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DR11.1-2 | HIV Dermatology — Assignment
CLINICAL SCENARIO
This written assignment asks you to work through a clinical case of a patient with HIV presenting with new skin lesions and an adverse reaction to antiretroviral therapy. You will integrate knowledge of HIV-associated dermatoses, their pathogenesis, diagnostic reasoning, and the clinical management of ART-related cutaneous reactions.
Instructions
Read the clinical scenario carefully. Answer all four sections in sequence. Your response should demonstrate clinical reasoning, not just recall. Cite the CD4 stratum, name the pathogen/mechanism where relevant, justify management decisions, and flag any uncertainties. Write in clear, structured prose with appropriate medical terminology. Aim for the word guidance given for each section.
Length: Total: 1,100–1,300 words across all four sections.
What to Submit
Mrs P, a 35-year-old HIV-positive woman not on ART, presents with a 6-week history of greasy scaling over the nasolabial folds and scalp, followed 3 weeks later by intensely itchy follicular papules on the trunk, and most recently by a violaceous nodule on the hard palate. Her CD4 count is 95 cells/μL.
(a) For EACH of the three cutaneous findings, state the most likely diagnosis, the causative agent or mechanism, and the approximate CD4 stratum at which each typically appears.
(b) Explain how the CD4 count functions as a 'skin-disease timeline' — what does the sequence of lesions tell you about the trajectory of her immunosuppression?
For the violaceous palatal nodule, two important diagnoses must be distinguished: Kaposi sarcoma and bacillary angiomatosis.
(a) List the clinical and histological features that help differentiate these two conditions.
(b) State the causative agent of each condition.
(c) What two targeted investigations (beyond skin biopsy) would you arrange to complete the diagnostic workup for Mrs P at this CD4 level?
Mrs P is started on a nevirapine-based first-line ART regimen. On day 14 she returns with fever (38.8°C), a maculopapular rash over 20% BSA, facial puffiness, cervical lymphadenopathy, and ALT 2.8× ULN. Blood count shows 12% eosinophils.
(a) Name the syndrome this presentation represents. Justify your diagnosis using the clinical and laboratory features provided.
(b) What is the IMMEDIATE management priority?
(c) Distinguish this syndrome from Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) — how would you recognise SJS/TEN, and how does its management differ?
(a) After recovering from the nevirapine reaction, the treating physician considers switching Mrs P to an abacavir-containing regimen. What pre-prescription step is essential, and why? Name the specific pharmacogenomic test and the clinical syndrome it prevents.
(b) Following ART switch and immune recovery, Mrs P's palatal Kaposi sarcoma lesions paradoxically worsen over the next 3 weeks despite viral load being undetectable. Explain this phenomenon and state whether ART should be continued.
(c) Outline two general principles of managing HIV-associated dermatoses that apply across multiple conditions encountered in this case.
Grading Rubric — HIV Dermatology Assignment Rubric
| Criterion | Points | Full-marks descriptor |
|---|---|---|
| Clinical interpretation and CD4 stratification (Section 1): Accurate diagnosis, causative agent, and CD4 stratum for all three lesions; coherent explanation of disease trajectory | 25 pts | All three diagnoses correct with accurate causative agents and CD4 strata; trajectory explanation demonstrates clear understanding of progressive immunosuppression as a timeline |
| Differential diagnosis: KS vs bacillary angiomatosis (Section 2): Accurate clinical/histological distinction; correct causative agents; appropriate targeted investigations | 20 pts | Correct causative agents (HHV-8 for KS; Bartonella for BA); histological features accurately distinguished (spindle cells/slit-like spaces vs lobular capillary proliferation/neutrophilic infiltrate); two appropriate targeted investigations stated |
| DRESS recognition and management (Section 3a–b): Syndrome correctly named; diagnostic justification uses all key features; immediate management correct | 25 pts | DRESS correctly named and justified using all four key criteria (rash + fever + eosinophilia + hepatitis + lymphadenopathy + delayed onset); immediate management = stop nevirapine permanently + systemic corticosteroids; NEVER rechallenge stated |
| SJS/TEN differentiation (Section 3c): Correct BSA thresholds; distinguishing features accurately described; management differences stated | 15 pts | SJS <10% BSA; TEN >30% BSA; key distinguishing features named (blistering, Nikolsky sign, mucosal erosions absent in DRESS); management differences clear (burns care vs DRESS corticosteroids) |
| Pharmacogenomics, IRIS, and management principles (Section 4): HLA-B*57:01 correctly identified; IRIS correctly explained with correct management; two valid management principles stated | 15 pts | HLA-B*57:01 test correctly named with rationale (abacavir HSR prevention); IRIS correctly explained (immune reconstitution → paradoxical worsening; continue ART); two relevant general principles stated (e.g., ART as cornerstone; treat the pathogen/condition) |
PEER REVIEW
Review your peer's assignment against the rubric criteria. For each of the five criteria, assign a score with a brief written justification (1–3 sentences). Identify: (1) one clinical reasoning strength in their response, and (2) one specific factual or reasoning gap. Your feedback should be specific enough for the author to act upon it — avoid generic praise or vague criticism. Maintain professional, constructive language.