A 30-year-old man comes to the office due to skin lesions, fever, and malaise for the last week. The patient was diagnosed with HIV 3 years ago. His medication regimen includes antiretroviral therapy and trimethoprim-sulfamethoxazole. Temperature is 39.3 C (102.7 F), blood pressure is 115/75 mm Hg, pulse is 84/min, and respirations are 18/min. Examination shows several 1-2 cm round, reddish, vascular, non-tender, and friable exophytic nodules, as shown below in the picture. Which of the following is the most likely diagnosis in this patient?

Question

A 30-year-old man comes to the office due to skin lesions, fever, and malaise for the last week.  The patient was diagnosed with HIV 3 years ago.  His medication regimen includes antiretroviral therapy and trimethoprim-sulfamethoxazole.  Temperature is 39.3 C (102.7 F), blood pressure is 115/75 mm Hg, pulse is 84/min, and respirations are 18/min.  Examination shows several 1-2 cm round, reddish, vascular, non-tender, and friable exophytic nodules, as shown below in the picture.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

Bright red, firm, friable, exophytic nodules in a patient with HIV are most likely bacillary angiomatosis. The classic lesion is shown in the above picture. Bacillary angiomatosis is caused by Bartonella, a Gram-negative bacillus. Oral erythromycin is the antibiotic of choice. (Choice A) Bacillary angiomatosis and Kaposi sarcoma may be difficult to distinguish. However, the skin lesions of Kaposi sarcoma also occur on the trunk and extremities. Typically, the lesions are papules that become plaques or nodules; the color changes from light brown, to pink, to dark violet. Bacillary angiomatosis is more likely given this patient's firm, exophytic nodules and fever. (Choice B) Pneumocystis may cause nodular and papular cutaneous lesions of the external auditory meatus in immunocompromised (HIV) patients. With use of prophylactic therapy (eg, trimethoprim-sulfamethoxazole), Pneumocystis infection is highly unlikely. (Choice D) Molluscum contagiosum is caused by a poxvirus and is characterized by centrally-umbilicated, dome-shaped papules that are non-pruritic. (Choice E) Herpes simplex lesions are painful and vesicular. Educational objective: Bright red, firm, friable, exophytic nodules in a patient with HIV are most likely bacillary angiomatosis.

A 30-Year-Old Man Comes to the Office Due to Skin