Oral hairy leukoplakia in HIV infection: a diagnostic pitfall

Prevalence of oral lesions in patients with AIDS: a systematic review and meta-analysis

Background Oral lesions are considered to be early clinical signs which may predict the progression of patients with acquired immune deficiency syndrome (AIDS). Due to the lack of a comprehensive study that includes oral lesions in people with AIDS, the global prevalence of oral lesions in people with AIDS was estimated by combining preliminary studies' results using meta-analysis.Material and methods Databases including PubMed, Science Direct and Scopus were searched using keywords as 'HIV', 'AIDS', 'oral candidiasis', 'Kaposi Sarcoma', 'LinearGingival Erythema' and OR operators, AND and NOT. After the elimination of duplicate documents, articles that met the inclusion criteria were selected. Quality assessment was performed based on the Newcastle-Ottawa Scale. After combining the results of preliminary studies, an overall estimate of each lesion was reported. Ninety-five studies met the criteria for inclusion in this meta-analysis.Results The global prevalence of 21 oral lesions in HIV-infected patients was estimated. The overall prevalence of oral candidiasis, pseudomembranous candidiasis, oral hairy leukoplakia, Kaposi sarcoma and erythematous candidiasis was as follows: 35% (95% CI: 28-42), 19% (95% CI: 15-22), 12% (95% CI: 11-14), 5% (95% CI: 4-6) and 18% (95% CI: 14-22).Conclusion The present meta-analysis showed that oral lesions have a high prevalence in patients with AIDS. Dentists should consider that the clinical appearance of the oral cavity reflects the overall systemic health of the patient. As such, oral lesions may be linked to underlying immunosuppression caused by AIDS.

Oral manifestations of HIV disease: an update

More than 40 different oral diseases and conditions have been described in patients infected with human immunodeficiency virus (HIV). The recognition of the oral manifestations of HIV disease is of great significance because they may represent the first signs of the disease and have been shown to be highly predictive markers of severe immune deterioration and disease progression. Although some oral diseases and conditions have a weak association with HIV disease, others are strongly linked with the disorder, and a few are acquired immune deficiency syndrome (AIDS)-defining in nature. The spectrum of oral manifestations of HIV disease is reviewed with emphasis on clinical recognition, diagnosis, and treatment.

Oral hairy leukoplakia in 71 HIV-seropositive patients: clinical symptoms, relation to immunologic status, and prognostic significance

BACKGROUND

Oral hairy leukoplakia (OHL) is a benign hyperplasia of the oral mucosa that is induced by Epstein-Barr virus. It occurs nearly exclusively in men infected with HIV. OHL is a marker of moderate to advanced immunodeficiency and disease progression in patients with HIV infection.

OBJECTIVE

We attempted to determine the clinical characteristics of OHL in a large group of patients infected with HIV and to analyze its relation to immune status and prognosis.

METHODS

A total of 456 patients with HIV-associated skin disorders were evaluated during the years 1982 through 1992. All patients had an oral examination. CD4+ cell counts were obtained within 3 months of the examination.

RESULTS

OHL was diagnosed in 15.6% of 456 patients. The median age of the patients was 35 years. OHL was found most often on the lateral aspect of the tongue; in one patient the lesion covered the entire dorsal surface of the tongue. Significant immunosuppression was present in the majority of patients at the time of OHL diagnosis (median CD4+ T-lymphocyte count, 235/microliter; median CD4+/CD8+ ratio, 0.3). The median survival time was 20 months in patients with OHL. In patients with a higher CD4 cell count (CD4+ T lymphocyte count, > or = 300/microliter) the diagnosis of OHL was associated with shorter survival times (median survival time, 25 months) compared with other patients with HIV (median survival time, 52 months).

CONCLUSION

OHL is a frequent finding in patients with HIV and indicates advanced immunosuppression. Even in patients with more than 300/microliter CD4+ T lymphocytes, OHL is associated with a poor prognosis.

Prognostic value of oral candidosis and hairy leukoplakia in 111 Mexican HIV-infected patients

A follow-up study was carried out to evaluate the prognostic value of hairy leukoplakia (HL) and oral candidosis (OC) in a cohort of 111 asymptomatic Mexican HIV infected patients. Oral exams were performed at baseline and every 6 months, from September 1989 to March 1994. Chi-square contingency table test, the Kruskall-Wallis one-way analysis of variance, the Kaplan-Meier product-limit method and the log rank test were used for the analysis. Univariate and multivariate Cox's proportional hazards analysis were also performed. Fifty-four patients (51%) progressed to AIDS (initially 36 CDC-II and 18 CDC-III). Individuals with HL and/or OC, showed faster development to AIDS than subjects without lesions or other HIV-related manifestations (P = 0.008). The presence of OC, HL or both always remained significant despite adjustment for total lymphocytes, CDC stage, zidovudine therapy or its combinations. Oral lesions in HIV infection may be regarded with other clinical and laboratory studies as markers of HIV disease progression and as indicators to begin antiretroviral treatment.

Exfoliative cytology and electron microscopy in the diagnosis of hairy leukoplakia

The diagnosis of lesions clinically suggestive of hairy leukoplakia was assessed by light and electron microscopic examination of cytologic smears. We found exfoliative cytology to be a simple and noninvasive technique that can confirm the clinical diagnosis of hairy leukoplakia. Our results suggest that electron microscopy may be more sensitive and reliable than light microscopy in confirming the clinical diagnosis of hairy leukoplakia.

Detection of Epstein-Barr virus DNA in tongue tissues from AIDS autopsies without clinical evidence of oral hairy leukoplakia

Epstein-Barr virus (EBV) DNA was detected by in situ hybridization at 3 sites of 30 samples taken from clinically normal lateral border of tongue mucosa from 15 AIDS autopsies and in none of 20 samples from 10 controls. The first positive case showed a thin layer of parakeratosis correlated with positive signals for EBV in one area and an adjacent area without obvious parakeratosis was also positive for EBV. These findings were present on both sides of the tongue. The second case was unilaterally positive for EBV and parakeratosis was absent. The hybridization signals were localised to koilocyte-like cells in the stratum spinosum, as in oral hairy leukoplakia (OHL). These observations suggest that the in situ hybridization technique can detect very early or subclinical OHL, and supports the role of EBV in the pathogenesis of this lesion.

In situ hybridization and the polymerase chain reaction (PCR) in the analysis of biopsies and exfoliative cytology specimens for definitive diagnosis of oral hairy leukoplakia (OHL)

The definitive diagnosis of oral hairy leukoplakia (OHL) demands that Epstein-Barr virus (EBV) is demonstrated in the lesional tissue, since the histopathological features on conventional light microscopy are not pathognomonic. We have investigated the possible use of polymerase chain reaction (PCR) technology in reaching a definitive diagnosis of this lesion by its application to ten biopsy specimens with definitive diagnoses of OHL determined by in situ hybridization. EBV DNA was demonstrated by PCR in all ten OHL biopsy specimens analysed, and none of ten control specimens. Furthermore, we have investigated the role of PCR in analysis of exfoliative cytology samples collected from the lateral border of the tongue by a minimally-invasive scraping technique. EBV DNA was not only detected in all OHL lesional scrapings but also in more than one-third of healthy controls, due to viral presence in saliva at the time of sampling. In this application, the highly sensitive PCR technique has low specificity and cannot be recommended.

Hairy leucoplakia and HIV-2--a case report and review of the literature

Type 2 human immunodeficiency virus (HIV-2), originally confined to West Africa, has lately appeared with increasing frequency in Europe. Oral lesions affect a large proportion of patients with AIDS. Hairy leucoplakia (HL), a clinical expression of Epstein-Barr virus (EBV), is a lesion of the oral mucosa (usually the lateral margin of the tongue) that is observed in patients who are immunocompromised due to HIV or, more rarely, due to immunosuppressive medication or other causes. We review the definition, clinical signs, histopathology, diagnosis, prognosis and treatment of HL, and report the (to our knowledge) first detailed description of an HIV-2-seropositive patient with HL, which affected the lateral and dorsal tongue and was the first clinical sign of HIV infection (this patient was at that time only the second native Spaniard in whom unique HIV-2 infection had been detected). EBV detection and subtyping by in situ hybridization and polymerase chain reaction were performed in paraffin-embedded tissue from the HL lesion of the dorsal tongue; EBV-1 and EBV-2 were detected by the latter technique.

Occurrence of corrugated white patch lesions on lateral border of tongue in lymphoma patients during cytostatic treatment

The question of whether or not there was an association between immunosuppression and occurrence of corrugated white patch lesions on the lateral border of the tongue was studied in 79 patients being treated for non-Hodgkin lymphoma or Hodgkin's disease. The mouths of 55 patients (mean age 47.8 years, 34 males, 21 females) were examined during periods of chemotherapy. All patients were HIV-seronegative. White non-removable lesions on the lateral margins of the tongue were noted in 27 patients (42.8%) 74 days after commencement of chemotherapy and 10 days after termination of medication. In 12 cases (44.4%) the lesions were bilateral. Epstein-Barr virus (EBV) DNA was found by gene amplification using polymerase chain reaction (PCR) in one of the two biopsy samples taken. No white lesion on the lateral border of tongue had been seen in any patient before treatment, nor were any evident 1 year after treatment. Leucocyte counts were significantly (P = 0.001) lower when the lesion was present than when it was not detected. Before chemotherapy, 70.4% of patients with lesions and 47.6% of patients without lesions had positive salivary yeast cultures. Yeasts could be cultured from the saliva of 80.5% of patients when the lesions were present. In 2 patients clinical oral candidiasis was diagnosed at the time of the lesion. The study revealed a correlation between the occurrence of corrugated white, non-removable lesions of the lateral borders of the tongue, high salivary yeast counts and leucocytopenia.(ABSTRACT TRUNCATED AT 250 WORDS)

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.

Hairy leukoplakia after bone marrow transplantation

Hairy leukoplakia in 10 patients after bone marrow transplantation was identified clinically and assessed histologically. In situ hybridization for Epstein-Barr virus and human papilloma virus confirmed Epstein-Barr virus in hairy leukoplakia in two cases, and human papillomavirus in three cases. All cases with clinical follow-up resolved without treatment. These findings suggest that severe immunosuppression after a bone marrow transplantation may result in the development of hairy leukoplakia, and that as the immunosuppression resolves after the transplant the lesions also resolve.

Expression of keratin 14 and 19 mRNA and protein in normal oral epithelia, hairy leukoplakia, tongue biting and white sponge nevus

This study was undertaken to analyze keratin gene expression at both the mRNA and protein level in oral hairy leukoplakia (OHL). Comparisons were made with normal lingual epithelium from a similar site, tongue biting, normal buccal mucosa and another condition which disturbs oral epithelial differentiation, white sponge nevus. Combined immunocytochemical and in situ hybridization studies for keratins 14 and 19 were carried out on 2 specimens of OHL from HIV-positive males and one sample each of the other cases. Keratin 14 protein expression was uniform throughout all the epithelia. In normal epithelia and in lesions other than OHL, keratin 14 mRNA was most strongly expressed in basal cells with weaker but still significant amounts in the spinous cell layer. In both cases of OHL there was weaker basal cell expression of keratin 14 mRNA and frequent absence in koilocytoid cells. Keratin 19 protein expression was heterogeneous in the basal layer of all specimens with suprabasal staining of occasional groups of cells. Its mRNA was uniformly distributed in all cases. The findings indicate the keratin mRNA expression does not always parallel that of protein and that, in the case of keratin 14, expression may be influenced by the presence of EBV.

Epstein-Barr virus latent and replicative gene expression in oral hairy leukoplakia

Oral hairy leukoplakia is an epithelial lesion of the tongue associated with productive infection by Epstein-Barr virus (EBV). However, no data concerning the pattern of EBV latent gene expression have been reported, and it remains unresolved whether true latent infection occurs in basal cell layers of oral hairy leukoplakia. We have studied six cases of oral hairy leukoplakia using monoclonal antibody immunohistology for EBV latent--EB nuclear antigen (EBNA) 1, EBNA 2 and latent membrane protein 1 (LMP 1); immediate-early (BZLF1); and replicative (EA, VCA, MA) proteins, and for the EBV-receptor (CD21 antigen). EBV DNA was demonstrated by nucleic acid in situ hybridization. Mid- to upper-zone keratinocytes contained EBV DNA and co-expressed EBNA 1, EBNA 2 (5 of 6 cases), LMP 1, BZLF1 protein, EA, VCA and MA. No EBV genome or gene expression could be demonstrated in basal or parabasal cells. Spinous keratinocytes were labelled by anti-CD21 antibodies HB5 and B2, but did not express the EBV-receptor as defined by reactivity with OKB7. The co-expression of latent and replicative infection-associated antigens is striking, indicating possible functional roles for latent proteins during the productive cycle. Our results suggest that oral hairy leukoplakia is caused by repeated direct infection of upper epithelial cells with virus from saliva or adjacent replicatively infected cells, rather than by a latent EBV infection of basal epithelial cells with a differentiation-dependent switch to productive infection as previously proposed.