AIDS and aging: Insights from years of practice

Berger

‘It’s an interesting circle. We began with HIV disease, and that gave us an insight we were able to apply to the aging population, which is a big issue right now. It turns out the same thing is happening to the HIV population, so it has come full circle,’ Timothy G. Berger, MD, said.

Insights occur on a variety of paths. They can come from analyzing data from dozens of studies or from careful observation and patient interaction over time. For Timothy G. Berger, MD, insight came after years of treating the elderly and HIV-positive patients, which he discussed Friday during the Everett C. Fox, MD, Memorial Lectureship.

“This talk is a reflection of my own learning as I practiced dermatology. It has to do with what practice setting I was in and how that influenced my way of thinking about things, and why it gave me an insight into something that is a challenge for all of us. Hopefully, these observations allow us to understand things a lot better,” Dr. Berger said of his address, “Immunology for the Practicing Dermatologist From AIDS to Aging.”

In the 1980s, at the height of the AIDS epidemic, Dr. Berger, the AAD vice president-elect, started a dermatology clinic in the San Francisco General Hospital HIV clinic, one of the largest AIDS treatment centers in the U.S. at the time. He was mentored by Marcus Conant, MD, a dermatologist renowned for his work with AIDS patients.

“After eight or nine years, Marcus said, ‘I’ve seen so many of these patients now, I know the status of their immune systems just by looking at their skin,’” Dr. Berger said. “It was an insight that the skin is a clear reflection of the immune state of the patient.”

HIV-infected patients first got shingles or Kaposi sarcoma, often while they were still feeling good and had a T-cell count above 200. However, when they were untreated, their T-cell counts fell below 200, and what followed were opportunistic infections, such as pneumocystis pneumonia. Unexpectedly, they were plagued with a variety of inflammatory, and often quite itchy, skin diseases, he said.

In the 1990s, Dr. Berger moved to the University of California, San Francisco, where many physicians referred geriatric patients with inflammatory and pruritic skin diseases to him.

“What I noticed was that the skin diseases these geriatric patients had looked a lot like the skin diseases that HIV-infected patients had,” Dr. Berger said. “In fact, when a patient came in to see me and they were having some kind of skin problem, often they had shingles, just like the AIDS patients had early on. Then, when they got skin disease, it was often an allergic, itchy skin disease — either an eczema or psoriasis. It turns out those were the same group of diseases we had seen in HIV-infected patients.

“When I saw elderly patients and they had different rashes on different parts of their bodies, and the biopsies showed different things, I came to believe that these all represented a consequence of the same process — loss of helper T-cell function. Just as in AIDS, it was the immune deficiency that created their disease, manifested in different anatomic locations and in different patients with different histology, but all triggered by the same underlying cause, age-associated immune deficiency — immunosenescence. I now use the term ‘eruptions of immunosenescence’ to include Grover’s, enhanced bug-bite reactions, nummular and other eczemas, and red itchy bumps — red papules that on biopsy show  ‘dermal hypersensitivity reaction.’”

The irony of this link is that HIV-infected patients who survived the initial epidemic are now in their 50s, but they have the immune systems of septuagenarians — and the same functional problems those elderly patients face.

“It’s an interesting circle. We began with HIV disease, and that gave us an insight we were able to apply to the aging population, which is a big issue right now. It turns out the same thing is happening to the HIV population, so it has come full circle,” Dr. Berger said.

The takeaway for dermatologists treating patients in this immune-dysregulated state is that a biopsy of rashes should not only be used to determine how to treat the rash but also to think about the patient’s immune status, he said.

“What’s important is to recognize that it is not the rash, but the cause of the rash,” Dr. Berger said. “This is all allergic skin disease occurring in the setting of aging, and we use the same principles to manage those diseases, with some variations.”

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