AIDS OVERVIEW

DEFINITION

Acquired Immunodeficiency Syndrome (AIDS) is a group of symtomps due to deficiency of immune system which is cause by Human immunodeficiency syndrome.

HIV infection is mainly via three ways which involve body fluid:

1. Sexual transmision
2. Blood or blood products transmission, for example in organ transplantation
3. Transplacental transmission: the fetus is infected by HIV and by perinatal infection.

CLINICAL SIGNS AND SYMTOMS

Almost every patient who is infected by HIV will progress to symptoms related to HIV and AIDS when they are not  adequately treated

Constitutional Symptoms

This group is commonly known as AIDS related complex. The Patient experiences at least two symptoms which last for three months or more. The symptoms are:

1. Constant fever of 37⁰C or more
2. Weight Loss 0f 10% or more
3. Inflammation of lymph nodes (two or more extra inguinal nodes)
4. Diarrhea of unknown origin                              
5. Excessive sweating at night

 Neurological Symptoms

This stadium gives various neurological symptoms like muscle weakness, dysphasia, balance disorder, disorientaton, hallucination, dementia, psychosis and even coma (sign of cerebral inflammation)

Infection symptoms

Opportunistic infection is a condition whereby immunity is very weak which leads to incapability to fight infection :

1. Pneumocystic carinii pneumonia (PCP)
2. Tuberculosis
3. Toxoplasmosis
4. Mucocutaneus infection

Tumor symptoms

Tumor commonly found in AIDS patients; Kaposi sarcoma and Non-Hodgkin lymphoma maligna.

DIAGNOSIS

WHO has announced the criteria for diagnosis if there is no serology or HIV antigen examination

Adults. AIDS is suspected if there are at least two major symptoms and one minor symptoms and no other immunosupression factors are present, such as cancer, severe malnutrition or others.

Major symptoms:

• Weight loss of more than 10% of the initial body weight
• Chronic diarrhea more than one month
• Fever more than one month

Minor symptoms :

• Cough more than one month
• Pruritus dermatitis
• Recurrent common infection (e.g herpes zoster)
• Oropharingeal candidiasis
• Progressive chronic herpes simplex infection
• Lymphadenopathy generalisata

Presence of kaposi sarcoma or cryptococcal meningitis are sufficient to establish diagnosis of AIDS.

Children

AIDS is established if there are two major symptoms and two minor symptoms and no other immunosupression factors are present, such as cancer, severe malnutrition or others.

Major symptoms:

1. Weight loss or abnormal growth
2. Chronic diarrhea more than one month
3. Fever more than one month

Minor symptoms

1. Lymphadenopathy generalisata
2. Oropharyngeal candidiasis
3. Cough more than one month
4. Pruritus dermatitis
5. Reccurent common infection (e.g herpes zoster)
6. Confirmation of HIV in the mother is considered as minor symtoms.

In areas whereby laboratory examination is already available, diagnosis is establised based on the examination to serum or other body fluid (e.g serebrospinal fluid) with three principles of ELISA. Currently, there are tree methods of ELISA, they are:

• Indirect ELISA
• Competitive ELISA
• “sandwich” ELISA or agglutination.

The HIV antigen used for this examination is prepared from cloning or synthesis of viral polypeptide. False-negative result is very rare. False-negative can be found if antibody titer is not detected during window period whereby the titer is actually detected after 4-12 weeks after infection. False-negative can aso be found in patients with low immunity. Serology test for anti HIV can also be carried out withWestern Blot to detect specific antibodies to HIV antigen. Laboratory examination for children under 18 months-old is better to use virology test (p24, PCR DNA or RNA) since anti HIV is not yet detected. Children above 18 months-old can use ELISA with three methods but they have to be free from breastfeeding for at least 6 weeks.

Treatment Of Urticaria

Differential Diagnosis

Hebra's erythema multiforme: Systemic fever, malaise, and mouth lesions are noted in children and young adults (see the next section of this chapter).

Dermographism: A common finding in young adults, especially those who present complaining of welts on their skin or vague itching of the skin with no residual lesions. To make the diagnosis, stroke the skin firmly to see if an urticarial response develops. The course can be chronic, but hydroxyzine, 10 mg b.i.d. or t.i.d., is quite helpful. (Warn the patient about the possibility of drowsiness.)

Urticarial vasculitis: Lesions may last more than 24 hours, be painful, leave a bruise, and be associated with hypocomplementemia.

1.Antihistamine H1

Diphenhidramine HCl i.m

                Adult     : 10-20 mg/dose, 3-4 times/24 hours

                Children: 0,5 mg/kg/dose, 3-4 times/24 hours

Chlorphenyramine maleat

                Adults   : 3-4 mg/dose, 3-4 times/24 hours

                Children: 0,09 mg/kg/dose, 3-4 times/24 hours

Hydroxyzin HCl

                Adults   : 25 mg/dose, 3-4 times/24 hours

                Children: 0,5 g/kg/dose, 3-4 times/24 hours

I becomes the best option for chronic urticaria, dermatographic urticaria, and cholinergic urticaria. It has an anti stress effect and could be combined with other antihistamine H1.

Cryptoheptadine HCl

                Adults   : 4 mg/dose, 3-4 times/24 hours

                Effective for cold urticaria

Loratadine 10 mg/dose, once a day

Cetirizine 10 mg/dose, once a day

2.Combination Antihistamine H1 and Antihistamine H2

 (Cimetidine ablet 200-400 mg, 2-4 times/day or 1 X 800 mg at nght sleep)

This therapy is for dermographisme urticaria, cold urticaria, and chronic urticaria.

3. Corticoseroid

Used for acute and severe urticaria

Due to type III reaction

Prednisone

                Adults : 5-10 g/dose, 3 times/24 hours.

                Children : 1 mg/kg body weight/day

Dexamethasone

                Adults   : 0,5-1 mg/dose, 3 times/2 hours.

                Children : 0,1 mg/kg body weight/day

                Use combination with antihistamine for 2 weeks, usually it will not relapse

4. Adrenaline subcutaneous injection for acute, intense, and wide urticaria

 (angioedemea + dyspnoea, thick urticaria on all part of the body)

                Adults   : 0,3-0,5 ml/time, could be repeated 15-30 minutes after

                Children: 0,1-0,3 ml/time (body weight < 35 kg)

5. Ephedrine ablet

                Adults   : 2 x 0,5 tablet, minmal use for 3 days

                Children: 0,2-0,3 mg/kg body weight/time, 2-3 times/dy

                Substitution for adrenaline injection

Herpes Zoster Overview

Herpes Zoster is a localized disease caused by varicella-zoster virus, mainly found in adult, characterized by radicular, unilateral pain and groups of vesicles distributed according to the dermatome innervated by one sensory nerve ganglion.

ETIOLOGY. Zoster is caused by the same virus that causes chickenpox. Trauma of the nerve root is believed to play a role in development of some cases of shingles. “Nervousness” plays little if any role.

Shingles is a common viral disease characterized by the appearance of several groups of vesicles distributed along a cutaneous nerve segment. Zoster and chickenpox are caused by the same virus. Susceptible children or rarely adults who are exposed to cases of zoster may develop chickenpox.

PRIMARY LESIONS. Multiple groups of vesicles or crusted lesions appear.

SECONDARY LESIONS. Bacterial infection with pustules occurs, rarely progressing to hemorrhagic gangrenous ulcers and scarring.

DISTRIBUTION. Unilateral eruption follows a nerve distribution, frequently in the thoracic region, the face, the neck, and, less frequently, the lumbosacral area and elsewhere. Eye involvement can be serious. Bilateral involvement of the body is rare but not fatal, contrary to the old wives' tale, and still predominates on one side of the body.

Clinical Symptoms

1. Prodormal Stadium. Itches and pain over the infected dermatome accompanied by fever, malaise, and headache.
2. Eruption Stadium. At first, papules or plakat in the form of urticaria will appear. After 1-2 days, groups of vesicles will appear over erythematous skin whereby the skin in between the groups remains normal. The stages of the lesions within a group ae the same whereas those of between groups are different. The location of the lesions follows the dermatome and unilateral. The lesions usually do not cross over the contralateral side.
3. Crustation stadium/ Vesicles become purulent and undergo crustation which then detach from the skin in 1-2 weeks. Post-herpetic neuralgia is common especially in elderly , which causes temporary paresthesia lasting for months.

SUBJECTIVE COMPLAINTS. Pain of a neuritic type can precede the eruption and, if in the abdominal area, can lead to erroneous diagnoses and surgical procedures. The common simple pain of young persons with shingles is readily treated and soon disappears. On the other hand, the severe, true post-herpetic pain of older patients can be very serious. To evaluate critically the therapeutic response to the many agents said to relieve this severe pain, a nerve-distribution pain should not be labeled as the true post-herpetic type unless it has been present for over 30 days. If this strict criterion is adhered to, many newly proclaimed treatments for such pain are found to be of limited value, but usage is common considering their low risk of side effects. For the best results use early in the course of disease.

LABORATORY FINDINGS. A cytodiagnostic test (Tzanck test) is positive for multinucleated giant cells. A culture or a polymerase chain reaction can be done.

Differential Diagnosis

1.     Dermatitis contacta allergica
2.       Varicella
3.       Herpes Simplex
4.       Disease with bulla, e.g pemphigus vulgaris
5.       Duhring’s herpetiformis dermatitis
6.       Bullous pemphigoid.

Complications
1.       Secondary infections
2.       Post-herpetic neuralgia
3.       Kerato-conjunctivitis in ophtalmic herpes zoster
4.       Ramsay-Hunt Syndrome
5.       Zoster Generalisata: zoster accompanied by varicella.

Clinical Aspects Of Urticaria

A urticaria or hives or wheal is an erythematous or white, nonpitting, edematous plaque that changes in size and shape by peripheral extension or regression during the few hours or days that the individual lesion exists. The evolution of urticaria is a dynamic process. New lesions evolve as old ones resolve. Hives result from localized capillary vasodilation, followed by transudation of protein-rich fluid into the surrounding tissue; they resolve when the fluid is slowly reabsorbed.

Clinical manifestation

In common, all allergy shows urticaria, an elevated local oedema on skin, red/white decolourisation, vary on size. Lesions vary in size from the 2 to 4 mm edematous papules of cholinergic urticaria to giant hives, a single lesion of which may cover an extremity. They may be round or oval; when confluent, they become polycyclic. A portion of the border either may not form or may be reabsorbed, giving the appearance of incomplete rings. Hives may be uniformly red or white, or the edematous border may be red and the remainder of the surface white. This variation in color is usually present in superficial hives. Thicker plaques have a uniform color.

Hives may be surrounded by a clear or red halo. Thicker plaques that result from massive transudation of fluid into the dermis and subcutaneous tissue are referred to as angioedema. These thick, firm plaques, like typical hives, may occur on any skin surface, but typically involve the lips, larynx (causing hoarseness or a sore throat), and mucosa of the gastrointestinal (GI) tract (causing abdominal pain) . Bullae or purpura may appear in areas of intense swelling. Purpura and scaling may result as the lesions of urticarial vasculitis clear. Hives usually have a haphazard distribution, but those elicited by physical stimuli have characteristic features and distribution.

Symptoms.

Hives itch. The intensity varies, and some patients with a widespread eruption may experience little itching. Pruritus is milder in deep hives (angioedema) because the edema occurs in areas where there are fewer sensory nerve endings than there are near the surface of the skin.

Diagnosis Technique

Detailed anamnesis

Angioedema (giant Urticaria,quinke’s oedema) if the urticaria is in imense size, followed by depper oedema until subcutaneous layer on palpebra,genetalia and lips for instance.Cholinergic urticaria if the urticaria is in small size,diffused, and very itchy.Dermographic urticaria (Physical urticaria) if the urticaria emerges due to a linear pressure matched with the part of the pressure/scratch. Dermographisme test is positive (it emerges when the skin is scratched). Old Urticaria emerges in minutes or hours after being exposed to cold air/water.it could be mild/local until severe (followed by hypotension, loss of consciousness, and dyspnoea).Solar urticaria emerges after being exposed to sunrays.Allergic urticaria, if it is caused by allergic to food or drugs Idiopathic urticaria, if the cause is unknown. Chronic urticaria, if urticaria constantly emerges everday for 6 weeks. 

Accurate physical examination of the urticaria and accopanied general/systeic disease.

Physical urticaria suspicion is examined with dermographism test,physical test (exercise)

c.       Laboratory examination/Supporting examination

Blood,urine and faeces examination to check a hidden infection. Tooth,ear,nose,throat,lungs and aginal examination to seek infection factor.If necessary, advanc allergy examination, could be done such as IgE, amount of eosinofil, complment proportion, and skin sratch/needle stick test.Cold urticaria suspicion is examinedwith ice tube test, cryogloblin, and cold heolysin

Urticaria Overview

Urticaria is one of vascular Dermatoses. Many People have suffered urticaria caused by allergy reaction.  Urticaria is a vascular reaction dne by erytheatous skin or whitish skin due to local intercellular which is limited to skin or mucosa only. The commonly seen entity of urticaria, or hives, can be acute or chronic and due to known or unknown causes..

Numerous factors, both immunologic and nonimmunologic, can be involved in its pathogenesis. Nonimmunologic factors that can release histamine from these cells include chemicals, various drugs (including morphine and codeine), ingestion of lobster, crayfish, and other foods, bacterial toxins, and physical agents. Examples of the type caused by physical agents are the linear wheals that are produced by light stroking of the skin, known as dermographism.

Immunologic mechanisms are probably involved more often in acute than in chronic urticaria. The most commonly considered of these mechanisms is the type I hypersensitivity state that is triggered by polyvalent antigen bridging two specific immunoglobulin E molecules that are bound to the mast cell or basophil surface.

CAUSES. After careful questioning and investigation, many cases of hives, particularly of the chronic type, are concluded to result from no apparent causative agent. Other cases, mainly the acute ones, have been found to result from the following factors or agents:

1. Drugs or Chemicals. Penicillin and derivatives are probably the most common causes of acute hives, but any other drug, whether ingested, injected, inhaled, or, rarely, applied on the skin, can cause the reaction
2. Foods. Foods are a common cause of acute hives. The main offenders are seafood, strawberries, chocolate, nuts, cheeses, pork, eggs, wheat, and milk. Chronic hives can be caused by traces of penicillin in milk products.
3. Insect Bites and Stings. Insect bites, stings from mosquitoes, fleas, or spiders, and contact with certain moths, leeches, and jellyfish cause hives.
4. Physical Agents. Hives result from heat, cold, radiant energy, and physical injury. Dermo-graphism is a term applied to a localized urticarial wheal produced by scratching the skin in certain people. Dermographism is commonly overlooked as a cause of the patient's “welts” or vague itching.
5. Inhalants. Nasal sprays, insect sprays, dust, feathers, pollens, and animal danders are some offenders.
6. Infections. A focus of infection is always considered, sooner or later, in chronic cases of hives, and in unusual instances it is causative. The sinuses, the teeth, the tonsils, the gallbladder, and the genitourinary tract should be checked.
7. Internal disease. Urticaria has been seen with liver disease, intestinal parasites, cancer, rheumatic fever, and others.
8. “Nerves.” After all other causes of chronic urticaria have been ruled out, there remain a substantial number of cases that appear to be related to nervous stress, worry, or fatigue. These cases benefit most from the establishment of good rapport between the patient and the physician.
9. Contact Urticaria Syndrome. This uncommon response can be incited from the local contact on the skin of drugs and chemicals, foods, insects, animal dander, and plants.
10. Cholinergic Urticaria. Clinically, small papular welts are seen that are caused by heat (hot bath), stress, or strenuous exercise.

Patients with chronic urticaria present a major problem in diagnosis and management. These patients are often subjected to detailed and expensive medical evaluations that usually prove unrewarding. Recent studies have demonstrated the value of a complete history and physical examination followed by the judicious use of laboratory studies in evaluating the results of the history and physical examination.