Acquired immune deficiency syndrome presenting as a palatal perforation

Traumatic palatal perforation after orotracheal intubation: a case report and a review of the literature

In this report, we describe an unusual case of a traumatic palatal perforation caused by orotracheal intubation. The paucity of reports of palatal perforation resulting from intubation in the literature suggests that it is a rare occurrence. However, recognizing this potential complication and managing the airway appropriately may reduce patient morbidity.

Hard palate perforation due to invasive aspergillosis in a patient with acute lymphoblastic leukemia

Invasive aspergillosis (IA) is a major cause of morbidity and mortality in immunosuppressed patients. Primary oral invasive aspergillosis is a rare condition. We present an acute lymphoblastic leukemia (ALL) patient with hard palate perforation due to invasive aspergillosis. Two months after the appearance of the fungal lesions, perforation of the hard palate was seen despite amphotericin-b and itracanazole therapy. After debridement of necrotic tissue the patient was followed for spontaneous closure for 6 months but it was seen that the fistula persisted despite the disappearance of the infection. The patient was operated for closure of the palatal fistula and there was no recurrence in 6 months of follow up. Surgical and medical management was performed successfully. Invasive oral aspergillosis is a potentially lethal disease and it should be considered in immunosuppressed patients with oral lesions.

Oral histoplasmosis in Brazil

OBJECTIVE

We report 10 cases of histoplasmosis with oral manifestations seen in a teaching hospital in Brazil.

STUDY DESIGN

This is a retrospective study of the sociodemographic, clinicopathologic, and treatment data of these cases.

RESULTS

Overall, 8 of 10 cases were seropositive for human immunodeficiency virus (HIV), whereas 2 were negative. The predominant oral manifestations found in HIV-seropositive patients were ulcers, oral pain, and odynophagia; both of the HIV-seronegative patients were symptom-free. HIV infection was suspected in 7 cases because of the presence of oral lesions of histoplasmosis. Asthenia, fever, weight loss, lymphadenopathy, and hepatosplenomegaly were found only in HIV-seropositive patients. Radiographs in 3 out of 10 patients suggested pulmonary involvement. Amphotericin B was the antifungal therapy chosen, and clinical remission of oral lesions occurred in an average of 30 days (accumulated doses: 500-1500 mg). Itraconazole was very effective as a follow-up treatment in terms of prevention of recurrence.

CONCLUSION

Histoplasmosis only rarely affects HIV-seronegative patients; however, the possibility of hidden immunodepression should be considered when oral manifestations of histoplasmosis are present.

Oral histoplasmosis as an indicator of HIV infection

Histoplasmosis as a serious opportunistic infection in association with AIDS has assumed considerable importance. We have gathered 20 case reports from the literature of oral histoplasmosis in HIV-infected patients. In some cases, oral lesions appear to be the primary or only manifestation of disease. We report one such case of oral histoplasmosis in a bisexual man who was seen with ulcerations on the palate and proved to be infected by HIV.

Disseminated histoplasmosis with orofacial involvement in HIV-I-infected patients with AIDS: manifestations and treatment

INTRODUCTION

Histoplasmosis is a deep mycosis which is increasingly seen in HIV disease. It has emerged as a relatively common infection in Argentina, mainly in HIV-infected and other immunocompromised persons, and is often disseminated (DH).

OBJECTIVE

The aim of this study was to describe 32 HIV-I-seropositive patients with AIDS who had DH, 21 of whom presented orofacial manifestations, and their treatment.

SUBJECTS AND METHODS

A retrospective study of 876 HIV-seropositive patients revealed 32 with a clinical diagnosis of DH confirmed by special stains on histopathologic specimens, or by culture.

RESULTS

Thirty-two HIV-infected patients had DH. Two-thirds (21 patients) had oral lesions of histoplasmosis, of which six presented with oral cavity (OC) lesions as the sole orofacial manifestation of disease, nine patients presented oral and facial (OF) lesions and six presented facial lesions only. A unique case of submandibular histoplasmosis is also reported. Antifungal therapy cleared more than 90% of the orofacial and disseminated lesions of histoplasmosis. Over the 7-year period there was a mortality of 85%.

CONCLUSION

DH should be considered as a possible diagnosis in HIV patients with chronic ulcerative or nodular orofacial or oral lesions. Itraconazole is an effective and acceptable therapy.

The deep mycoses in HIV infection

The deep mycoses are uncommon infections, usually acquired from the inhalation or ingestion of fungal spores, sometimes from the soil in areas of endemicity, such as in the Americas and south-east Asia, or from decaying vegetable matter. They are also seen in immunocompromised persons and, increasingly, in HIV-infected persons. Respiratory involvement is frequent, with granuloma formation, and mucocutaneous involvement may be seen. Oral lesions of the deep mycoses are typically chronic but non-specific, though nodular or ulcerative appearances are common. Person-to-person transmission is rare. In HIV disease, the most common orofacial involvement of deep mycoses has been in histoplasmosis, cryptococcosis, aspergillosis and zygomycosis. Diagnosis is usually confirmed by lesional biopsy although culture may also be valuable. Treatment is with amphotericin or an azole.

Oral manifestations of human immunodeficiency virus infection

This article includes the oral manifestations which have been reported to be associated with human immunodeficiency virus (HIV) infection. The clinical appearance, diagnostic criteria and treatment of fungal, viral and bacterial infections, neoplasms and lesions of uncertain etiology are described. Accurate diagnosis of the oral lesions is important in the management of patients infected with HIV. Identification of oral lesions may suggest the need for HIV testing or may be an indicator for preventive intervention. Early identification, diagnosis and treatment may prevent extensive tissue destruction and may improve the quality of life for HIV-infected patients.

Mucocutaneous histoplasmosis in AIDS

A 36-year-old man, who was an intravenous drug abuser, developed thoracic herpes zoster, paronychia, oral candidosis, necrotizing gingivitis and bilateral parotid salivary gland swelling. Granulomatous oral lesions and ulceration on the nose were shown to be due to disseminated histoplasmosis.

Oral histoplasmosis in HIV-infected patients. A report of two cases

Histoplasmosis is a fungal infection caused by the organism Histoplasma capsulatum. Disseminated disease usually occurs in immunosuppressed patients or in patients with chronic illnesses. Although relatively uncommon, histoplasmosis has been reported in patients with AIDS, and oral lesions have been noted on multiple sites and in various clinical presentations. We present two HIV-positive cases with oral lesions as the initial signs of histoplasmosis. Both patients responded well to IV amphotericin B but later suffered recurrences despite being maintained on systemic antifungal therapy.

Oral histoplasmosis in a patient infected with HIV. A case report

Histoplasmosis is a frequent complication of HIV infection and is usually the result of reactivation. In the immunocompromised host, histoplasmosis may cause a chronic pulmonary infection or disseminated disease. In the setting of disseminated disease, oral lesions are present in 30% to 50% of patients and may occur in almost every part of the oral mucosa. The most common sites are the tongue, palate, and buccal mucosa. In some cases, oral lesions appear to be the primary or only manifestation of disease. We have been able to find only five case reports in the literature of histoplasmosis in HIV infection with oral lesions. In two of the cases, histoplasmosis was apparently localized to the oral cavity, whereas two cases also had evidence of disseminated disease, the fifth was undetermined. We report one such case of apparently localized oral histoplasmosis in a patient with HIV infection.

Oral manifestations in HIV-infected patients: diagnosis and management

Oral lesions have been observed since the beginning of the AIDS epidemic. The number of HIV-infected patients is still increasing, especially in the heterosexual population. Oral diseases in HIV-infected patients are often more difficult to diagnose because the clinical presentations may differ from the same diseases in HIV-negative patients. HIV-associated oral lesions have diagnostic, prognostic, and therapeutic impact. Approximately 10% of the HIV-infected population will have oral manifestations as a first sign of their disease. In HIV-infected men oral hairy leukoplakia and oral candidiasis are useful markers for disease progression. This article summarizes the oral manifestations and the management of oral health in persons with HIV infection.

Complications of dental surgery in persons with HIV disease

Post tooth extraction infective complications have occasionally been described in HIV-infected persons. However, there is little objective data as to the frequency of this and the need for antibiotic prophylaxis. Similarly the frequency of postextraction bleeding in patients infected with HIV, who may have thrombocytopenia, is unknown. In the present study the frequency of postextraction complications has been investigated in a group of 38 persons at stages 2 to 4 of HIV infection and 26 matched subjects from patients groups commonly at risk of HIV infection but not seropositive. During 40 clinical procedures in HIV-infected patients, 100 (range 1 to 23, median 1) teeth were extracted. Three episodes of delayed postextraction healing were recorded. During 30 procedures in the non-HIV-infected persons, 68 (range 1 to 5, median, 2) teeth were extracted, and two episodes of delayed postextraction healing were recorded. These differences were not significant. Only one HIV-infected patient had an episode of severe postextraction bleeding: this was a hemophiliac who bled despite receiving factor VIII prophylaxis. The bleeding occurred 7 days after the extraction and ceased with tranexamic acid and additional factor VIII. No control subject had severe postextraction hemorrhage. It is concluded that postextraction complications are uncommon in HIV-infected patients and that routine antibiotic prophylaxis is not indicated.

The simultaneous occurrence of oral herpes simplex virus, cytomegalovirus, and histoplasmosis in an HIV-infected patient

Numerous publications have reviewed the oral manifestations of HIV infection and AIDS. Although uncommon, herpetic infections and histoplasmosis are among the diseases reported. The case that follows presents the first description of the simultaneous occurrence of oral herpes simplex virus, cytomegalovirus, and histoplasmosis in an HIV-infected person. These infections appeared as extensive oral ulcerations and were the only clinical manifestation of HIV infection. Eleven months after the initial presentation, the patient died of complications of AIDS.

Evaluation of prognosis and survival of the HIV-infected patient

HIV disease, once considered an acute disease with a 100% mortality rate but a very short symptomatic stage, has begun to emerge as a preventable, treatable, chronic disease. Interactions between patients, dentists, and physicians are essential to gain the information necessary to provide appropriate dental care for both short-term and long-term survivors. The prognosis and survival time of the dental patient may influence treatment protocols and necessitate modified dental procedures. Certain clinical and laboratory parameters, which may be useful indicators of disease progression, need to be recognized by the dental clinician. These parameters include systemic signs, symptoms, and serologic data as well as intraoral manifestations associated with HIV disease. Although a perfect classification system for progression of HIV disease does not exist, trends among larger cohorts may enable health care providers to estimate the prognosis and survival of HIV-infected patients on an individual basis. This article presents clinical and laboratory parameters that indicate HIV disease progression. Providers who care for HIV-infected patients need to consider these parameters to establish an appropriate and flexible treatment plan based on changes in the patient's medical status.

Orofacial manifestations of the systemic mycoses

Aspergillosis, cryptococcosis and zygomycosis (mucormycosis) are overall the most common systemic mycoses but histoplasmosis is particularly endemic in parts of central USA and other areas worldwide. Orofacial lesions caused by systemic mycoses have rarely been reported in the past though they have been recorded particularly in outdoor workers from geographic areas with a high prevalence of infection and occasionally in immunocompromised individuals. Increasing world-wide travel, and the dramatic increase in numbers of immunocompromised persons, especially those with human immunodeficiency virus (HIV) disease, have been responsible for an increase in reports and other studies of orofacial disease in systemic mycoses and new opportunists are now being recognized. Those in Oral Medicine and Pathology must now be aware of the possibility of a systemic mycosis as the cause of chronic oral ulceration, chronic maxillary sinus infection, or bizarre mouth lesions, especially in patients with HIV disease, lymphoproliferative disorders, or diabetes mellitus, or in those who have been in endemic areas. Diagnosis and management should be undertaken in consultation with a physician with appropriate expertise, as pulmonary and other systemic infection may well be present. This paper reviews the eight main systemic mycoses.

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.

Oral mycoses in HIV infection

Oral mycoses in human immunodeficiency virus (HIV) infection are becoming increasingly common. Of these, oral candidiasis is by far the most prevalent; fewer than 10 cases of cryptococcosis, histoplasmosis, and geotrichosis have thus far been reported. Oral candidiasis is one of the earliest premonitory signs of HIV infection and may present as erythematous, pseudomembranous, hyperplastic, or papillary variants, or as angular cheilitis. Cumulative data from 23 surveys (incorporating 3387 adults) suggest that in general, oral candidiasis may develop in one third to half of HIV-seropositive persons. Almost equal numbers of cases manifest with either erythematous or pseudomembranous variants. These and related concepts pertaining to oral mycoses in HIV infection are reviewed.

Oral Histoplasma capsulatum infection in association with HIV infection: a case report

The fungus Histoplasma capsulatum causes histoplasmosis, the most common endemic respiratory mycosis in the United States. Disseminated histoplasmosis in adults is often associated with immunosuppression, such as occurs in HIV infection. We report a case of oral histoplasmosis in an HIV-seropositive patient who presented with an ulceration on the left tip of the tongue, extending to the floor of the mouth, but was otherwise free of any active systemic disease. Histoplasma capsulatum was shown, by both histopathology and staining with a fluorescent antibody reagent specific for the organism, to be present in the lesion and was deduced to be the causative organism.

Intraoral cytomegalovirus lesion and HIV-associated periodontitis in a patient with acquired immunodeficiency syndrome

Exposure to cytomegalovirus (CMV) is common in persons infected with the human immunodeficiency virus. Autopsy studies have documented the presence of CMV in multiple organs, but CMV is seldom indicated as the causative agent in specific diseases. Few reports have described localized CMV infection in the oral cavity. This may be due to the occult histopathologic appearance during oral mucosal CMV infections and to a lack of awareness of CMV infection as a potential etiologic agent in nonspecific oral ulcerations and other oral disease entities. This report describes an intraoral ulceration with documented presence of a localized CMV infection in association with human immunodeficiency virus-associated periodontitis in a patient with acquired immunodeficiency syndrome. A causative relationship between these two entities, however, cannot be established or excluded.

Oral manifestations of HIV infection and their management. II. Less common lesions

This second of two articles reviews the many uncommon and rare oral lesions that have arisen in persons infected with human immunodeficiency virus (HIV). The various drug-related oral disorders of HIV disease are also considered.

Oral histoplasmosis as a presenting disease in acquired immunodeficiency syndrome

A 43-year-old homosexual man visited his dentist with painful, nodular, ulcerated lesions on the soft palate, right buccal mucosa, and right posterior maxillary gingiva. Serologic studies for exposure to human immunodeficiency virus, performed before biopsy, were positive. Biopsy of the maxillary gingiva demonstrated sheets of histiocytes containing small intracellular yeasts, which on culture were identified as Histoplasma capsulatum. Bilateral leukoplakic lesions with some vertical furrowing involving the lateral borders of the tongue were also noted. Histologically, hyperkeratosis and fungal hyphae were identified. The patient was treated for histoplasmosis with amphotericin B, which resulted in significant improvement of the oral lesions. He was subsequently hospitalized for fatigue and dyspnea and was found to have Pneumocystis carinii pneumonia. Pulmonary status deteriorated within a 3-week period, and the patient died. Autopsy findings were negative for histoplasmosis but positive for necrotizing and cavitary P. carinii pneumonia, pulmonary and hepatic herpes simplex infections, and pulmonary and intestinal cytomegalovirus infection.