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.

Unusual clinical aspects of oral non-Hodgkin lymphomas in patients with HIV infection

Patients with HIV infection are at greater risk of developing malignancies. We report two HIV-seropositive patients with primary oral manifestation of a B-cell non-Hodgkin lymphoma (NHL). Localisations of tumours were the palate, with an unusual bifocal origin, and the tongue which is rarely the primary site of NHL. Ulcerations and extensive tissue necrosis were observed. Histologically both cases were high grade malignant lymphomas, immunoblastic. Epstein-Barr virus DNA was detected with in situ hybridisation in 1 patient.

White lichenoid lesions of the buccal mucosa in patients with HIV infection

We report on eight patients who developed white lichenoid lesions of the buccal mucosa during the course of human immunodeficiency virus infection. In five patients the lesions appeared after the administration of zidovudine, in two after the intake of both zidovudine and ketoconazole, and in one after ketoconazole. In the majority of cases, lesions presented as bilateral reticular keratosis or atrophic changes of the buccal mucosa. Three patients manifested lichenoid atrophic changes of the dorsum of the tongue. The histopathologic features were hyperkeratosis, epithelial atrophy, basal cell liquefaction, and the presence in the lamina propria of either a patchy or diffuse lymphocytic infiltrate. All specimens tested negative for Epstein-Barr virus and human papillomavirus. Our study suggests that lichenoid lesions of the buccal mucosa, similar to what has been described as lichenoid drug reactions or idiopathic lichen planus, can be observed during human immunodeficiency virus infection and that administration of zidovudine and ketoconazole should be considered as a possible cause.

Effect of chronic intermittent stress on rat pregnancy and postnatal development

The present study evaluates the effect of chronic intermittent cold-swimming stress on body weight gain of pregnant rats and subsequent development of the offsprings after birth, till peripubertal stage. When stress was administered during the first half (1-11 days) of gestation, weight gain of pregnant rats was significantly lower at the 9th and 11th days (P < 0.05 vs. control, respectively). No differences of weight gain in comparison with control rats were found at term gestation in pregnant rats exposed to stress continuously. Similarly, stress administered, starting from 12th day till term gestation, had no effect on weight gain. Even though weight gain of pregnant rats during the second half of pregnancy in group stress 1-11 was restored to normal values, a high mortality rate of neonates 1, 2 and 3 weeks after birth was found in this group (P < 0.02, 0.01 and 0.001 vs. controls). There was no significant difference between stressed and control groups with respect to the number or body weight of litters, as well as weight gain of neonates during the first 21 days of life. In addition, in offsprings from all stressed groups, a high number of small for date animals was found after 14 days of life, and 74.4% of these small for date animals died during the peripubertal period. The present data demonstrate that the exposure to stress in utero may induce damaging effects on postnatal development.

Effect of different chronic intermittent stressors and acetyl-l-carnitine on hypothalamic beta-endorphin and GnRH and on plasma testosterone levels in male rats

Chronic stress affects the reproductive function by modifying the neuroendocrine homeostasis. The aim of the present study was to clarify the neuroendocrine and the gonadal changes following chronic intermittent stress in male rats and the action of a neuroactive drug, acetyl-l-carnitine (ALC). The effect of two different stressors, cold water swimming or ether, on central beta-endorphin (beta-EP) and GnRH contents, and on plasma testosterone levels was investigated. In addition, the response to an acute stress in chronically stressed rats, treated or untreated with ALC (10 mg/day/rat p.o.), was evaluated. The stressors were applied twice a day for 10 days, and rats were killed before, during and after the last stress session. Mediobasal hypothalamus (MBH) beta-EP and GnRH contents, and plasma testosterone levels were evaluated by radioimmunoassay. The following results were obtained: (1) both chronic swimming and ether stress caused a decrease in hypothalamic beta-EP contents; (2) MBH GnRH contents increased after chronic swimming stress but not after ether stress; (3) chronic swimming stress induced a twofold decrease in plasma testosterone levels, while no changes were observed after ether stress; (4) the treatment with ALC prevented the decrease in plasma testosterone levels after chronic swimming stress, and (5) acute stress in chronically stressed animals caused an increase in MBH-beta-EP. The present data showed that chronic swimming stress reduces the reproductive capacity and impairs the capacity to respond to the acute stress and that ALC modulates the hormonal changes to physical stress and prevents the antireproductive effect of chronic cold swimming.

Early oral presentation of lues maligna in a patient with HIV infection. A case report

We present a case of a patient infected with the human immunodeficiency virus who developed syphilis manifested by atypical early oral and skin ulcerations. The profound immune defects associated with human immunodeficiency virus may lead to an altered clinical presentation and a more aggressive course in patients infected with Treponema pallidum. The unusual clinical manifestations observed in this case emphasize the importance of considering secondary syphilis in the differential diagnosis of any inflammatory mucosal and skin disorder in patients with the human immunodeficiency virus.

Clinical aspects and microbiology of HIV-associated periodontal lesions

This study examines the clinical aspects of HIV-associated periodontal lesions and the prevalence of periodontal pathogens. Subgingival plaque samples were taken from 55 subjects in six study groups: 1) HIV-seropositive patients with gingivitis, 2) necrotizing gingivitis, 3) periodontitis or 4) with health periodontium, 5) patients with rapidly progressive periodontitis or 6) periodontally healthy in whom there was no evidence of HIV infection. Among HIV-positive patients there was a majority (66%) of intravenous drug users. We detected more Bacteroides intermedius, B. buccae and B. oralis in HIV-infected patients with periodontal lesions and in HIV-negative subjects with rapidly progressive periodontitis than in the other groups. High levels of Spirochetes were recovered in both HIV associated necrotizing gingivitis and periodontitis. The results indicate that there is a similarity in the microbiological profile of HIV-associated gingivitis, necrotizing gingivitis, periodontitis and rapidly progressive periodontitis of HIV-negative subjects although significant differences in the clinical aspects of the lesions and in the immune status of the host have been observed.

Acetyl-L-carnitine effect on pituitary and plasma beta-endorphin responsiveness to different chronic intermittent stressors

The aims of the present study were: 1) to compare the effect of two different chronic intermittent stressors i.e. cold-swimming versus ether, on the pituitary opioidergic system; 2) to evaluate the response of pituitary and plasma beta-endorphin (beta-EP) to an acute stress in chronically stressed rats; and 3) to evaluate the effect of acetyl-l-carnitine treatment (10 mg/day/rat per os at night) on pituitary and plasma beta-EP changes induced by two different types of chronic stress. The stressors were applied twice a day for 10 days. Rats were killed either before, during or after the last swimming or ether stress session. beta-EP was measured by radioimmunoassay in anterior pituitary and in neurointermediate lobe extracts and in plasma. The following observations were made: 1) Chronic intermittent cold-swimming stress increased anterior pituitary contents and plasma beta-EP levels; 2) both chronic intermittent cold-swimming stress and ether stress caused an increase of neurointermediate lobe beta-EP contents; 3) as in control animals, rats exposed to chronic intermittent swimming stress reduced pituitary beta-EP contents and raised plasma beta-EP levels in response to the last acute swimming stress; 4) in contrast to control animals, rats exposed to chronic intermittent ether stress did not show any significant response of the pituitary-plasma opioidergic system to the last acute ether session; 5) the acetyl-l-carnitine treatment counteracted the changes evoked by chronic intermittent cold-swimming stress on the pituitary and plasma beta-EP levels.(ABSTRACT TRUNCATED AT 250 WORDS)

Oral Crohn's disease and pyostomatitis vegetans. An unusual association

Oral features of Crohn's disease include ulcers, lip fissuring, cobblestone plaques, angular cheilitis, polypoid lesions, and perioral erythema. Pyostomatitis vegetans is a rare eruption of the oral mucosa characterized by tiny yellow pustules. It is considered a marker for inflammatory bowel disease. We describe a 45-year-old woman with a 6-month history of painful sores in her mouth, diarrhea, weight loss, and cutaneous lesions. Oral examination revealed cobblestone plaques and indentation on the tongue and friable vegetating pustules on the labial commissures. Staphylococcus simulans was isolated from the pustules. Laboratory studies revealed leucocytosis, eosinophilia, and low hemoglobin and zinc levels. Histologic study of the labial lesions revealed hyperplastic epithelium with intraepithelial clefts that contain eosinophils and neutrophils. Tongue lesions showed chronic inflammation with noncaseating granulomas. Later, colonoscopy and biopsy demonstrated Crohn's disease of the anorectal region. Pyostomatitis vegetans lesions regressed after oral zinc supplementation. Prednisone treatment resulted in healing of the tongue lesions. In our patient, pyostomatitis vegetans appeared to be related to zinc deficiency that may have been caused by malabsorption. The pathogenetic interrelationship between pyostomatitis vegetans and Crohn's disease is discussed.

Actinomycosis of the tongue: a diagnostic challenge

Actinomycotic infections of the cervicofacial area are rare and frequently show a confusing clinical picture. We report a case of actinomycosis that mimicked a neoplasm of the tongue. The clinical and pathologic features and the differential diagnosis of this unusual oral infection are discussed.

Hairy leukoplakia with involvement of the buccal mucosa

Oral hairy leukoplakia occurs mainly on the tongue of human immunodeficiency virus (HIV)-infected persons. An HIV-infected patient with hairy leukoplakia involving the tongue and buccal mucosa was studied by light and electron microscopic methods, in situ hybridization, and polymerase chain reaction. Our findings indicate that hairy leukoplakia may involve the buccal mucosa and should be considered in the differential diagnosis of white oral lesions in HIV-positive patients. Epstein-Barr virus particles were found in the epithelial cells of both buccal and tongue mucosa.

Polymerase chain reaction: relevance for oral pathology

The polymerase chain reaction (PCR) is a recent innovation in biotechnology for amplifying specific nucleic acid sequences by use of repeated cycles of DNA synthesis. Application of PCR has been extended to a wide variety of biological and medical disciplines; fields of application include molecular genetics, pathology, microbiology, forensic medicine, and infectious diseases. Because of its speed and powerful sensitivity, PCR has become a highly valuable method for detecting small amounts of target nucleic acid sequence with the caveat that it has certain limitations. Importantly, false-positive reactions can result from the amplification of contaminating DNA whereas false-negative reactions can result from introduction of inadequate numbers of primer sequences. The application of PCR in the context of oral pathology is presented along with a discussion of the utility of this technique to aid in the elucidation of the etiology of oral disease.

Melatonin treatment delays reproductive aging of female rat via the opiatergic system

In female rat age-related reproductive decline is accompanied by progressive impairment of the neuroendocrine mechanisms that regulate LH secretion. The biosynthetic activity of the pineal gland is markedly depressed and the nocturnal secretion of melatonin decreases significantly. The aim of the present study was to evaluate whether the nocturnal administration of melatonin via the drinking water (0.4 micrograms/ml) throughout the course of aging from 14 to 24 months of age could (1) influence the age-related changes that occur in basal serum levels of LH and in the LH response to GnRH or to naloxone stimulation at 16, 18 and 20 months of age, and (2) delay the onset of the postreproductive constant estrous-anovulatory state as evaluated by the daily recording of vaginal smears and by occurrence of polyfollicular ovaries at 24 months of age. Our results demonstrate that melatonin replacement delays the increase in LH serum levels and the decrease in LH response to GnRH that occur in 18-month-old control animals. Furthermore, they show that melatonin treatment prevents the loss of LH response to naloxone manifested in control rats between 16 and 20 months of age. Melatonin also appears to prevent the progressive increase in the monthly occurrence of estrus phases as well as to decrease the number of rats with polyfollicular ovaries at 24 months of age in comparison to control animals. These results suggest that the age-related decrease in circulating melatonin during the night may contribute to the reproductive decline of aging, and that this effect may involve the central opioid system.

HIV-related infections of the oral cavity

Oral infections are among the first manifestations of infection by the human immunodeficiency virus (HIV). They include fungal, viral, and bacterial infections and range from being essentially trivial, through troublesome to life threatening. Although some infections are due to overproliferation of the normal oral flora, others are due to organisms that normally are not found in the mouth. The clinical features of many of these infections have now been characterized, and clinical trials have indicated the optimal management. However, for many infections, the underlying processes are still not clear, and improvements in treatment are necessary.

Prevalence of Epstein-Barr virus and human papillomavirus in oral mucosa of HIV-infected patients

Epstein-Barr virus (EBV) has been implicated in the genesis of oral hairy leukoplakia (OHL). Initially, OHL was also associated with human papillomavirus (HPV) as evidenced by staining with antiserum to papillomavirus common structural antigens and reports of two HPV-positive OHL as detected by in situ DNA hybridization. The aims of this study were to determine the prevalence of EBV and HPV DNA in OHL and normal oral mucosa and to explain the basis for the staining of OHL tissues with antibodies to papillomavirus common structural antigens. EBV DNA was detected by in situ hybridization in 47 of 47 cases of OHL from human immunodeficiency virus (HIV)-seropositive individuals and in 1 of 10 biopsies of clinically normal buccal mucosa from the same group of individuals. Twenty-five of 35 OHL specimens stained with antibody to papillomavirus common structural antigens. There was no staining of two EBV-containing lymphoblastoid lines, indicating that the staining with anti-papillomavirus antibody was not due to antigenic cross-reactivity with EBV antigens. HPV DNA was detected by polymerase chain reaction amplification in 10 of 18 OHL specimens and in 6 of 10 normal buccal mucosa specimens. Our results indicate that EBV and HPV are present frequently in OHL and that HPV can be found regularly in histologically normal mucosa.

[A spindle-cell carcinoma of the oral mucosa. A case report]

Spindle cell carcinoma is a relatively rare tumor which occurs often in the upper respiratory tract, the oral cavity, and in the esophagus and skin. In this paper a patient who presented a tumor mass of the lover gingiva which was subsequently diagnosed as a spindle cell carcinoma is reported. The clinicopathologic aspects and diagnostic problems of this unusual tumor of the oral mucosa are discussed.

[Benign lymphoepithelial cysts of the parotid in a patient with HIV infection]

We report on a HIV-positive patient presenting bilateral enlargement of the parotid gland. The ultrasound examination demonstrated multiple lesions with cystic aspect. A partial surgical excision of the parotid gland was performed, and histologic examination confirmed the diagnosis of a cystic benign lymphoepithelial lesion. The specimens which were tested for Epstein-Barr virus and cytomegalovirus by in situ hybridization proved negative. The clinical and pathologic features of this unusual salivary gland lesion which affects HIV-positive patients are discussed.

Oral lesions of iatrogenic and undefined etiology and neurologic disorders associated with HIV infection

A review of a miscellaneous group of oral mucosal disorders in the setting of infection with the human immunodeficiency virus is presented. Included is a discussion of oral lesions of iatrogenic and undefined etiology and neurologic disorders. Mechanisms of pathogenesis, including possible common pathways and relationships to underlying immunosuppression, are emphasized.

[Dentists' knowledge and attitudes on HIV infection]

A questionnaire was given out to a group of 124 dentists in order to find out their level of knowledge of HIV infection. The answers show that dentists are reluctant to work with HIV-seropositive patients and that knowledge of control and diffusion of the disease is poor.

Oral hairy leukoplakia: clinical aspects, histologic morphology and differential diagnosis

Clinical and histologic morphology of oral hairy leukoplakia in 85 HIV-positive patients were studied. Differential diagnosis of oral hairy leukoplakia in comparison with the normal lingual and buccal epithelium from both HIV-positive and HIV-negative patients, and with other tongue conditions was also examined. Oral hairy leukoplakia lesions were located on the lateral borders of the tongue and showed a corrugated/hairy aspect in the majority of cases. Hyperparakeratosis, hyperplasia/acanthosis, and a papillated epithelial surface were common findings. A parakeratin band and ballooning cells were present in 60% and 99% of the cases, respectively. Some of the histologic features of oral hairy leukoplakia were present in the normal lingual epithelium of both HIV-negative and HIV-positive patients as well as in other tongue conditions. Thus, many histologic features of oral hairy leukoplakia appear not to be specific.

Recurrent oral condylomata acuminata and hairy leukoplakia: an early sign of myelodysplastic syndrome in an HIV-seronegative patient

Oral hairy leukoplakia (OHL) has been observed in all risk groups seropositive for HIV infection. Recently, this lesion has also been described in HIV-seronegative patients with immunosuppression of iatrogenic origin. We report on a HIV-1 and HIV-2 seronegative, heterosexual man affected by refractory anemia with ringed sideroblasts (myelodysplastic syndrome), who developed recurrent oral condylomata acuminata and OHL as an early clinical manifestation. The diagnosis of OHL was confirmed by identifying Epstein-Barr viral particles by electron microscopy and by in situ DNA hybridization. HIV infection was ruled out using polymerase chain reaction and testing for HIV-1 and HIV-2 antibodies.

CD36(OKM5)+ dendritic cells in the oral mucosa of HIV- and HIV+ subjects

In this study, we have investigated by light and electron microscopy the presence, distribution, and inner structure of CD36(OKM5)+ dendritic cells (DC) in the lamina propria and epithelium of the oral mucosa of HIV- and HIV+ subjects; in the latter, both clinically healthy areas and areas of hairy leukoplakia (HL) were studied. Perivascular CD36+ DC were present in the lamina propria of all the specimens studied. They were also found in small numbers in the epithelium of clinically healthy mucosa of HIV- and HIV+ subjects, but were practically absent from the epithelium of HL. CD36+ DC seemed to be regularly HLA-DR+ in HIV-subjects; this positivity was recognized only in some cells in the clinically healthy mucosa of HIV+ subjects, and practically never in HL. Because the only perivascular cells observed in the clinically healthy areas of HIV+ subjects were CD36+, we investigated the ultrastructure of perivascular DC in these same areas. These cells were characterized by the presence of a prominent Golgi apparatus, many lysosomes, and focal adhesions to the extracellular matrix. It may be concluded that 1) CD36+ DC are physiologic components of the oral mucosa, 2) they share some ultrastructural features with macrophages, 3) no differences in numbers were found between HIV+ and HIV- subjects, and 4) these cells are affected in their expression of HLA-DR antigens during HIV infection, particularly in areas of HL. This may be a hint that the antigen-presenting function of these cells in the oral mucosa is negatively affected during HIV infection.

[Peripheral facial paralysis and HIV infection]

Two cases of peripheral facial paralysis associated with infection by the human immunodeficiency virus in young intravenous drug abuser patients are reported. One patient manifested AIDS-related complex (ARC) and the other fulfilled the Center for Disease Control (CDC) criteria for AIDS. Clinical symptoms and signs occurred as facial paralysis and headache. One patient presented progressive motor slowing and the computerized tomography (CT) of the brain showed a wide hypodense lesion in the left temporal-anterior region and the involvement of the left basal ganglia. In this patient the impairment of the facial nerve was associated with a HIV-related encephalitis. In the second patient the CT did not show cerebral lesions and the etiology of the paralysis was unknown.