Oral manifestations of cytomegalovirus infection

Oral immunocontraceptive vaccines: A novel approach for fertility control in wildlife

The overabundant populations of wildlife have caused many negative impacts, such as human-wildlife conflicts and ecological degradation. The existing approaches like injectable immunocontraceptive vaccines and lethal methods have limitations in many aspects, which has prompted the advancement of oral immunocontraceptive vaccine. There is growing interest in oral immunocontraceptive vaccines for reasons including high immunization coverage, easier administration, frequent boosting, the ability to induce systemic and mucosal immune responses, and cost-effectiveness. Delivery systems have been developed to protect oral antigens and enhance the immunogenicity, including live vectors, microparticles and nanoparticles, bacterial ghosts, and mucosal adjuvants. However, currently, no effective oral immunocontraceptive vaccine is available for field trials because of the enormous development challenges, including biological and physicochemical barriers of the gastrointestinal tract, mucosal tolerance, pre-existing immunity, antigen residence time in the small intestine, species specificity and other safety issues. To overcome these challenges, this article summarizes achievements in delivery systems and contraceptive antigens in oral immunocontraceptive vaccines and explores the potential barriers for future vaccine design and application.

A Case of Cytomegalovirus-Induced Oral Ulcer in an Older Adult Patient with Nephrotic Syndrome due to Membranous Nephropathy

We report a case of cytomegalovirus- (CMV-) induced buccal ulcer in a patient with nephrotic syndrome. An 82-year-old man with membranous nephropathy was on immunosuppressive therapy presented with an ulcer in the oral cavity and was hospitalized. Intraoral examination revealed an inflamed and painful ulcer on the left buccal mucosa. Blood test results showed CMV positivity, and histopathological examination confirmed the diagnosis. Anti-CMV therapy (ganciclovir) was initiated from the third day of hospitalization. However, he developed dyspnea on the 14th day. Computed tomography images of the chest revealed the presence of ground-glass opacities, and noninvasive positive pressure ventilation was initiated under the provisional diagnosis of pneumocystis pneumonia caused by ganciclovir-associated myelosuppression and/or steroid-induced immunocompromised state. The patient died of pneumocystis pneumonia on the 21st day. The patient had received immunosuppressive therapy for renal dysfunction. Immunocompromised patients with CMV infection should be treated with caution, as drugs for CMV may themselves cause myelosuppression, deteriorating the prognosis of the patient.

Viral, bacterial, and fungal infections of the oral mucosa: Types, incidence, predisposing factors, diagnostic algorithms, and management

For millions of years, microbiota residing within us, including those in the oral cavity, coexisted in a harmonious symbiotic fashion that provided a quintessential foundation for human health. It is now clear that disruption of such a healthy relationship leading to microbial dysbiosis causes a wide array of infections, ranging from localized, mild, superficial infections to deep, disseminated life-threatening diseases. With recent advances in research, diagnostics, and improved surveillance we are witnessing an array of emerging and re-emerging oral infections and orofacial manifestations of systemic infections. Orofacial infections may cause significant discomfort to the patients and unnecessary economic burden. Thus, the early recognition of such infections is paramount for holistic patient management, and oral clinicians have a critical role in recognizing, diagnosing, managing, and preventing either new or old orofacial infections. This paper aims to provide an update on current understanding of well-established and emerging viral, bacterial, and fungal infections manifesting in the human oral cavity.

Recurrent Aphthous Stomatitis Caused by Cytomegalovirus, Herpes Simplex Virus, and Candida Species in a Kidney Transplant Recipient: A Case Report

Recipients of organ transplants are immunosuppressed and at high risk of oral infection. Oral diseases are often neglected compared with infections of other organs that typically confer higher morbidity. However, severe local symptoms hinder oral intake, decrease quality of life, and are sometimes lethal. Here we describe a case of a 57-year-old woman who developed recurrent aphthous stomatitis after kidney transplantation; the cause of the infection was complex and included cytomegalovirus, herpes simplex virus, and Candida species. Since misdiagnosis of oral diseases impairs patient quality of life and increases morbidity, clinicians should be aware of possible etiologies of oral infections in renal transplant recipients.

Oral ulceration associated with concurrent herpes simplex virus, cytomegalovirus, and Epstein-Barr virus infection in an immunocompromised patient

In immunocompromised patients, oral ulcerations are common and have a wide spectrum of causes, including herpesvirus infection. We report on a case in which an oral ulcer was simultaneously infected by herpes simplex (HSV), cytomegalovirus (CMV), and Epstein-Barr virus (EBV) in a kidney-pancreas transplant recipient. A 46-year-old woman presented with a clinically nonspecific dorsal tongue ulcer of 3 months duration. Histopathologic evaluation indicated keratinocytes exhibiting herpetic viral cytopathic effect. Nuclear and cytologic alterations suggestive of CMV infection were found in endothelial cells subjacent to the ulcer. Immunohistochemistry testing for HSV and CMV was positive in these cells. Large atypical mononuclear cells were also evident in the ulcer bed's inflammatory infiltrate, which had intense nuclear positivity for Epstein-Barr encoding region in situ hybridization. We believe this is the first well-documented report of the definitive concomitant presence of HSV, CMV, and EBV in an immunocompromised patient. Although the pathogenesis of coinfected ulcers remains unknown, a synergistic effect is possible.

Oral complications in hematopoietic stem cell recipients: the role of inflammation

Hematopoietic stem cell transplantation (HSCT) is widely used as a potentially curative treatment for patients with various hematological malignancies, bone marrow failure syndromes, and congenital immune deficiencies. The prevalence of oral complications in both autologous and allogeneic HSCT recipients remains high, despite advances in transplant medicine and in supportive care. Frequently encountered oral complications include mucositis, infections, oral dryness, taste changes, and graft versus host disease in allogeneic HSCT. Oral complications are associated with substantial morbidity and in some cases with increased mortality and may significantly affect quality of life, even many years after HSCT. Inflammatory processes are key in the pathobiology of most oral complications in HSCT recipients. This review article will discuss frequently encountered oral complications associated with HSCT focusing on the inflammatory pathways and inflammatory mediators involved in their pathogenesis.

Human cytomegalovirus-associated oral and maxillo-facial disease

Human cytomegalovirus is a ubiquitous pathogen with protean clinical manifestations. After initial infection, the virus remains in a persistent state in the host. Immunity plays a pivotal role in counteracting its virulence, albeit intermittent virus shedding occurs in immunocompetent individuals. Should deficiencies in immunity occur, e.g., as a consequence of AIDS or iatrogenic immunosuppression, then virus replication and subsequent pathogenic manifestations ensue. In the oral and maxillo-facial region, the virus causes a wide variety of diseases, mainly atypical chronic ulcerations and sialadenitis. These morbidities are rarely reported and sometimes cause significant problems for clinicians.

Congenital and infantile nephrotic syndrome in Thai infants

Congenital and infantile nephrotic syndrome reported from the Eastern world is rare and might be a different entity from that in the West. In a retrospective review of 10 nephrotic syndrome in Thai infants (5 girls and 5 boys), 7 were diagnosed with congenital nephrotic syndrome and 3 with infantile nephrotic syndrome. Two had congenital nephrotic syndrome secondary to congenital syphilis. All had edema, ascites, and failure to thrive. Of the 3 patients tested for thyroid function, all showed hypothyroidism. Two patients developed renal failure. Renal tissue was examined from 4 patients from 3 biopsies and 2 autopsies; only 1 patient showed tubular microcysts. Symptomatic therapy was performed concurrently with penicillin therapy in 2 patients having congenital syphilis. Prednisolone, cyclophosphamide, captopril, and enalapril were tried in some patients, with little effect. Five patients died from respiratory failure complicated by later infection, 1 patient died from renal failure, and 4 patients were lost to follow-up. Nephrotic syndrome in the first year of life in the Eastern world is rare. Prognosis of nephrotic syndrome in Thai infants at this time is still poor.

Cytomegalovirus-induced gingival hyperplasia

We report a rare presentation of gingival hyperplasia associated with cytomegalovirus infection in a 33-year-old human immunodeficiency virus-infected man.

Cytomegalovirus infection in a patient with rheumatoid arthritis

Background. - Pulmonary dysfunction in rheumatoid arthritis (RA) patients treated with low-dose methotrexate is usually caused by bacterial infection and less frequently by an immunoallergic reaction to the drug (acute hypersensitivity pneumonitis). Opportunistic infections are a rare cause. We report a case of cytomegalovirus pneumonia during bone marrow aplasia in a patient with RA taking methotrexate and cyclosporine.Conclusions. - Cytomegalovirus infection is a rarely reported cause of pulmonary dysfunction. This diagnosis should be considered in immunocompromised RA patients with no other satisfactory explanation for pulmonary dysfunction.

Antifungal and antiviral chemotherapy

Fungal and viral infections are difficult to treat, since fungal infections commonly rebound after suppression by the antifungal agent and current antiviral drugs are only virustatic, allowing the virus to reassert its pathogenicity if not eliminated by the host defenses. In addition, fungal infections commonly are associated with significant biofilms, retarding drug penetration, and the fluid nature of the oral cavity does not promote drug-fungus contact for long periods of time. Both mycotic and viral pathogens are developing sophisticated methods to elude the toxic effects of drugs intended to eliminate their existence. The drug therapy of oral fungal and viral infections is therefore limited but occasionally successful (more with fungal than viral infections) and is often relegated to palliative care. The specter of drug resistance and its promotion by prolonged, repetitive and frivolous use must always be foremost in the clinician's mind.

Cytomegalovirus and cyclosporin-induced gingival overgrowth in children with liver grafts

OBJECTIVE

To determine whether cytomegalovirus (CMV) is associated with gingival overgrowth in paediatric liver graft recipients treated with cyclosporin.

STUDY DESIGN

Thirty-four children, 25 of whom were under 5 years of age, who had undergone liver transplantation, were examined. An Index of Severity of Gingival Overgrowth was used to measure the prevalence and severity of the gingival overgrowth. The trough cyclosporin level was recorded and the CMV status of the patient matched to the dental findings. The association between the severity of gingival overgrowth and CMV infection was examined using the contingency coefficient. An anova was used to assess the association between the circulating trough cyclosporin concentration and the severity of gingival overgrowth. Pearson's Product Moment Correlation Coefficient was used to examine the association between the duration of exposure to cyclosporin and the severity of gingival overgrowth.

RESULTS

There was a significant inverse association between the duration of exposure to cyclosporin and the severity of gingival overgrowth. There was no relationship between the trough cyclosporin concentration and the severity of gingival overgrowth. There was no association between CMV and gingival overgrowth.

CONCLUSION

Gingival overgrowth was related to the duration of cyclosporin therapy but was neither more prevalent nor more severe in subjects who were CMV seropositive.

Periodontal disease and periodontal management in patients with cancer

Periodontal infection may exacerbate during cancer therapy and may result in oral pain and infection, and systemic infection, which may cause morbidity and can lead to mortality in neutropenic cancer patients. Periodontal disease in head and neck cancer patients treated with radiation therapy may lead to acute and chronic complications. The literature was reviewed by a search of Medline of the National Library of Medicine. The search was conducted to identify publications assessing periodontal disease in cancer patients. In addition, a review of papers referenced in the retrieved papers was conducted to identify additional publications for review. Periodontal disease should be assessed and managed prior to medical treatment of cancer for those with oropharyngeal cancer, and for patients in whom neutropenia may develop during treatment. Pretreatment assessment and management, and maintenance of oral hygiene have been shown to be effective in preventing oral and systemic complications during treatment. A complete oral and periodontal examination is appropriate for all patients planned to receive head and neck radiation therapy and those to be treated with medical protocols that are anticipated to result in neutropenia. Oral and periodontal care must continue following cancer therapy, and requires that the health care provider have an understanding of the malignant disease, oral manifestations of the disease, medical management of the disease, and of the oral complications that may develop.

A case series of acquired immunodeficiency syndrome patients with initial neoplastic diagnoses of intraoral Kaposi's sarcoma

BACKGROUND

Oral Kaposi's sarcoma (KS) may represent the initial clinical manifestation of immunosuppression in human immunodeficiency virus disease. This article reviews the treatment provided to these patients and the outcome of the disease and provides the opportunity to assess the impact of improvements in the medical therapy of acquired immunodeficiency syndrome on disease outcome.

METHODS

A tumor registry was examined to identify patients in whom oral KS was the first neoplastic diagnosis.

RESULTS AND CONCLUSIONS

Thirty-seven cases of oral KS representing 1.9% of all cases of KS were identified as the first malignant diagnosis in patients with acquired immunodeficiency syndrome. Patients with oral KS have limited survival; the cause of death is either infection or malignancy. In our study, the palate was the most common site of primary involvement in the oral cavity. Recently diagnosed patients remained alive longer than those diagnosed earlier, and the patients with the most recently diagnosed cases were alive at the completion of the study, suggesting that medical management of human immunodeficiency virus has improved with new therapies.

Oral complications associated with immunosuppression and cancer therapies

The oral manifestations of oropharyngeal infection in immunocompromised patients present a particular challenge for both medical and dental professionals because clinical signs and symptoms may be minimal and accurate diagnosis and appropriate treatment may be difficult. Effective control of infection and management of oral symptoms are important and may be achieved by the judicious use of topical and systemic agents and by maintaining good oral hygiene. Prevention of mucosal breakdown, suppression of microbial colonization, control of viral reactivation, and effective management of severe xerostomia are all critical steps to reduce the overall morbidity and mortality of oromucosal infections in the severely immunocompromised patient.

Oral management of the patient with end-stage liver disease and the liver transplant patient

The patient with end-stage liver disease who is in need of a liver transplant should have a pretransplant dental evaluation. Such a patient faces lifelong immunosuppression with an increased risk of infection. This article discusses both the need for control of oral diseases before liver transplantation and guidelines for oral care in the immediately postoperative and long-term transplant patient. Specific indications for antibiotic prophylaxis and antibiotic regimens are presented; in addition, adverse reactions and side effects of immunosuppressant drugs are discussed. Pertinent drug interactions salient to the dental management of patients with end-stage liver disease are reviewed, and specific management recommendations for these patients are presented.

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 infections in the immunocompromised host

The prevalence of infections in the immunocompromised host is increasing. The oral cavity is a primary or sole site in many cases. It is important for the practicing clinician to recognize the more common infections in this growing patient population. Oral examinations are an essential component of all physical examinations, especially when immunosuppression is known or suspected. We recommend that all patients starting immunosuppressive therapy receive a comprehensive oral examination before the institution of such therapy to eliminate potential sources of oral and odontogenic infections. The examination should include full mouth dental radiographs and a complete soft-tissue examination. Timely, accurate diagnoses may have important implications with regard to management, prognosis, cost, morbidity, and mortality.

Oral lesions in organ transplant patients

Patients who have undergone organ transplantation can present with a variety of oral lesions that appear to be related either directly to their medication or arise as a consequence of drug-induced immunosuppression. Such lesions include hairy leukoplakia, an increased propensity to both fungal and viral infections and a high incidence of malignant change, especially lip cancer. Cyclosporin remains the immunosuppressant of choice in most transplant patients. Gingival overgrowth is the main unwanted oral effect associated with cyclosporin. Some 30% of dentate transplant experience this problem, which is further compounded by concomitant medication with a calcium channel blocker. This review appraises the various oral problems that can arise in this group of patients and emphasises the importance of regular oral screening and the establishment of links with the various transplant teams.

Oral ulcerations in HIV infection

Oral ulceration in HIV infection may be due to: (1) mycotic; (2) bacterial, protozoan; (3) and viral infections; (4) oral neoplasia; (5) aphthous ulceration/ulceration not otherwise specified (NOS); or (6) ulceration of iatrogenic origin. Of particular significance are oral ulcerations caused by viruses of the herpes virus group (HSV 1/2, CMV, VZV) and ulcerations of the aphthous type. It was shown recently that coinfection of viral ulcers occurs. The aetiopathogenesis of the aphthous type of ulcerations including the still debated ulceration NOS is not clear. Further basic and clinical research is necessary in order to better understand ulceration particularly in relation to immunoregulation, tissue breakdown and repair.

Periodontal implications: medically compromised patients

The presence of systemic disease in patients requiring periodontal therapy creates challenges for management. Alteration of treatment plans, with emphasis on physician consultation and preventive periodontal care, is frequently needed to minimize the impact of periodontal disease on the systemic condition. Conversely, detection and treatment of systemic disorders may impact upon the status of the periodontium and the success of periodontal therapy. The goal of holistic patient management is facilitated by a free flow of information between the patients and their medical and dental health care providers.

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.

Herpesviridae-associated persistent mucocutaneous ulcers in acquired immunodeficiency syndrome. A clinicopathologic study

Persistent mucocutaneous ulcers in AIDS represent a variety of disease entities. The purpose of this study was to characterize clinicopathologic features of persistent oral ulcers associated with cytomegalovirus and herpes simplex virus in AIDS. Forty-seven persons infected with HIV with persistent ulcers (mean, 2.4 ulcers/person) were included in this study. A biopsy specimen from a representative ulcer was taken from each patient. Hematoxylin-eosin, periodic acid-Schiff, cytomegalovirus, and herpes simplex virus immunocytochemical stains were performed on tissue sections. The most common sites of involvement were the buccal/labial mucosa (27%), tongue (25%), and gingiva (18%). Mean ulcer size was 1.8 cm with a mean duration of 5.6 weeks. The ulcerogenic viral agents were cytomegalovirus alone in 53% of cases, cytomegalovirus and herpes simplex virus coinfection in 28% of cases, and herpes simplex virus alone in 19% of cases. Treatment response to ganciclovir with or without topical steroids resulted in lesion resolution in the cytomegalovirus and cytomegalovirus/herpes simplex virus groups; however, recurrence/resistance was relatively high (23%). Herpes simplex virus/cytomegalovirus ulcers responded to oral acyclovir in combination with systemic ganciclovir. Increasing the oral acyclovir dosage resulted in resolution of herpes simplex virus-only ulcers in all but one case. Cytomegalovirus and herpes simplex virus are associated with persistent mucocutaneous ulcers in AIDS. These lesions responded to systemic antiviral therapy but are difficult to differentiate from other ulcerogenic diseases such as aphthous major, necrotizing stomatitis, and ulcerations not otherwise specified without biopsy and histopathologic examination.

Viral infections in the immunocompetent patient

Human herpesviruses and human papillomaviruses are ubiquitous and may cause an array of oral disease. Herpesviruses are unique because recurrent localized disease occurs after the primary infection. Human papillomaviruses are known for their ability to produce benign epithelial proliferations and increasingly are implicated in the development of oral cancer. This article reviews the pathogenesis of common oral lesions induced by these viruses.

Herpes simplex and cytomegalovirus coinfected oral ulcers in HIV-positive patients

Four HIV-positive patients with herpes simplex virus and cytomegalovirus coinfected oral ulcers are presented. All patients had persistent oral pain associated with nonhealing mucosal ulcers. Lesions occurred on the palate, retromolar pad, tongue, and lip, and the clinical appearance of the ulcers was nonspecific. Histologic and immunohistochemical stains showed herpes simples virus alterations in keratinocyte nuclei and cytomegalovirus alterations in mesenchymal/endothelial cell nuclei and cytoplasm. Lesions in one patient responded to ganciclovir therapy. One patient improved with acyclovir, and another healed normally after excisional biopsy. Each virus alone has been described as causing oral ulcerations; their appearance together in the same lesion would suggest a synergistic relationship.

Oral cytomegalovirus infection in an unrelated bone marrow transplantation with possible mediation by graft-versus-host disease and the use of cyclosporin-A

Graft-versus-host disease remains as a significant sequela in allogeneic bone marrow transplantation patients. Reports of oral presentations of cytomegalovirus infection in this patient population are rare. Although the usual manifestation of oral cytomegalovirus is mucosal ulceration, we report a case that we believe reflects a dynamic among graft-versus-host disease, cytomegalovirus, and the use of cyclosporin A, commonly used as an immunosuppressive agent in bone marrow transplantation.