Cause of oral ulcers in HIV-infected patients: a study of 19 cases

OBJECTIVES

To study the cause and clinical aspects of oral ulcers in HIV-infected patients.

STUDY DESIGN

Forty-one consecutive HIV-positive patients with long-standing oral ulcers were examined; 19 were evaluated by biopsy. From these 19 cases, viral, bacterial, and fungal cultures and biopsies were taken in each patient. When indicated, special microbial stains were undertaken to identify bacteria or fungi. Ten cases without granulomatous bacterial fungal or lymphomatous features were available for in situ hybridization to detect viral DNA of herpes simplex virus 1 and 2, cytomegalovirus, varicella-zoster virus, and Epstein-Barr virus.

RESULTS

Most of the oral ulcers occurred in patients with severe immunodepression. Median CD4 T-lymphocyte count was 60 cell/mm3 (range, 3 to 335). It was ascertained that nine (47%) patients had nonspecific aphthous-like ulcers, and ulcers caused by herpes group viruses were identified in six (31.5%) patients. One (5%) person was diagnosed with non-Hodgkin's lymphoma; and in one (5%) patient, multiple ulcers were an expression of lues maligna. Two ulcers (10.5%) in the palate harbored mycotic granulomatous foci (cryptococcosis, histoplasmosis). In this population, almost all of these ulcers were found to be large, persistent, and painful.

CONCLUSIONS

Nontumefactive oral ulcers in HIV-positive patients may be a source of diagnostic difficulties because of the diverse array of underlying pathologic entities and multiplicity of etiologic agents. Biopsy should always be performed on long-standing ulcers because either infection or a neoplastic process may be extant. In the absence of infection or neoplasm, such lesions are then designated as ulcers not otherwise specified.

[Eosinophilic ulcer of the oral mucosa]

The eosinophilic ulcer is a rare lesion of the oral mucosa; it is a benign disease, the etiology and the pathogenesis are unknown. The authors describe a patient with eosinophilic ulcer of the oral mucosa. The clinical, pathologic and therapeutic aspects of this rare disease are discussed.

Adrenergic and serotoninergic receptors mediate the immunological activation of corticosterone secretion in male rats

In order to elucidate the mechanism of action of immune agents on corticosterone secretion, the present study evaluated the possible involvement of some neuronal pathways (serotoninergic, noradrenergic/adrenergic) in the lipopolysaccharide (LPS)-induced corticosterone release in male rats. Serotoninergic antagonists, mianserin (5-HT2C receptor blocker) or pindolol (5HT1A receptor blocker) or noradrenergic/adrenergic antagonists, prazosin (alpha 1-adrenoceptor blocker) or propranolol (beta-adrenoceptor blocker), were intraperitoneally (i.p.) injected before (5 min) the administration of LPS. In each experiment a group of rats i.p. injected with vehicle served as controls. Animals were sacrificed by decapitation 90 min after administration of LPS and trunk blood was collected for corticosterone radioimmunoassay. Results showed that pretreatment with mianserin, but not with pindolol, significantly reduced plasma corticosterone levels following administration of LPS (p < 0.05); prazosin attenuated the plasma corticosterone response to LPS (p < 0.05), while propranolol did not induce significant change. The present study indicated that serotoninergic and noradrenergic/adrenergic pathways are involved in the immunoneuroendocrine modulation of hypothalamus-pituitary-adrenal function in rats. In particular, it is probably mediated by the activation of 5-HT2C receptors and of alpha 1-adrenoceptors, while type 1A serotonin receptors or beta-adrenoceptors do not seem to be involved in such a phenomenon.

Metastatic renal cell carcinoma involving Wharton's duct: a case report

This article describes a case of renal cell carcinoma that metastasized to the right Wharton's duct of a 73-year-old man. Metastases of renal cell carcinoma to the oral tissues are rare. Involvement of salivary gland tissue appears to be exceedingly rare, and a metastatic focus localized only in the Wharton's duct never has been reported in the literature.

Malignant acanthosis nigricans with florid papillary oral lesions

Acanthosis nigricans is a distinctive skin disease of importance, because it has served as an external marker for a variety of systemic disorders including endocrinopathies, and malignant tumors of internal organs. It typically appears as hyperpigmented, roughened plaques of velvety consistency and infrequently as verruca-like papillations. The oral cavity and lips can be affected by florid papillary growths. Because of its rarity and nonspecific microscopic appearance, clinical recognition of acanthosis nigricans continues to be a challenge. A case of mucocutaneous "malignant" acanthosis nigricans is presented in which pigmented skin lesions led to the discovery of a gastric adenocarcinoma, which in turn was followed by the appearance of massive oral papillomatosis. No effective treatment was found.

Relationship of circulating CD4+ T-lymphocytes and p24 antigenemia to the risk of developing AIDS in HIV-infected subjects with oral hairy leukoplakia

To investigate the relationship of circulating CD4+ T-lymphocytes and p24 antigenemia to the development of AIDS in HIV-infected subjects with hairy leukoplakia (HL), we have followed over eight years 173 HIV-positive patients, all asymptomatic at the start of the study, and compared those who developed HL (n=55) to those who did not (n=118). Both groups included injection drug users (IDUs), homosexual men, and hemophiliacs. At the time of their first visit, both HL+ and HL- patients had a normal value of CD4+ cells and a low frequency of p24 antigenemia. During the years of follow-up, patients in the HL+ group showed a greater reduction in CD4+ cells, a significant increase in p24 antigenemia, and a higher rate of progression to AIDS. Our study demonstrates that in HIV-positive patients, HL is associated with more compromised immunological parameters and a higher viral replication and that its appearance has a negative prognostic value in relation to AIDS progression.

Bicuculline enhances the corticosterone secretion induced by lipopolysaccharide and interleukin-1 alpha in male rats

Lipopolysaccharide (LPS)-induced inflammatory stress activates the hypothalamus-pituitary-adrenal (HPA) function. Interleukin-I (IL-1) is one of the key factors during this event; however, the mechanisms mediating IL-1 stimulation of HPA axis are still unclear. The present study evaluated the possible involvement of gamma-aminobutyric acid (GABA) in LPS-induced activation of HPA axis in adult male rats. In addition, the possible existence of diurnal changes of LPS-induced HPA axis activity was also investigated. Bicuculline (0.8 mg/kg BW), a GABA-A receptor antagonist and GABA (1 g/kg BW) were intraperitoneally (ip) injected 15 min before LPS (2 mg/kg BW, ip) or recombinant human IL-1 alpha (microgram/rat) administration in intact rats. Control animals received an equivalent volume of 0.9% saline. Rats were sacrificed at 60 min or 90 min after LPS, or IL-1 alpha or saline injection. Plasma corticosterone levels were measured by radioimmunoassay. Results showed that pretreatment with bicuculline enhanced both LPS- and IL-1-induced corticosterone secretion; while pretreatment with GABA significantly reduced the LPS-stimulated corticosterone release (p < 0.05, vs LPS alone). The effect is dependent on the time of sampling and such effect of bicuculline or GABA was not observed when rats were stimulated in the evening. In addition, the maximal changes of plasma corticosterone following LPS administration in the evening were significantly lower than in the morning (p < 0.01). The present study provides evidence that GABA is involved, at least in part, in the neuroendocrine regulation of LPS/interleukin-1a-induced corticosterone secretion via GABA-A receptor in rats. In addition, the response of plasma corticosterone to LPS has a diurnal variation, which corresponds to a diurnal change of GABAergic modulation of the immunoneuroendocrine response.

Evidence for a role for the neurosteroid allopregnanolone in the modulation of reproductive function in female rats

The present study investigated the effect of allopregnanolone (5 alpha-pregnan-3 alpha-ol-20-one) or of passive immunoneutralization of brain allopregnanolone, the most potent steroid produced by neurons, on ovulation rate and sexual behavior in female rats. Allopregnanolone was injected intracerebroventricularly in rats on diestrus and proestrus and tests were done on estrus. The intracerebroventricular injection of allopregnanolone significantly decreased the number of oocytes collected on estrus (p < 0.01). To support a physiological involvement, antiserum to allopregnanolone was injected centrally to block the activity of the endogenous neurosteroid. When administered on diestrus and proestrus or only on proestrus, the antiserum was shown to be correlated with a significant increase (p < 0.01) in oocytes retrieved on estrus. In female rats treated with antiserum to allopregnanolone, the lordosis intensity was augmented significantly as compared to controls. Finally, the possible changes of medial basal hypothalamus concentration of allopregnanolone throughout the estrous cycle and at the time of ovulation were investigated. Hypothalamic extracts were eluted on high-pressure liquid chromatography and allopregnanolone concentration was measured by radioimmunoassay. Brain cortex was used as control tissue. Hypothalamic allopregnanolone concentration on proestrus morning and afternoon was found to be significantly lower than in the remaining phases of the estrous cycle (p < 0.01), while no significant changes were observed in brain cortex concentration of allopregnanolone. The present results suggest that hypothalamic allopregnanolone may be involved in the mechanism of ovulation, affecting hormonal and behavioral events.

Evidence for a role of neurosteroids in modulation of diurnal changes and acute stress-induced corticosterone secretion in rats

The neurosteroid allopregnanolone has been shown to be a potent ligand of gamma-aminobutyric acid (GABA)-A receptors and enhances its receptor-mediated inhibitory events. Since central GABA plays a major inhibitory role, via GABA-A receptors, in hypothalamic-pituitary-adrenal (HPA) function in rats, the present study has evaluated the effect of passive immunoneutralization of allopregnanolone on diurnal changes in corticosterone secretion and acute stress-induced corticosterone secretion in rats. In the first protocol, four groups of male rats (prepubertal, fertile, castrated adult and aged) and three groups of female rats (prepubertal, fertile at different phases of the estrous cycle and aged) were studied. Rats were injected intracerebroventricularly (i.c.v.) with 10 microliters anti-allopregnanolone serum or 10 microliters normal rabbit serum (control) 24 h before exposure to an acute cold swimming stress, and sacrificed either before stress or after 5 min stress. In the second protocol, fertile male or female rats at diestrus II were injected i.c.v. with anti-allopregnanolone serum or normal rabbit serum and sacrificed on the following day at 10.00 or 18.00. Truncal blood samples were collected for measuring plasma corticosterone. Our results showed that there was no significant difference in basal plasma corticosterone levels between antiserum-treated and control rats of both sexes. However, in male rats, central injection of antiserum to allopregnanolone significantly potentiated plasma corticosterone response to stress in prepubertal and adult fertile rats as well as in castrated rats. Likewise, in female rats, the stress response of plasma corticosterone was enhanced by passive immunoneutralization of allopregnanolone in prepubertal and fertile rats throughout the estrous cycle.(ABSTRACT TRUNCATED AT 250 WORDS)

Oral hairy leukoplakia in two children with perinatally acquired HIV-1 infection

We report on two children with acquired immunodeficiency syndrome (AIDS), a 5-year-old girl and a 9-year-old boy, who presented with oral hairy leukoplakia (OHL) as a late clinical manifestation of perinatally acquired human immunodeficiency virus type 1 (HIV-1) infection. The reasons why OHL is a rare symptom in HIV-1-infected children, compared with HIV-1-infected adults, are discussed.

[The Melkersson-Rosenthal syndrome. A report of 2 cases]

The Melkersson-Rosenthal syndrome is a rare condition of unknown etiopathogenesis. This syndrome is characterized by a triad of recurrent orofacial edema, recurrent facial palsy, and fissured tongue. In this paper two patients with Melkersson-Rosenthal syndrome are reported. Also the clinicopathologic aspects and diagnostic problems of this rare disease are discussed.

Pituitary and ovarian interleukin-1 alpha content changes according to estrous cycle and acute stress exposure

A complex interaction between the immune and neuroendocrine systems has been established. In particular, cytokines are known to be one of the mediators of the stress response, and modulate hormone secretion by acting in the brain, pituitary and gonads. The aim of the present study is to investigate whether pituitary and ovarian interleukin-1 alpha (IL-1 alpha) content changes according to the estrous cycle. In addition, the possible pituitary and ovarian IL-1 alpha changes in rats exposed to acute (5 min) or chronic intermittent (twice a day for 4 days) cold swimming stress were studied. The IL-1 alpha content of ovarian and pituitary homogenates was measured by a sensitive and specific radioimmunoassay. Immunoreactive IL-1 alpha (irIL-1 alpha) was detectable only in ovaries collected in rats at proestrus and estrus while not in those collected at diestrus I and II. The highest values were found at proestrus. No significant changes were found in ovarian irIL-1 alpha content in rats exposed to acute or chronic intermittent stress in comparison to control rats. In the pituitary, no difference in IL-1 alpha content was found throughout the estrous cycle. Acute stress induced a significant increase in pituitary irIL-1 alpha content only at proestrus (p < 0.01), however, no significant differences were found in comparison to control rats after chronic intermittent stress. The proestrus-related changes of ovarian IL-1 alpha may constitute a hormone-dependent signal within the ovary that is involved in the ovulatory process.(ABSTRACT TRUNCATED AT 250 WORDS)

Leukocyte adhesion molecules in oral lichen planus: a T cell-mediated immunopathologic process

Oral lichen planus exhibits features of a mucosal type IV immunopathologic process. Adhesion molecules involved in the trafficking and homing of T lymphocytes to the subepithelial compartment were assessed by immunohistochemical methods. Laminin, type IV collagen and type VII collagen extracellular matrix components at the epithelial-connective tissue junction are significantly increased and serve as ligands for beta 1 integrins on lymphocyte membranes. Endothelial-associated intercellular adhesion molecule 1 and extracellular matrix basement membrane components are also significantly increased in the submucosa. Keratinocyte expression of major histocompatibility complex class II molecules and intercellular adhesion molecule 1 may serve as ligands for lymphocyte T cell receptor complex and beta 2 integrins, respectively. These adhesion molecules are probably involved in the trafficking of lymphocytes to the epithelial connective tissue interface in response to as of yet undefined antigens.

Acute stress- or lipopolysaccharide-induced corticosterone secretion in female rats is independent of the oestrous cycle

The aim of the present study was to test whether oestrous cycle is associated with the hypothalamus-pituitary-adrenal (HPA) axis function. Thus, corticosterone secretion in rats was investigated following lipopolysaccharide (LPS), acute cold-swimming or ether stress or synthetic corticotrophin-releasing factor (CRF) administration throughout the oestrous cycle. Moreover, plasma corticosterone response to cold-swimming stress or LPS administration also was studied at different times of day on pro-oestrus of di-oestrus-I. The following observations were obtained: the morning plasma corticosterone levels in control rats did not differ with the stage of the oestrous cycle; plasma corticosterone levels increased significantly following LPS administration (2 mg/kg, ip) or following acute exposure to cold (4 degrees C)-swimming or ether stress. However, this increase in plasma corticosterone levels was not related to the stage of the oestrous cycle; synthetic CRF injection induced an increase in plasma corticosterone levels constant on di-oestrus-I and pro-oestrus; plasma corticosterone response to LPS administration or acute cold-swimming stress showed diurnal changes, with the lowest values at 18.00 h, which was independent of the oestrous cycle. By showing the unchanged corticosterone response to LPS, to acute stress and to exogenous CRF throughout the oestrous cycle, and the independence of the diurnal pattern of stress response on the oestrous cycle, the present study suggests that the oestrous cycle has no influence on the HPA activity under the present experimental conditions in rats.

Facial and perioral molluscum contagiosum in patients with HIV infection. A report of eight cases

Facial and perioral molluscum contagiosum is a common and often disfiguring condition in patients with HIV infection. The purpose of this study was to report on the clinical aspects of eight HIV-positive patients with facial molluscum contagiosum. Also we describe the histopathologic and electron microscopic findings and discuss the treatment modalities for this unusual disease.

[Bone involvement of the jaws in AIDS-related Kaposi's sarcoma]

The authors report on five patients with jaw bone involvement of Kaposi's sarcoma. In this study clinical, radiographic and histopathological aspects are described.

Ontogeny of the circadian rhythm in medial basal hypothalamic beta-endorphin content in female rat

The present study evaluated the possible role of estrogens in generating the circadian rhythm of medial basal hypothalamus content at the time of puberty in female rats. Accordingly, changes in medial basal hypothalamus beta-endorphin (beta-EP) content were investigated in female rats, before and at puberty. Groups of intact or ovariectomized rats were studied after estradiol-benzoate or placebo treatment. The results showed that circadian rhythm of beta-EP content of medial basal hypothalamus is absent in prepubertal rats, while it appears at puberty, associated to a significant increase of beta-EP concentration. The primary involvement of steroids in generating this circadian rhythm was supported by the finding that estradiol-benzoate treatment caused a precocious appearance of beta-EP hypothalamic diurnal changes in prepubertal rats. Moreover, estradiol-benzoate replacement restored the loss of beta-EP nocturnal increase induced by ovariectomy in pubertal animals. Therefore, these data support the significant role of estrogen in inducing the circadian rhythm of beta-EP content in medial basal hypothalamus at the time of puberty in female rats.

[Benign pemphigoid of the mucous membranes: the clinical and histopathological aspects in 20 patients]

Benign mucous membrane pemphigoid is an autoimmune vesiculo-bullous disease which affects the oral mucosa. The purpose of this study is to report the clinical and pathological features of 20 patients with benign mucous membrane pemphigoid. Four patients were men and 16 female with a mean age of 58 years. The ratio of male to female was 1:4. Seventy percent of patients showed gingival involvement. Other locations were buccal mucosa, palate and floor of the mouth. The majority of patients had ulcers covered by pseudomembranes, complained of pain and burning and 40% reported bleeding gums. Nikolsky's sign was observed in 60% of cases. In all cases microscopic features of benign mucous membrane pemphigoid showed a separation of epithelium from the connective tissue along the basement membrane (sub-epithelial bulla).

Cowden's syndrome: a case report with clinical, histopathologic and immunological studies

Cowden's syndrome is a rare autosomal dominant condition characterised by multiple hamartomas of the gastrointestinal tract and cancer of the breast and thyroid. We present a patient with multiple papillomatous lesions of the hard palate, facial papules, and a history of breast cancer and papillomas of the uterine cavity. We also report the results of light and electron microscopy of the palatal lesions and immunological studies of patient's T-lymphocyte function.

[Evaluation of the clinical efficacy of azithromycin in acute respiratory infections in children]

Azithromycin activity in vivo has been studied in a group of children with acute respiratory tract infections in order to test the efficacy and tolerability of this antibiotic. The study involved 135 children treated with a single daily 10 mg/kg dose of azithromycin for three consecutive days. Ten days after this treatment 100% of children with otitis media, tracheobronchitis, or rhinosinusitis and 95.9% of children with pharyngo-tonsillitis were cured. Recurrences were never observed. Azithromycin proved remarkably effective for treatment of acute respiratory infections and otitis media in children. Tolerability and therapeutic compliance were excellent.

HIV-related tumors of the oral cavity

In HIV-infected patients with AIDS the most frequent malignancies are Kaposi's sarcoma and non-Hodgkin's lymphoma. In these patients, the natural history of these tumors is quite different from those of HIV-negative subjects. These tumors may present atypical clinical aspects, may be very aggressive, and the coexistence of immunosuppression and opportunistic infections may render their treatment more difficult. The aim of this article is to provide updated information on the epidemiology, pathogenesis, natural history, and management of tumors that develop in the oral cavity of patients with AIDS.

Oral lesions among HIV-infected hemophiliacs. A study of 54 patients

BACKGROUND

HIV-infected individuals develop a large variety of oral manifestations. This study was designed to assess the prevalence and types of oral lesions among HIV-positive hemophiliacs.

MATERIALS AND METHODS

A study population of 54 hemophiliacs was evaluated from February, 1987 to March, 1992 in order to analyze types, prevalence and relationships to clinical stages of HIV-related oral lesions. Thirty-six (67%) of the group of patients were HIV seropositive. The remaining 18 tested negative to HIV during the observation period.

RESULTS

The majority of patients suffered from hemophilia A. One patient was also bisexual and two were also intravenous drug abusers. Analysis of patient stage revealed that half had a CD4+ T-lymphocyte count over 0.5 x 10(9)/L cells, 10 between 0.2 and 0.499 x 10(9)/L and 8 showed a count lower than 200 x 10(9)/L. Oral lesions were recorded in 18 (50%) HIV-seropositive hemophiliacs. No oral lesions were observed among the HIV-seronegative hemophiliacs. Advanced stage of immunosuppression and presence of oral lesions were significantly associated (p = 0.040). Candidiasis was the most common disturbance, followed by hairy leukoplakia. Oral herpes simplex infection, necrotizing gingivitis and facial herpes zoster were found in a small number of patients. Those with oral lesions showed a lower median CD4+ T lymphocyte count (0.209 x 10(9)/L cells; range 0.008 to 0.615) when compared to the ones without oral lesions (median CD4+ count was 0.539 x 10(9)/L cells; range 0.042 to 1.180; p = 0.002).

CONCLUSIONS

HIV-seropositive hemophiliacs may develop oral lesions during the course of their disease. Candidiasis and hairy leukoplakia are among the most common manifestations. A careful oral examination should be included in the clinical evaluation of all HIV-infected hemophiliacs.