virus often cause painful cheilitis, stomatitis, or pharyngitis and can manifest at any stage of HIV infection. Candida (oral thrush), cytomegalovirus (CMV) (oral ulcers), Epstein–Barr virus (EBV) (oral hairy leukoplakia), varicella-zoster virus, mycobacterial infection, Cryptococcus neoformans, Histoplasma capsulatum, Kaposi’s sarcoma, squamous cell carcinoma, and NHL may be visible on oral examination, and idiopathic aphthous ulcers are a significant cause of troublesome oral pain. Toothache and dental tenderness may indicate periodontal disease or abscess and may cause both fever and headache. Gingival and periodontal infection are particularly aggressive in patients with HIV infection.
Facial pain, nasal obstruction, postnasal drip, and headache can be caused by sinusitis, which occurs frequently in HIV infection. Atopy may coexist.
Blurred vision, scotoma, floaters and/or decreased visual acuity may suggest CMV retinitis or other opportunistic infectious retinochoroiditis. Complete eye examinations at baseline and when retinitis is a consideration are essential, especially in hosts with CD4 cell count below 50/mm3. This is especially important if ART is not successful and/or patients are noncompliant with ART.
Headache of new onset or changing character may be an early manifestation of a central nervous system opportunistic process.
Cardiopulmonary
Precise baseline pulmonary and cardiovascular examinations are important because of increasing pulmonary and cardiac complications in advancing HIV disease. Shortness of breath at rest or with exertion, its duration and progression, whether a cough is dry or productive, sputum color, amount, and odor may help with the differential diagnosis. Hemoptysis can be caused by tuberculosis, thrombocytopenia, bacterial pneumonia, or other lung pathology. Chest pain can be caused by pneumonia, spontaneous pneumothorax (often Pneumocystis-related), pericarditis, herpes zoster, or HIV-related cardiomyopathy. Palpitations and postural hypotension may suggest symptomatic anemia.
Gastrointestinal
Gastrointestinal diseases are increasingly frequent as HIV disease progresses. Odynophagia, dysphagia, retrosternal chest pain, nausea, anorexia, and weight loss are commonly associated with esophagitis due to Candida, herpes simplex, CMV, or more rarely, lymphoma. Hepatic or splenic enlargement may be an early manifestation of HIV-related complications and baseline size should be accurately quantified and documented.
Right upper quadrant pain associated with fever and elevated liver enzymes may indicate viral or drug-induced hepatitis, cholelithiasis, or acalculous cholecystitis related to Mycobacterium avium complex (MAC), cryptosporidiosis, microsporidia, or CMV.
Epigastric or left upper quadrant pain may indicate drug-induced pancreatitis. Abdominal distension, tenderness, masses, constipation, or fecal incontinence may be caused by Kaposi’s sarcoma, lymphoma, carcinoma, gastrointestinal opportunistic infections (CMV, histoplasmosis, tuberculosis), or parasitic infestation. Diarrhea occurs in 30% to 66% of adults with HIV. Salmonella, Cryptosporidium, Isospora, CMV, microsporidia, and other enteric pathogens commonly occur. Constipation is commonly seen in patients taking methadone, heroin, or opioids, as well as other medicines. Antibiotic use predisposes patients to Clostridium difficile infection.
Painful defecation or rectal pain can be caused by trauma, perirectal abscess, herpes, squamous cell carcinoma, or other sexually transmitted diseases (e.g., lymphogranuloma venereum, LGV), all of which are increased in persons having anal intercourse. Careful sexual and social histories may help identify pathogens. Perirectal areas should be carefully examined for lesions, abscess, fissures, proctitis, and ulcerations. Stools should be tested for occult blood.
Genitourinary, obstetric, and gynecologic manifestations
Painful, frequent urination may indicate urinary tract infection, sexually transmitted disease, or vulvovaginitis. The latter are more common and possibly more difficult to treat in HIV infection. Recurrent or severe vaginitis, vaginal discharge, and pruritus are common and may not be related solely to sexual practices. Prompt evaluation of all genital discharges, ulcers, and lesions will allow correct identification of any sexually transmitted disease.
Women should be queried regarding menstrual history, fertility, method of birth control, and numbers and dates of pregnancies and abortions. Menstruation may become irregular in worsening HIV infection, and fertility declines as well. Prior tubal scarring from salpingitis or pelvic inflammatory disease predisposes to ectopic pregnancy and infertility. An external genital, rectal, and complete pelvic examination (speculum and bimanual), including Pap tests and appropriate cultures and stains, should be performed initially and at least annually if exams are normal.
Neurologic
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