More about... HIV-related surgery

Vascular disease in HIV/AIDS The Pavia consensus statement3 brought the Henoch-Schönlein purpura, drug-related RG BOTHA, MB ChB, DA (SA), following important aspects to attention: hypersensitivity vasculitis, temporal MMed (Surg), CVS (SA) • HIV infection may directly cause arteritis/polymyalgia rheumatic and Consultant Vascular Surgeon, Department of cardiovascular disease nonspecific unclassified vasculitis) and Surgery, Faculty of Health Sciences, University of • HIV therapy may cause cardiovascular • microvascular changes (thrombocytic the Free State disease thrombotic purpura (TTP) and haemolytic • HIV therapies may interact with drugs uraemic syndrome).1 Correspondence to: [email protected] used for cardiovascular complications • Primary prevention of coronary Prothrombotic state heart disease in patients receiving An increased prothrombotic state is observed The well-documented relationship between antiretroviral therapy includes exercise, in HIV patients with active opportunistic vascular disease and HIV infection has diet and treatment of hyperlipidaemia, infections or malignancy and in patients with evolved from infectious and inflammatory hypertension and glucose intolerance. AIDS. The potential mechanisms proposed vasculitides to: are the presence of antiphospholipid • premature atherosclerosis Peripheral arterial occlusive disease antibodies, such as anticardiolipin antibodies • its related contributing conditions (PAOD) in HIV-infected patients and lupus anticoagulants, and also increased (metabolic syndrome, dyslipidaemia, Van Marle reported the classic risk factors levels of von Willebrand factor, fibrinogen and insulin resistance syndrome) and for PAOD to be less prevalent in their studied D-dimers as well as deficiencies of protein C, • complications (acute coronary and HIV population. Patients were also of protein S, antithrombin III, heparin cofactor cerebrovascular syndromes).1 younger age than expected at presentation.4 II and increased platelet activation. Three clinical syndromes may present: Triple antiretroviral therapy ensures adequate Thus, the multifactorial pathogenesis viral suppression, which is paramount to Atherosclerotic disease may explain the peculiar characteristics the successful clinical management of HIV- Contributing risk factors are: and features of HIV-associated occlusive infected patients. The associated metabolic • disease specific (metabolic syndrome, vasculopathy (Table I). effects as well as the increased longevity dyslipidaemia, insulin resistance syndrome, associated with these drugs increase the antiretroviral therapy, i.e. protease in- Aneurysms in HIV-infected patients cardiovascular manifestations, which should hibitors) or (Fig. 1) be prevented and treated. • due to a high prevalence of the traditional The pathogenesis is uncertain. It is commonly risk factors for atherosclerosis in this associated with, but not exclusively due to, Perioperative risk assessment and population. a leucocytoclastic vasculitis. This process reduction results in obliteration of the vasa vasorum and The American Heart Association (AHA) Future research has to determine whether transmural necrosis. Infective aetiologies are ‘Initiative to Decrease Cardiovascular Risk HIV infection and antiretroviral therapy a sporadic rather than a consistent finding. and Increase Quality of Care for Patients contribute independently to increased Living with HIV/AIDS’2 concluded that cardiovascular disease.1,2 Unlike degenerative aneurysms, these are metabolic and anthropometric abnormalities found in atypical sites (common carotid and contribute to cardiovascular disease risk. Non-atherosclerotic disease superficial femoral artery) with a saccular/ These abnormalities may be due to HIV • Infectious arteritis (CMV, varicella multi-loculated morphology and tend to or its therapy and may be affected by zoster virus, mycobacterium and fungal be multiple. Low CD4 counts as well as environmental and immunological factors infections) hypoalbuminaemia are consistent findings with the net effect of being pro-atherogenic. • inflammatory vasculitis (leucocytoclastic with prognostic implications.11,12 vasculitis),5 polyarteritis nodosa (PAN),

Table I. Characteristics and features of HIV-associated occlusive vasculopathy

Young age at onset of disease (mean age 40 yrs)6,7 Most patients present with advanced vascular disease (>50% critical limb ischaemia)2 Smoking is a common traditional risk factor4 CD4+ T cell count <200 cells/µl7 Hypo-albuminaemia is a reliable predictor of increased perioperative complications and poor long-term survival4 Infra-inguinal disease more often than aorto-iliac occlusive disease4 Macroscopic findings Normal arteries proximal,8 and the occlusion is of a fibro-obliterative nature with cords/strings of fibrous tissue which can be removed from the arterial lumen4 Arteriographic findings Pristine proximal arteries with extensive disease extending into the small and medium-sized arteries with poor run-off5,8,9 Duplex ultrasonographic findings Hyperechoic ‘spotting’ in the arterial wall, the ‘string of pearls sign’10 Prognosis Limb salvage rate 27%8 Wound sepsis Graft sepsis Perioperative mortality 6.95% Late mortality 28.75%

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HIV therapies may The 2008 American College of Chest Table I. Anal disorders in HIV- interact with drugs Physicians guidelines make no reference to positive patients (most often found the HIV-infected patient suffering from VTE. used for cardiovascular Veller and Eyal recommend prophylaxis along in combination) complications. the same guidelines as those for a patient Disorder Average suffering from cancer and standard treatment incidence (%) protocols for patients with proven VTE.14 Proctitis/skin involvement 40 Condylomata acuminata 43 References available at www.cmej.org.za Fissure-in-ano 30 Anal ulcer 29 Haemorrhoids 15 HIV-related anal disease Chlamydia/gonorrhoea 2 E J THERON, FRCS (Edin) Kaposi’s sarcoma 2 Emeritus Professor of Surgery/Consultant/Reader/ Squamous cell carcinoma 1 Training Co-ordinator, Department of Surgery, University of the Free State, Bloemfontein Anal incontinence and soiling is a socially Correspondence to: E J Theron (mwetron@mweb. unacceptable and often devastating problem Fig. 1. Histology of an aorta aneurysm in an co.za) associated with anal disease in AIDS. HIV-infected 40-year-old woman. The slide reveals granuloma formation as well as a TB The higher prevalence of malignant disease bacillus in the wall of the aneurysm. Anal disorders are very common in HIV- in these patients should also be kept in mind, infected patients. It is estimated that at least i.e. Kaposi’s sarcoma of the anal canal skin, As for management, the same principles as in one-third of HIV-positive patients suffer Hodgkin’s lymphoma and possibly squamous the case of other infected aneurysms apply, from an anal disorder and that anorectal cell carcinoma.4 although aneurysm as well as patient factors disease is the most common reason for may influence the definitive therapy of each. surgical referral and intervention in these Clinical approach patients.1 History Venous thromboembolism A careful history of the main complaint, all In addition to classic risk factors, HIV-infected It is therefore imperative that all patients symptoms associated with the anal area, and persons have additional predictors for the presenting with anal disorders should function and anatomy of the anus should development of venous thromboembolic be tested for HIV, and conversely that all be obtained in an objective, formal yet events (VTEs). VTEs are 2 - 10 times more seropositive patients be questioned and sympathetic fashion. Patients are reluctant common among HIV-infected persons if necessary examined for the presence of to divulge details and may have to be gently compared with the general population, with anorectal disease.2 prompted to obtain an adequate picture incidence rates of 1.9 - 7.6 per 1 000 person- of the pathology and altered function years and a median age of 37 years.13 Clinical presentation involved. Questions on sexual practices and The primary care physician should be particularly anal intercourse can sometimes Additional risk factors for VTE in HIV- acutely aware of the symptoms and signs be embarrassing to both patient and infected patients are listed in Table II. that may become apparent; these should be physician. Matter-of-fact queries with regard kept in mind and actively looked for. Pain to pain during anal intercourse will afford Table II. Additional risk factors for (proctalgia) or severe discomfort is the most the patient the opportunity to deny or admit VTE in HIV-infected patients common presenting symptom (55 - 60%), to such practice; subsequent response to followed by a mass or swelling (>28%).1 questioning may then follow spontaneously. Infection by HIV itself – low CD4 cell Blood or bloodstained discharge is often counts and high HIV viral loads13 associated with these symptoms or could be Keeping in mind the possible pathology, Thrombophilic abnormalities: antiphos- the single presenting symptom in up to ≥20% sensitively formulated leading questions will pholipid and anticardiolipin antibodies, of cases. Other presenting complaints include often clear doubts regarding the problem to decreased activities of natural anticoagu- pruritus, painful defecation, incontinence and be managed and its intensity. lants, especially protein S, and increased diarrhoea. Any symptom with regard to the platelet activation1 anal area in an HIV-positive patient should Local examination be investigated and assessed thoroughly. Most patients can be examined in a consulting Endothelial lesions: thrombotic microan- giopathy (TMA) also occurs at elevated room or clinic cubicle. Privacy, nursing/ rates among patients with HIV13 Pathology assistant support and good lighting are basic In order to assess any of the above in an requirements, as well as anaesthetic jelly, An active infectious process – infections orderly and scientific manner, the pathology swabs, lubricant, a proctoscope, malleable may lead to activation of endothelial cells affecting the anal area should be considered probes and suctioning equipment. Facilities and a procoagulant state13 (Table I). for needle, forceps and open biopsies should HIV-associated malignancies (e.g. Kaposi’s be available and a bi-valve speculum for sarcoma) Condyloma acuminatum (human papilloma- vaginal examination in female patients Inflammatory and/or dysmetabolic states virus) is the most common finding (40 - 50%) should always be at hand. Positioning is very in many series, followed by peri-anal ulcers important: in addition to the usual Sims’ (32%), fistula-in-ano (30%), anal fissures position (left lateral knee flexed), the knee- A recent retrospective review found that (30%), sepsis and abscesses, complicated chest (jack-knife) position can be practical.5 the current use of antiretroviral therapy, the haemorrhoids and proctocolitis. Inflamed duration of therapy and the percentage of skin tags and hypertrophied/infected anal In a limited number of patients the above time with HIV on therapy were not different papillae are often associated with many of approach will not be possible because of age, among those with and without a VTE.13 the abovementioned findings in the HIV- non-compliance and pain. An examination positive patient.3 under general anaesthesia should then be

AUGUST 2010 Vol.28 No.8 CME 377 More about... done. Look for pathology that should be Be careful not to hurt the patient or to cause expected, i.e. skin lesions, condylomata, further harm. Every clinical finding during abscesses and sepsis, proctitis, small peri- the physical examination should be fully anal fistulas, fissures, infected thrombosed investigated and adequately documented in haemorrhoids and sphincter tone. Anal the patient᾽s file.5 canal ulcers and multiple fissures may be missed, and associated rectal disease should Management be identified. In advanced destructive anal Protection of the clinician and all nursing disease of fully fledged AIDS the findings and other staff, including students, should be may be confusing because of the presence of a priority. Gloves, masks and/or a visor must multiple pathology, and a descriptive clinical Fig. 4. Acute proctitis. be used.5 assessment should be made (Figs 1-6). Surgical intervention in the treatment of anal disease, e.g. haemorrhoidectomy, should be carefully considered in the HIV-positive patient because of delayed wound healing and even non-healing. According to some, the use of surgery should be limited to the drainage of pus. Disease in this area is usually more aggressive and persistent, and the recurrence rate of resected condylomata has been reported to be as high as 50% within 3 months.3 Peri-anal necrosis and necrotising fasciitis after surgery is a dire and often fatal complication.

In spite of the above, recent reports have been Fig. 1. Perineal abscess. more positive regarding healing and cure rates after surgery. Acceptable results are reported with most interventions and an ‘appropriately aggressive approach’1 seems justified.

It is however very important that surgical intervention be restricted to conditions that require surgery as a matter of urgency and in Fig. 5. Anal canal tissue breakdown. which conservative management is deemed inadequate. Therefore, a haemorrhoidectomy on uncomplicated haemorrhoids would be contraindicated in the HIV-positive patient, while abscesses, active infected fistulas, anal ulcers, complicated haemorrhoids and extensive condylomata are important when considering surgery. Patients on antiretroviral therapy generally respond well. Satisfactory wound healing and eventual cure usually follow meticulous surgical technique and follow-up in more than 80% of cases.1 Patients scheduled for surgical intervention must be Fig. 2. Hypertrophied anal papillae. on effective antiretroviral therapy; a low CD4 count (<200µl) and a high viral load may lead to poor or no healing of surgical wounds.

Careful selection of patients for surgery, gentle tissue-saving techniques and meticulous postoperative follow-up should result in a positive outcome. Fig. 6. Squamous carcinoma. Every patient’s needs should be individualised and potential life-threatening complications Fig. 3. Condylomata acuminata. anal canal should be available to come to a of a conservative approach should be weighed final diagnosis. against the 20% chance of poor results and non-healing after surgery. It may be necessary to perform procto- The presenting symptoms of anal disease in sigmoidoscopy, either of the rigid or HIV-positive patients in order of prevalence References available at www.cmej.org.za preferably of the flexible variety, to exclude are the following: or confirm the presence of associated • pain rectosigmoid disease. • soiling • lump/tumour Appropriate special investigations such as • blood/pus in stool MCS, histology and ultrasonography of the • diarrhoea/tenesmus.

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Soft-tissue tumours and HIV/ aspiration should be avoided, as this does Epstein-Barr virus-associated smooth AIDS not allow grading or histological typing. muscle tumours (EBV-SMT) N PEARCE, MB BCh, MMed (Surg), Incision biopsies have a potential to seed Patients presenting with EBV-SMT seem FCS (SA) cancerous cells and should be done by the to have a significantly low CD4 count, with Consultant, Department of General Surgery, surgeon who takes responsibility for the tumour locations ranging from the central University of the Free State, Bloemfontein final surgical management of the tumour, if nervous system to the endocrine organ possible. systems. Management must be tailored to the Correspondence to: N Pearce (nic.pearce@mweb. location of the tumour, but most tumours can co.za) Therapy be managed by surgical excision. EBV-SMT In the past amputation was considered to has a slow disease progression; however, be the only option for treating soft-tissue optimal treatment still seems to evade us.7 Soft-tissue sarcomas are a diverse group of tumours of the extremities. Currently, malignancies, with the majority originating excision with a margin of at least 1 - 2 cm Non-Hodgkin’s lymphoma has not been from the mesoderm. The mesoderm accounts is considered adequate. Compartment discussed above, but should be noted, both for approximately 75% of the body’s mass but excisions have shown to be of no greater because its incidence increases in the HIV- only for about 1% of tumours in the adult benefit than wide local excisions. Excision positive population and because it can population. Approximately 43% arise from with clear margins yields recurrence rates of present as a soft-tissue mass. Lymphoma is the extremities and the remainder from between 12% and 31%. not classified by the WHO as a soft-tissue various other anatomical sites.1 tumour.8 Kaposi’s sarcoma With the advent of increasingly available This particular disease represents the most References available at www.cmej.org.za antiretroviral drugs, patient life expectancy common tumour in the HIV population. is increasing and so is the incidence of As stated above, with an increasing life previously rare conditions, such as Kaposi’s expectancy the prevalence of Kaposi’s Male genital disease in HIV and sarcoma and lymphoma. sarcoma is increasing. AIDS SCHALK W WENTZEL, MB ChB, Risk factors Four clinical variants are described:5 MMed (Urol) There are certain well-defined risk factors, • classic/sporadic/Mediterranean Professor and Head, Department of , including ionising radiation, chromosomal • endemic African University of the Free State, Bloemfontein abnormalities, chemical exposure and • organ transplant associated lymphoedema. Some sarcomas have an • epidemic (AIDS related). Correspondence to: S W Wentzel ([email protected]) increased incidence in the HIV population, notably Kaposi’s sarcoma and various There exists a theory of multiple infectious lymphomas. events. Kaposi’s disease has been shown The first case of acquired immune deficiency to be related to Kaposi’s sarcoma-related syndrome (AIDS) was described in 1981.1 In Epstein-Barr virus is associated with smooth- herpesvirus (KSRHV) or herpesvirus type 8.6 the past 29 years the number of AIDS cases muscle tumours in patients with HIV.2 has increased at a rapid pace and in 2004 it The diagnosis is primarily clinical, with was estimated that 34 - 42 million people The most commonly used staging system characteristic lesions that are not painful were living with HIV infection.2 is based on the AJCC (American Joint and usually located on the extremities. Committee on Cancer) guidelines. The Lymphoedema occurs secondarily to the The situation is even worse in sub-Saharan AJCC guidelines combine various factors, obstruction of the lymphatics. A Zimbabwean Africa, where in 2003 it was estimated that i.e. tumour grade, tumour size, depth of study revealed that most patients present in 25 million people were living with HIV invasion, degree of nodal involvement and the late stages of AIDS (stages 3 and 4). infection. A suspected 3 million new cases presence or absence of metastatic disease.3 and 2.2 million deaths due to AIDS were A histological diagnosis should be made before reported that year.3 Examination initiating therapy, but it bleeds. However, it Examination often reveals very few should be borne in mind that the disease is The three modes of transmission of HIV are: abnormalities, but the following factors not curable and one should aim to: unprotected intercourse, contact with blood, indicate an increased risk of malignancy • alleviate symptoms and mother-to-child transmission. There are and should be actively sought and noted in • reduce the tumour mass several urological risk factors involved in the patient records:4 • reduce the oedema transmission of HIV. • pain • prevent disease progression. • function loss Urological risk factors in HIV • neurovascular bundle invasion Treatment can be broadly grouped into two transmission • >5 cm in size groups: • Sexually transmitted infections (STIs). All • located deep to the fascia STIs have a similar mode of transmission • systemic symptoms Treatment targeting lymphoedema: and there is evidence that genital ulcers • metastasis • elevation of the limb and non-ulcerative STIs facilitate HIV • recurrence • exercise transmission.4 • increased vascularity, i.e. warm. • multilayer bandages • Antiretroviral therapy and genital • compression stockings secretions. Although patients on Biopsy • manual lymphatic drainage. antiretroviral treatment may have A mass that has been present for more lower HIV levels in their blood, sexual than 4 weeks or is greater than 5 cm in Treatment targeting the disease: transmission may still be possible.5 diameter is an indication for a biopsy. • radiation • Circumcision status. Uncircumcised men Core needle biopsy (e.g. Tru-cut needle®) • antiretroviral therapy have an increased risk of infection by way has been shown to be accurate with regard • chemotherapy – this may suppress an of STIs and HIV.6 to sensitivity and specificity. Fine needle already depressed immune system. • Specific sexual behaviour. Male-to-female

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transmission is more prevalent than vice versa.7 In anal intercourse the insertive partner is less likely to contract HIV than the receptive partner.

Male genital manifestations of HIV infection HIV can present in different forms in the male urogenital tract. The different manifestations are summarised in Table I.

Table I. Male genital manifesta- Fig. 1. Condylomata acuminata on the glans tions of HIV and foreskin. Non-malignant conditions • Sexually transmitted infections • Genital herpes simplex virus (HSV) • Human papillomavirus (HPV) • Syphilis • Chancroid • Urethritis • • HIV-related genito-urinary tract infec- tions Fig. 4. Molluscum contagiosum on the penis. • • and • Necrotising fasciitis (Fournier’s gan- grene) Neoplasms • Kaposi’s sarcoma (KS) Fig. 2. Chancre caused by syphilis on the • Non-Hodgkin’s lymphoma (NHL) glans penis. • Squamous genital cancers •

Sexually transmitted infections Genital herpes simplex virus (HSV) Fig. 5. Typical picture of Fournier’s gangrene. HSV types 1 and 2 are very common in HIV- infected men.8 The course of the infection may be prolonged and intravenous acyclovir may be necessary to cure the lesions. Patients with acyclovir-resistant HSV have been described and need treatment with foscarnet or topical cidofovir gel.

Human papillomavirus (HPV) Warts (condylomata acuminata) are found on the penis, urethra, scrotum and perineum.

Other clinical presentations of HPV include bowenoid papulosis and epidermodysplasia verruciformis. Men with extensive penile warts should be screened for HIV.

Syphilis There is a high prevalence of syphilis in HIV- infected populations, especially homosexual Fig. 3. Chancroid (Haemophilus ducreyi). men.9 It progresses faster from secondary to tertiary syphilis in HIV-infected men, who, Urethritis with early syphilis, have a high risk for the Patients with HIV have a high risk for the development of neurological complications development of urethritis caused by Neisseria Fig. 6. Kaposi’s sarcoma of the penis. and treatment failure of standard regimens. gonorrhoeae and Chlamydia trachomatis. There is a link between AIDS and Reiter’s widespread in AIDS patients.11 HIV-infected Chancroid syndrome10 (urethritis, uveitis and arthritis), patients with molluscum contagiosum Chancroid, caused by Haemophilus ducreyi, is but the association is poorly understood. usually have a CD4 count of less than 250 a co-factor for HIV transmission. Chancroid cells/µl. Molluscum contagiosum lesions in HIV-infected individuals may be resistant Molluscum contagiosum may simulate more serious infections, such to standard regimens. Ulcers heal more It is caused by a sexually transmitted pox as cutaneous pneumocytosis, histoplasmosis slowly and prolonged courses of treatment virus and is found in 10 - 20% of AIDS and cryptococcosis, and should be confirmed may be needed. patients, most often on the face and genital by biopsy. areas. The lesions can become very large and

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HIV-related genito-urinary tract than in non-infected individuals.21 These is not easily removable (as is the case with infections tumours are also more often bilateral candida). It has a hairy appearance and Prostatitis and there is a great risk of high-grade is most commonly located on the lateral It is found in up to 8% of HIV patients12 lymphoma in the testes. This is important border of the tongue. It can also involve the and presents as . It can be when considering treatment, because all the ventral tongue and in rare cases the buccal associated with superimposed urinary tract known chemotherapeutic regimens will lead mucosa. Patients are usually asymptomatic infections. to further immune suppression. and lesions can only be observed. If a lesion should show change, however, a biopsy Epididymitis and orchitis Conclusion should be done. In autopsy studies 39% of AIDS patients It is clear that several dermatological have signs of opportunistic testes infections. conditions and tumours of the male external Infections usually cause atrophy of the testes genitalia are associated with HIV infection. with spermatogenetic arrest and depletion Patients with these lesions should be screened of Leydig’s cells. Immunocompromised for HIV. patients can also develop epididymitis caused by atypical organisms such as Candida and References available at www.cmej.org.za cytomegalovirus.13

Necrotising fasciitis (Fournier’s gangrene) Common head and neck It may be the presenting condition in problems in HIV-positive previously undiagnosed AIDS patients.14 All patients Fig. 1. Oral hairy leukoplakia. patients with this life-threatening infection JOHLENE DU PLESSIS, MB ChB, should be screened for HIV. MMed (Chir) Erythroplakia (Fig. 2) describes any red Surgeon, De Aar Hospital, Northern Cape, and mucosal lesion and is more likely to indicate Neoplasms Private Practitioner, De Aar a malignant lesion. These lesions should Kaposi’s sarcoma (KS) therefore always be biopsied and followed up Two types of KS are described, i.e. the Correspondence to: Johlene du Plessis (johlene_ closely to rule out malignancy. classic type, which occurs in patients with [email protected]) lymphoma or immune deficiencies, and the epidemic type, which is associated with AIDS. KS can affect any skin area, including Approximately 41 - 68% of all HIV-infected the male genitalia. A new herpesvirus, patients will present with pathological human herpesvirus 8, is associated with all conditions of the head and neck at some point cases of KS.15 An experienced observer can in the disease.1 easily diagnose the typical purple indurated plaques, but the diagnosis needs to be Common head and neck problems in HIV- confirmed by biopsy. positive patients are briefly discussed under the following headings: Non-Hodgkin’s lymphoma (NHL) • ulcers, plaques and gum disease Fig. 2. Erythroplakia. Patients with NHL usually have widespread • neoplastic growths in and around the disease at presentation and genito- mouth Candida albicans urinary sites may be involved primarily • lumps and bumps. Candida can present in 4 different forms: or secondarily.16 Since the introduction of • pseudomembranous /thrush antiretroviral therapy the incidence of KS Ulcers, plaques and gum disease (most common form) has decreased and therefore NHL is the most Ulcerations • erythromatous candidiasis (red lesions on common AIDS-associated malignancy in Recurrent oral ulcerations classify the patient palate/dorsum of tongue) patients on therapy. as having stage II disease according to the • angular chelitis (red, flaking lesions at WHO staging of HIV/AIDS.2 Causes for corners of mouth) Squamous urogenital cancers these ulcers include viruses (herpes simplex • hyperplastic candidiasis (thick white HIV-infected patients have a higher risk virus (HSV), varicella zoster (VZ) and plaques on mucosa) (Fig. 3). of developing HPV-associated squamous cytomegalovirus (CMV)), immunological cancer of the penis as well as precancerous causes (aphthous ulcers) and fungal infections lesions associated with HPV. A study in the (candida, histoplasmosis). USA confirmed that HPV accounts for 50% of all penile carcinomas.17 Several studies HSV and VZ () most often involve on squamous carcinoma at other sites, such the perioral skin, but can also involve the as the cervix, anorectum and oral cavity, oral mucosa. The typical prodrome precedes have confirmed that these cancers have a the vesicular eruption. It is very important to higher incidence in HIV-infected patients.18 remember that if the tip of the nose is involved However, only a few cases of invasive penile in shingles, the patient must be evaluated and cancer in the HIV-infected population have monitored for possible involvement of the eye been described.19 In an as yet unpublished (corneal/conjunctival ulcerations) as this can Fig. 3. Hyperplasic candidiasis. study at the Department of Urology, lead to serious problems if left undiagnosed. University of the Free State, Bloemfontein, These oral lesions can also be an indicator we found that 56% of patients with penile CMV and aphthous ulcers can look very that candida is involving the oesophagus carcinoma were HIV positive.20 similar to VZ, but lack the typical prodrome. if accompanied by odynophagia and retrosternal pain. Oesophageal candida can Testicular cancer Leukoplakia and erythroplakia be confirmed with gastroscopy. Treatment is Testicular tumours are 50 times more Oral hairy leukoplakia (Fig. 1) presents as a with oral nystatin drops (only oral candida) or common in the HIV-infected population painless, white, slightly elevated plaque that miconazole gel (Daktarin). Fluconazole 400

AUGUST 2010 Vol.28 No.8 CME 381 More about... mg daily PO for 14 days is used if oesophageal to WHO staging of HIV/AIDS.2 Patients candida is diagnosed. complain of mildly tender, soft parotid swelling that can be unilateral or bilateral Acute necrotising ulcerative gingivitis/perio- (Fig. 6). The pathophysiology behind dontitis this phenomenon is a diffuse lymphoid This is an acute opportunistic infection of infiltrate, hence the name diffuse infiltrative the gingiva that can spread to the underlying lymphocytosis syndrome or DILS. alveolar bone. Causative organisms include Treponema spp, Selenomonas spp, Prevotella intermedia, Borrelia spp, Gram-positive cocci, beta-haemolytic group B streptococci Fig. 4. Kaposi’s sarcoma. and Candida albicans.3 Patients present with painful, bleeding gums with varying Lymphoma amounts of necrotic tissue. Treatment Lymphoma can present in the oral cavity as consists of meticulous oral hygiene, a swelling or mass, but is extremely rare and debridement of necrotic tissue and local and usually associated with a poor prognosis. systemic antibiotics. Oral antiseptics such as Glycothymol mouth wash can be used as Squamous cell carcinoma adjunct therapy. Squamous cell carcinoma will present as in HIV-negative patients and the treatment Neoplastic growths in the mouth approach will be the same. Human papillomavirus infection These lesions present as condylomata Molluscum contagiosum Fig. 5. Molluscum contagiosum. acuminata, warts or focal epithelial These lesions are characterised by flesh- hyperplasia. Treatment consists of simple coloured, dome-shaped, smooth or surgical excision; biopsies can be done first if umbilicated papules and are caused by a there is doubt about the diagnosis. DNA poxvirus. They are found commonly on the lips, buccal mucosa and palate (Fig. Kaposi’s sarcoma 5). Treatment of these lesions consists of Kaposi’s sarcoma usually presents on the cryotherapy or excision.4 skin, but the hard palate, gingiva, buccal mucosa and the dorsum of the tongue can Lumps and bumps also be involved (Fig. 4). Lesions present as Lymphadenopathy red to purple raised plaques which can also HIV-related lymphadenopathy is discussed ulcerate and cause pain and bleeding. Most by WJ Jacobs.5 of the time, mucosal lesions will accompany cutaneous lesions. Treatment consists of triple Parotid enlargement antiretroviral therapy and external beam Unexplained persistent parotid enlargement radiation in collaboration with an oncologist. is also a stage II-defining disease according Fig. 6. DILS

Table I. Diagnosis and treatment of HIV-associated head and neck lesions Disease Clinical appearance Diagnosis Management Candida See text for different clinical types Clinical picture +/- • Topical antifungal treatment culture/biopsy • Systemic anti-fungal treatment for oesophageal candida Periodontal disease Halitosis, bleeding gums, severe Clinical picture • Aggressive plaque removal and debride- pain in gums ment by dentist • Topical or systemic antibiotics • Good oral hygiene Oral hairy leukoplakia White lesion lateral aspect of Clinical picture +/- • Observation! tongue, non-removable tissue biopsy • Biopsy indicated if there is change in lesion’s appearance • In severe cases consider oral aciclovir Herpes virus ulcers Painful solitary/multiple vesicular Clinical picture +/- smears +/- • Oral aciclovir lesions, may erode/coalesce viral culture +/- biopsy • Can consider ganciclovir for CMV ulcers Recurrent aphthous Painful, well-circumscribed, Clinical picture +/-biopsy • Topical analgesics (Teegel) ulcers shallow ulcers Topical or systemic steroids in severe cases Kaposi’s sarcoma Painless red, bluish/purple maculae, Clinical picture +/- biopsy • Antiretroviral therapy papules/nodules • Radiation, co-ordinate with oncologist Non-Hodgkin’s Firm, painless focal swelling or Biopsy • Oncology referral lymphoma poorly defined alveolar mass • Surgical debulking in case of airway obstruction DILS Painless uni/bilateral parotid swelling Sonar, FNA • Antiretroviral therapy +/- external beam radiation Molluscum contagiosum Flesh-coloured, dome-shaped, smooth Clinical picture • Cryotherapy or excision or umbilicated papules

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There are numerous labour, or during breastfeeding. It has been is under severe pressure from underlying head and neck shown that infants born to mothers who have HIV, it may be falsely negative. We use the full-blown syndrome are more affected computed tomography (CT) scans in our conditions that are than those born from mothers who are HIV- institution to help with the diagnosis, but commonly seen in HIV- positive.4 The Cochrane database from 2002 often a histological diagnosis is necessary. positive patients, not shows the advantages of programmes to Here, minimal access surgery (MAS) prevent mother-to-child transmission, also becomes particularly useful, because all requiring surgical recognising the fact that transmission rates these children are often too sick for a referral. drop to 1 - 2% in mothers on antiretroviral traditional laparotomy. Tissue and fluid therapy.5 The PMTCT programme in South for histology, microbiology, as well as Africa aims to minimise transmission of the PCR testing should be taken. Adenosine The diagnosis of DILS can be made by virus. deaminase (ADA) testing on ascitic fluid ultrasound/CT, which will show multiple is also helpful. cystic lesions throughout the superficial Testing difficulties and deep lobes of the parotid gland. It has Infants (babies up to the age of 1 year) are • Lymphadenopathy is a reality in our been described as having a Swiss cheese notoriously difficult to test, because the everyday practice. This poses a real appearance on imaging. FNA of this lesion maternal antibodies are still detected up diagnostic dilemma: it may be that will reveal a benign lymphoepithelial cyst. to this age. Therefore the commonly used the patient has recently seroconverted Please do not do true-cut biopsies! You don’t Elisa test cannot be used in this population and therefore has generalised want the pathology report to come back group. A test where viral material is detected, lymphadenopathy, but it also may be due reporting ‘pieces of normal facial nerve’! such as the polymerase chain reaction (PCR) to tuberculosis or even lymphoma. All of Management of these lesions is not surgical test, is a good option for those above the age these are highly treatable conditions and and consists of antiretroviral therapy and/or of 1 month, although more expensive than not necessarily terminal. It is therefore external beam radiation. the normal tests. Below the age of 1 month, important that the paediatric surgeon however, the PCR test has 100% specificity, does lymph node biopsies in HIV- The diagnosis and treatment of HIV- but only 70% sensitivity.6,7 This has resulted positive children with the following associated head and neck diseases are in the term ‘HIV-exposed’. criteria: more than 2 cm in diameter, summarised in Table I. present for longer than 2 months, and/or Surgical problems caked together. Conclusion Infectious diseases There are numerous head and neck Necrotising enterocolitis (NEC). The Malignancies conditions that are commonly seen in HIV- preliminary results of our own research on Lymphoma. As in adults, the incidence of positive patients, not all requiring surgical the incidence of NEC among HIV-exposed the lymphomas is vastly increased in HIV- referral. It is very important that primary babies suggests that they are more prone infected children. For instance, the incidence care physicians recognise these conditions to develop NEC with a worse outcome. of primary central nervous system lymphoma and know when to refer them and when they This is consistent with other findings.8 The (PCNSL) is more than 1 000 times that of the can be managed at primary care level. possibility exists that these patients’ disease normal population.9 In a series by Bonnet is complicated by the cytomegalovirus in France, 11% of deaths in HIV-infected References available at www.cmej.org.za (CMV) – a source of concern in the adult patients were caused by lymphoma.10 group as well. This results in CMV enteritis, Still, it appears that the prognosis of these a disease that is notoriously difficult to treat malignancies compares very favourably with The paediatric surgeon and surgically, because a large proportion of the those in uninfected patients, especially when HIV bowel is usually involved in the inflammatory the patients are on antiretroviral therapy. ESMÉ LE GRANGE, MB ChB, process, with several perforations along MMed(Surg), Cert Ped Surg (SA) its tract. Peritoneal drainage traditionally Kaposi’s sarcoma. Likewise, Kaposi’s sarcoma Head, Clinical Unit, Paediatric Surgery, Universitas used for NEC seems appropriate in these is treated very successfully in children. One Hospital, Bloemfontein and Senior Lecturer circumstances. In our own series 49% of should remember that antiretroviral therapy Department of Surgery, University of the Free State, patients escaped an operation. is the first line of treatment, combined with Bloemfontein other forms of ablation, such as cryotherapy Tuberculous adenitis and peritonitis. and radiation, as well as different regimens of Correspondence to: Esmé le Grange (legransm.@ufs. Tuberculosis (TB) is endemic and pandemic chemotherapy.11 ac.za) in sub-Saharan Africa. There are also high rates of resistant disease (RTB), as well as Other malignancies. Incidental findings extremely resistant (XRTB) strains. We also of seropositivity and even AIDS are found Children form a large proportion of the see other strains, such as bovine tuberculosis, among our patients with different forms HIV-positive population. A portion of especially where patients present with the of malignancy. These patients are put on infected infants progress rapidly to full- peritonitic variant of the disease. antiretroviral therapy at the time that they blown AIDS and die within 1 year without start chemotherapy. Care should be taken, treatment.1,2 However, a larger proportion of • TB peritonitis is notoriously difficult to because these patients are known to develop infected infants and children (36%) are slow diagnose: the textbook clinical picture of immune reconstitution inflammatory progressors2 who have a median survival age peritonitis in the presence of pulmonary syndrome (IRIS).12 of 16 years. tuberculosis is not often seen, because commonly these patients have tuberculosis References available at www.cmej.org.za Prevention of mother-to-child of the gastroenteric tract only – often of transmission (PMTCT) the bovine type. If suspected, a tuberculin Mother-to-child-transmission3 (MTCT) skin test is useful in younger children; takes place either during pregnancy, during however, if the patient’s immune system

AUGUST 2010 Vol.28 No.8 CME 383 More about...

The impact of HIV/AIDS on receiving and not receiving a protease debridement and fracture stabilisation orthopaedic surgery inhibitor regimen.2 still hold. It might be worthwhile to prefer PEET VAN AARDT, MB ChB, MMed external immobilisation when dealing with (ORT) Approach to emergency and elective open fractures in HIV-positive patients, Consultant, Department of Orthopaedic Surgery, orthopaedic surgery especially open tibia fractures. University of the Free State, Bloemfontein When dealing with an HIV-positive patient presenting with an orthopaedic Elective surgery Correspondence to: Peet van Aardt (peetvan@ complaint, one has to distinguish between Arthroplasty mweb.co.za) the asymptomatic seropositive patient and Most of the research in this regard was on the symptomatic AIDS patient. Staging the HIV-positive haemophiliac patients. A disease, using the WHO staging system based large retrospective multicentre study found As is the case with other surgical disciplines, on CD4 counts and clinical information, led an increased rate of deep sepsis – as high orthopaedic surgery was dramatically to a more aggressive surgical approach in as 18.7%. These patients are also at risk influenced by the HIV pandemic. Early these patients.3 Furthermore, the surgical for bleeding in and around their joints as experience, reporting complication rates of approach is dictated by whether it is an well as bacteraemia associated with regular 140% and mortality rates of 55 - 70%, led to emergency or an elective case. factor transfusions. Both of these factors a pessimistic approach to surgery in HIV- may contribute to late sepsis. HIV-positive positive patients. The initial perception was Trauma haemophiliac patients may not be a true that these patients were prone to: Polytrauma reflection of the infection risk associated • poor wound healing1 HIV is reported as a significant prognostic with HIV-positive arthroplasty. HIV-positive • high postoperative complication rates indicator for an adverse outcome in acute non-haemophiliac patients may also have • a protracted postoperative period lung injury and adult respiratory distress a need for arthroplasty because of a higher • higher mortality rates. syndrome in ICU patients. It is also reasonable incidence of avascular necrosis. The risk of to expect higher secondary infection rates in sepsis seems to be lower in these patients, but These early studies were skewed by the HIV-positive patients. literature remains lacking.3,6 fact that these procedures were usually performed as emergencies presenting as Closed fracture Spinal surgery7 direct consequence of HIV infection. Later Initial unrefined studies reported infection Young and others found no major follow-up work changed this perspective rates as high as 24 - 40%, but recent complications on a small series of HIV dramatically. The success of antiretroviral studies3,4 showed infection rates of 3.5% positive patients undergoing spinal surgery.7 therapy has further led to a change in the in patients with CD4 counts as low as The mean CD4 count in these patients was initial approach to the HIV positive. 200 cells/µl. The recommendations are 279 cells/µl. effective prophylactic antibiotic use (first- The impact of HIV can be divided into generation cephalosporin), clean operating Other implants and elective surgery orthopaedic diseases caused by HIV/AIDS environment, strict theatre discipline and A prolonged course of prophylactic and problems or potential complications careful soft-tissue handling. antibiotics (10 days of cefuroxime) was found with orthopaedic surgery and implants in to be beneficial in WHO group A patients. HIV-positive patients. Open fracture Otherwise elective surgery seems to be safe Depending on the level of contamination, in HIV-positive patients.8 HIV-related orthopaedic diseases infection rates as high as 42% can be expected Osteonecrosis, osteopenia, and osteoporosis compared with 11% in controls. Open tibia Wound healing are conditions seen increasingly in patients fractures are particularly prone to deep Harrison et al.9 found that in the absence of with HIV. These conditions may be caused chronic infection and the use of external preoperative wound contamination, there by the infection itself, antiretroviral therapy fixation seems well advised.5 is no higher incidence of wound infection or lipodystrophy. regardless of the CD4 count. Buehrer Fracture union confirmed this in a similar HIV-positive Osteopenia and osteoporosis A higher incidence of HIV was found in haemophiliac study. The same was found by A change in bone turnover occurs in HIV- patients presenting with delayed union or Harrison et al., but they also found a more positive patients. This is probably because non-union, but this seems to respond to rapid progression to AIDS in patients who of deregulation between osteoclast and stable internal fixation and autologous bone had a lower CD4 count.9 osteoblast function. Studies reported grafting. increased cytokine levels (IL, TNF) and Conclusion increased osteoprotegerin levels, leading to Late sepsis The initial nihilistic surgical approach to deregulation of RANKL-RANK interaction.2 An increased risk of late sepsis was found in HIV-positive patients seems to have been trauma and arthroplasty patients and removal too cautious. With a few exceptions, most Antiretroviral therapy (specifically protease of instrumentation may be indicated as the orthopaedic surgery can be undertaken inhibitors) and lipodystrophy caused by disease advances. These late infections can be safely in these patients, provided that one antiretrovirals have also been linked to bone due to reactivation of latent bacteria or may adheres to proper surgical principles. loss, but conclusive evidence remains lacking. be because of late haematogenous seeding. The incidence of osteopenia is 14 - 84% and References available at www.cmej.org.za that of osteoporosis is up to 45% in HIV The approach to trauma should be guided patients, but no difference in fracture rates by the merits of the patient’s injury, and the could be demonstrated between patients established priorities of early and adequate

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