Parotid gland enlargement and xerostomia associated with labial sialadenitis in HIV-infected patients

HAART medication and oral health status in children and adolescent HIV infected: A case control study

BACKGROUND

The advent of Highly Active Anti-Retroviral Therapy (HAART) does influence the overall oral health care of children. The children undergoing HAART have shown an increase in caries activity owing to sugars in medicines to make them more palatable.

AIM

The aim of the study was to assess and compare the Oral Health of Children Living with HIV/AIDS (CLHAs) and Adolescents Living with HIV/AIDS (ALHAs) undergoing HAART and those who are HAART-naïve.

METHODS

This study was carried out at different Non-Governmental Organizations (NGO's) across Kerala, India. The study group consisted of 150 HIV-infected children aged 6-18 years. They were divided into two groups. Group 1 comprised of children prior to onset of HAART and Group 2 included children who had been on HAART for more than 3 years (HAART naïve). The assessment of dental caries status and dental plaque status was done. The observations were tabulated and statistically analyzed.

RESULTS

On Statistical Analysis, significant difference was noted between the groups with the Group 1(2.26 ± 0.58;p value = .000*) showing higher scores of dental plaque and a significant difference was also observed with respect to dental caries scores with DMFT and dmft scores higher in Group 2(dmft 2.08 ± 2.85; p value = .001* and DMFT 4.10 ± 1.71;p value = .003*).

CONCLUSION

It was concluded that oral hygiene conditions were poor in children with HIV, with dental plaque scores more in HAART-naïve which may be due to their lesser visits and reinforcements regarding oral hygiene from a dentist and dental caries score more in HAART group, this may be attributed to the hidden sugars present in HAART medications to make it more palatable. Early recognition and management of oral conditions are important to improve the quality of life for these children.

Salivary Glands and Viral Pathogenesis

The oral cavity is an epidemiologically relevant route of viral transmission due to the shedding of viruses in saliva. With advancements in salivary diagnostics, an increasing number of viruses have been detected. However, the anatomic source of virus in saliva is still largely unknown. Some viruses have a well-established tropism for the salivary glands (SGs), and recent studies have emphasized the importance of the glands as potential reservoirs for infectious viruses. Viral infections of the SGs have been linked to acute and chronic SG pathology and may be associated with SG dysfunction, with phenotypes similar to those seen in SjÖgren's disease (SjD), an autoimmune condition that affects the salivary and lacrimal glands. Understanding the breadth of viruses that infect the SG and the conserved or distinct host responses to these infections may provide insights into the pathogenesis of virus-mediated SG diseases. There is a need for further research to fully understand the molecular mechanisms by which viruses enter and replicate in the glands, their physiologic impact on SG function, and whether the SGs can serve as a long-term reservoir for infectious viral particles. The purpose of this review is to highlight a group of viruses that infect the salivary gland: hepatitis C virus, hepatitis D virus, severe acute respiratory syndrome coronavirus 2, enteric viruses, human T-cell leukemia virus type I, human immunodeficiency virus, human cytomegalovirus, and BK polyomavirus. We focus on the effects of viral infection on salivary gland (SG) inflammation, function, and its association with SjD.

Immunoassay Detects Salivary Anti-SSA/Ro-52 Autoantibodies in Seronegative Patients with Primary Sjögren's Syndrome

The diagnostic work-up for Sjögren's syndrome is challenging and complex, including testing for serum autoantibodies to SSA/Ro and a labial salivary gland biopsy. Furthermore, the diagnosis is often delayed. In this study, we tested the hypothesis that anti-SSA/Ro autoantibodies are detectable in the saliva of patients with primary Sjögren's syndrome (pSS) because the disease affects the salivary glands, and these autoantibodies display greater discriminatory performance in saliva than in serum. SSA/Ro-52 Ags were used to develop what is, to our knowledge, a novel quantitative electrochemical-based immunoassay: the electric field-induced release and measurement (EFIRM) platform. The clinical utility was determined by measuring salivary anti-SSA/Ro-52 autoantibodies in patients with pSS and sicca (n = 34), patients without pSS with sicca (n = 35), and healthy subjects (n = 41). The statistical analysis of discrimination included the area under the receiver operating characteristic curve. Salivary anti-SSA/Ro-52 autoantibodies were measured in 94% (32 of 34) of patients with pSS with 85% (29 of 34) seropositivity. Four of the five seronegative patients with pSS had EFIRM-measurable anti-SSA/Ro-52 autoantibodies in saliva. Additionally, 60% (21 of 35) of the seronegative patients without pSS who had sicca had EFIRM-detectable SSA/Ro-52 autoantibodies in saliva, indicating the onset of autoimmune disease. Two of the 41 healthy control subjects had EFIRM-detectable SSA/Ro-52 autoantibodies in their saliva. Salivary SSA/Ro-52 autoantibodies significantly discriminated patients with pSS or patients with the initial stage of autoimmune disease from healthy subjects with an area under the receiver operating characteristic curve of 0.91. Our findings suggest that the proposed saliva SSA/Ro-52 immunoassay improves early and accurate diagnosis of seronegative patients with pSS and patients with early-onset autoimmune disease.

Benign Lymphoepithelial Cyst of Parotid Glands in HIV Infected Patients on Anti-Retroviral Therapy: A Narrative Review

Human immunodeficiency virus-associated salivary gland disease is a complication seen in patients infected with the human immunodeficiency virus (HIV), with the commonest manifestation being the benign lymphoepithelial cyst (BLEC). The purpose of this study was to systematically review the effects of antiretroviral therapy (ART) in Human Immune Virus-infected patients with confirmed benign lymphoepithelial cysts of the parotid gland. The review was conducted between August 2020 and December 2021 using the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. Patients infected with a diagnosis of BLEC of parotid gland based were included. Studies from all countries were included with no age, language, and time restrictions. We used Microsoft Excel to create a data extraction form piloted before the official start. Inter-rater agreement was calculated for most of the data collection. The risk of bias was assessed using a Cochrane tool. After reviewing 512 records, 42 met the study criteria with a total of 785 patients. The median sample size of all eligible studies was 10 ranging from 2 to 60. The pooled mean age was 29 years ± 24.2. Studies primarily assessed the effect of ART on BLECs. Patients examined in the studies ranged from children to the elderly. Studies from South Africa had a higher proportion of women while American studies had a higher proportion of men. There is evidence that ARVs are effective in treating BLEC and may be used as first-line therapy for HIV infected patients.

Sonographic Features of Salivary Glands in Sjögren's Syndrome and its Mimics

PURPOSE OF REVIEW

For 30 years, ultrasound has been investigated as a means to evaluate salivary gland abnormalities in patients with autoimmune disease. We aim to review the test characteristics of ultrasound for diagnosing Sjögren's syndrome, the scoring systems used for this purpose, and the ultrasound similarities and differences between Sjögren's syndrome and some of its potential salivary gland mimics.

RECENT FINDINGS

Hypo/anechoic glandular lesions are the major ultrasound characteristic found in Sjögren's syndrome. Most studies have reported such ultrasound abnormalities to have a sensitivity and specificity in the range of 65-85% and 85-95%, respectively, as well as a positive likelihood ratio between 4 and 12. However, similar findings can also be seen in sarcoidosis, amyloidosis, IgG4-related disease, HIV, and lymphoma. A "nodal" pattern of involvement or the ultrasound artifact of "through transmission" can help distinguish some of these mimics from Sjogren's syndrome. Ultrasound can substantially influence the diagnosis of Sjögren's syndrome.

Role of Viral Infections in the Pathogenesis of Sjögren's Syndrome: Different Characteristics of Epstein-Barr Virus and HTLV-1

Viruses are possible pathogenic agents in several autoimmune diseases. Sjögren’s syndrome (SS), which involves exocrine dysfunction and the appearance of autoantibodies, shows salivary gland- and lacrimal gland-oriented clinical features. Epstein-Barr virus (EBV) is the most investigated pathogen as a candidate that directly induces the phenotype found in SS. The reactivation of the virus with various stimuli induced a dysregulated form of EBV that has the potential to infect SS-specific B cells and plasma cells that are closely associated with the function of an ectopic lymphoid structure that contains a germinal center (GC) in the salivary glands of individuals with SS. The involvement of human T-cell leukemia virus type 1 (HTLV-1) in SS has been epidemiologically established, but the disease concept of HTLV-1-associated SS remains unexplained due to limited evidence from basic research. Unlike the cell-to-cell contact between lymphocytes, biofilm-like structures are candidates as the mode of HTLV-1 infection of salivary gland epithelial cells (SGECs). HTLV-1 can infect SGECs with enhanced levels of inflammatory cytokines and chemokines that are secreted from SGECs. Regardless of the different targets that viruses have with respect to affinitive lymphocytes, viruses are involved in the formation of pathological alterations with immunological modifications in SS.

Common oral opportunistic infections in Human Immunodeficiency Virus infection/Acquired Immunodeficiency Syndrome: Changing epidemiology; diagnostic criteria and methods; management protocols

There were 36.9 million in the world living with human immunodeficiency virus (HIV) infection/acquired immunodeficiency syndrome (AIDS) as of 2017, and new infections have seen a reduction by 18% since 2010. But this rate of decline is not sufficient for the goal of eradication of AIDS by 2030. Only 21.7  million people infected with HIV have accesses to antiretroviral therapy, with the rest at risk of the potential complications of HIV infection. It has been shown that oral lesions are diagnostic and prognostic of HIV infection, and many oral opportunistic infections continue to be a major problem, particularly in developing countries. It is therefore important that dental surgeons be aware and updated to recognize and manage the oral effects of HIV infection/AIDS. This chapter describes the classification, diagnosis, and management of oral lesions in these patients, based on our current understanding of the infection. This review also discusses the standardization of diagnosis of oral lesions in HIV infection/AIDS patients, immune reconstitution inflammatory syndrome case definition, and the research priorities formulated at the 7th World Workshop on Oral Health and Disease in AIDS.

Shear wave elastography of parotid glands in pediatric patients with HIV infection

OBJECTIVES

Parotid gland (PG) involvement is common among the patients with HIV infection. Shear wave elastography (SWE) is a noninvasive method used to measure the tissue stiffness of several organs including PG. The aim of this study was to evaluate the tissue stiffness values of PGs of HIV-infected children via SWE and compare the results with the counterparts of healthy subjects.

MATERIALS AND METHODS

This single-center, prospective study included the PG examinations of 23 pediatric HIV patients and 40 healthy children via grayscale ultrasound and SWE. Independent sample T test and Mann-Whitney U test were used in statistical analysis.

RESULTS

Stiffness of both PGs was significantly higher in patients' group when compared with control subjects. In addition, when the patients were separated into two groups according to the appearance of PG on grayscale ultrasound as homogeneous and heterogeneous, stiffness values were increased in the patients with homogeneous parenchymal appearance. No significant difference was achieved in terms of median CD4 and CD8 counts, HIV RNA levels or median duration of illnesses.

CONCLUSIONS

PG examination of HIV-infected children via SWE reveals increased tissue stiffness when compared with healthy subjects. SWE can be used as an ultrasound-assisted noninvasive technique in this manner.

Contribution of HIV Infection, AIDS, and Antiretroviral Therapy to Exocrine Pathogenesis in Salivary and Lacrimal Glands

The structure and function of exocrine glands are negatively affected by human immunodeficiency virus (HIV) infection and its co-morbidities, including innate and adaptive immune responses. At the same time, exocrine function may also be influenced by pharmacotherapies directed at the infectious agents. Here, we briefly review the role of the salivary glands and lacrimal glands in normal physiology and exocrine pathogenesis within the context of HIV infection and acquired immune deficiency syndrome (AIDS), including the contribution of antiretroviral therapies on both. Subsequently, we discuss the impact of HIV infection and the types of antiretroviral therapy on disease management and therapy development efforts.

Oral Mucosal Immunity and HIV/SIV Infection

Human Immunodeficiency Virus (HIV) transmission through genital and rectal mucosa has led to intensive study of mucosal immune responses to HIV and to the development of a vaccine administered locally. However, HIV transmission through the oral mucosa is a rare event. The oral mucosa represents a physical barrier and contains immunological elements to prevent the invasion of pathogenic organisms. This particular defense differs between micro-compartments represented by the salivary glands, oral mucosa, and palatine tonsils. Secretory immunity of the salivary glands, unique features of cellular structure in the oral mucosa and palatine tonsils, the high rate of oral blood flow, and innate factors in saliva may all contribute to the resistance to HIV/Simian Immunodeficiency Virus (SIV) oral mucosal infection. In the early stage of HIV infection, humoral and cellular immunity and innate immune functions in oral mucosa are maintained. However, these particular immune responses may all be impaired as a result of chronic HIV infection. A better understanding of oral mucosal immune mechanisms should lead to improved prevention of viral and bacterial infections, particularly in immunocompromised persons with Acquired Immune Deficiency Syndrome (AIDS), and to the development of a novel strategy for a mucosal AIDS vaccine, as well as vaccines to combat other oral diseases, such as dental caries and periodontal diseases.

Hepatitis Delta Virus Detected in Salivary Glands of Sjögren's Syndrome Patients and Recapitulates a Sjögren's Syndrome-Like Phenotype in Vivo

Background:

Low-level, chronic viral infections have been suspect in the development of select autoimmune diseases, including primary Sjögren's syndrome (pSS). Multiple studies have shown stimulation of antiviral response pathways in pSS tissues suggestive of a viral infection. Yet, with this data in hand, a causal link between a viral infection and development of pSS had not been identified. Therefore, a study was designed to further define the viral landscape within pSS-affected salivary gland tissue to identify potential viral-mediated triggers in the pathogenesis of this autoimmune disease.

Methods:

A viral microarray was utilized to measure viral transcripts present in salivary gland tissue from patients diagnosed with pSS compared to healthy controls. Murine models of salivary gland localized HDV antigen expression were developed to evaluate the capacity of a chronic HDV signature to trigger the development of a pSS-like phenotype.

Results:

Through this analysis, two distinct viral profiles were identified, including the increased presence of hepatitis delta virus (HDV) in 50% of pSS patients evaluated. Presence of HDV antigen and sequence were confirmed in minor salivary gland tissue. Patients with elevated HDV levels in salivary gland tissue were negative for detectible hepatitis B virus (HBV) surface antigen and antibodies to HBV or HDV. Expression of HDV antigens in vivo resulted in reduced stimulated saliva flow, increase in focal lymphocytic infiltrates, and development of autoantibodies.

Conclusion:

Identification of HDV in pSS patients and induction of a complete pSS-like phenotype in vivo provides further support of a viral-mediated etiopathology in the development of pSS.

A Pilot Study on the Treatment of Posterior Cheek Enlargement in HIV+ Patients With Botulinum Toxin A

BACKGROUND

Posterior cheek enlargement in human immunodeficiency virus (HIV)+ individuals can lead to significant cosmetic disfigurement. Both parotid gland and masseter muscle overlie the mandibular ramus, contributing to lower facial contour. However, posterior cheek enlargement has not been well characterized anatomically. There are also limited treatment options. Botulinum toxin is a highly efficacious minimally invasive option for improving the shape of the lower face.

OBJECTIVE

A pilot study was undertaken to better characterize posterior cheek enlargement in HIV+ patients and explore treatment with botulinum toxin A.

MATERIALS AND METHODS

Five HIV+ patients with posterior cheek enlargement were treated with botulinum toxin A. Clinical, photographic, and radiological evaluations allowed the precise calculation of any change in volumes resulting from botulinum toxin A.

RESULTS

All 5 patients had a good response with a mean decrease of 21.4% and 11.2% in the volumes of the masseter muscle and parotid gland, respectively. The effect was long lasting even at 6 months after injection and well tolerated.

CONCLUSION

Botulinum toxin A may be a less invasive treatment of posterior cheek enlargement in HIV+ patients, with advantages of a good result that is long lasting with good tolerability and minimal risk.

A review and assessment of drug-induced parotitis

OBJECTIVE

To review the current literature on drug-induced parotitis.

DATA SOURCES

Literature was accessed through MEDLINE/PubMed (1980-May 2012), using the search terms sialadenitis/chemically induced and parotitis/chemically induced. EMBASE (1980-May 2012) was searched using the terms parotitis/diagnosis, sialadenitis/side effect, and parotitis/side effect. International Pharmaceutical Abstracts (1970-May 2012) was searched using the search terms parotitis and sialadenitis. All searches were limited to articles on humans written in English. Inclusion criteria were published letters, case reports, reviews, and clinical trials involving drugs that may be associated with parotitis. Articles pertaining to parotitis induced by iodine-containing drugs were excluded. References of all relevant articles were reviewed for additional citations.

STUDY SELECTION AND DATA EXTRACTION

Review articles, clinical trials, background data, and case reports of drug-induced parotitis were collected and case reports were assessed for causality.

DATA SYNTHESIS

Parotitis is an uncommon adverse effect; however, signs and symptoms of parotitis have been noted in case reports as an adverse drug reaction related to various medications. Assessing causality of an adverse drug reaction such as parotitis is challenging. To help determine the probability of causality for these events, algorithms such as the Naranjo probability scale have been developed. Eighty-four case reports of drug-induced parotitis from 40 different drugs were reviewed using a modified Naranjo probability scale that included criteria specific for parotitis. Medications that met the criteria for establishing causality included l-asparaginase with 7 case reports, clozapine with 13 case reports, and phenylbutazone with 13 case reports.

CONCLUSIONS

Drug-induced parotitis is a rare adverse drug reaction. Based on the quantitative and qualitative evidence collected from the case reports, medications that are associated with drug-induced parotitis include l-asparaginase, clozapine, and phenylbutazone. Many other drugs have been implicated in the development of parotitis; however, the evidence supporting this association is insufficient to determine causality at this time.

Do we need new diagnostic criteria for Sjögren's syndrome?

Diagnostic and classification criteria for Sjögren's syndrome (SS) continue to evolve as more is learned about SS and about autoimmune diseases in general. Among diagnostic or classification criteria for SS that are in current use, most include various and variable combinations of results from questions about symptoms and objective tests, many of which are not specific to SS. Given the rapid increase of genetic knowledge about other autoimmune diseases and the potential of finding and testing new biological agents to treat SS, selection of patients who have as uniform a disease process as possible becomes an important goal to better understand and treat this prevalent autoimmune disease. Such is the goal and promise of the latest entry into the SS classification criteria field.

Polyneuropathy associated with the diffuse infiltrative lymphocytosis syndrome

Diffuse infiltrative lymphocytosis syndrome (DILS) arises in HIV-positive patients secondary to infiltration of lymphocytes into the peripheral tissues and produces the disease's characteristic symptoms-parotid gland enlargement and a sicca syndrome. Many patients, however, first seek medical attention for treatment of the extraglandular manifestations of DILS, most commonly interstitial pneumonitis. In this case report, we describe an atypical presentation of DILS characterized by polyradiculoneuropathy in the absence of parotid gland enlargement or interstitial pneumonitis. Minor salivary gland biopsy of the patient's lip confirmed a chronic inflammatory state with lymphoid aggregates within the minor salivary glands. He was started on prednisone with immediate improvement in his symptoms. This report illustrates for clinicians the diverse extraglandular manifestations of DILS and underscores the importance of considering it in the differential diagnosis of HIV-positive patients with a preserved CD4 count who present with peripheral neuropathy.

Viruses and salivary gland disease (SGD): lessons from HIV SGD

Viral infections are often associated with salivary gland pathology. Here we review the pathogenesis of HIV-associated salivary gland disease (HIV-SGD), a hallmark of diffuse infiltrative lymphocytosis syndrome. We investigate the presence and contributions of viral diseases to the pathogenesis of salivary gland diseases, particularly HIV-SGD. We have detected BK viral shedding in the saliva of HIV-SGD patients consistent with viral infection and replication, suggesting a role for oral transmission. For further investigation of BKV pathogenesis in salivary glands, an in vitro model of BKV infection is described. Submandibular (HSG) and parotid (HSY) gland salivary cell lines were capable of permissive BKV infection, as determined by BKV gene expression and replication. Analysis of these data collectively suggests the potential for a BKV oral route of transmission and salivary gland pathogenesis within HIV-SGD.

Diagnostic ultrasound patterns of parotid glands in human immunodeficiency virus-positive patients in Mulago, Uganda

OBJECTIVES

The purpose of this study was to determine sonographically, in parotid glands of human immunodeficiency virus-positive patients, the condition of glands with or without enlargement, and propose a classification system for the patterns observed using diagnostic ultrasound imaging.

METHODS

In this prospective clinical study, ultrasound scans were performed on 200 patients aged 4-62 years at Mulago Hospital, Uganda.

RESULTS

There were four main distinct ultrasound pathological patterns in the parotids, i.e. lymphocytic aggregations (LAs), lymphoepithelial cysts (LECs), fatty infiltration (FI) and lymphadenopathy only. There were additional subdivisions depending on the presence of echogenic foci and intraparotid lymphadenopathy. Of those patients (n = 64) without parotid enlargement, only 8% showed normal ultrasound features, whereas 34% showed LECs and 31% showed LAs. Of those (n = 136) with parotid enlargement, 46% showed LECs, 23% showed FI and 15% showed LAs. The overall prevalence of LECs in the study sample was 42%. LECs were multiple, mainly between 7 mm and 12 mm in diameter and 26% showed internal echogenic foci either mobile or stationary. In contrast, LAs tended to be ill-defined, less than 5 mm and were not associated with posterior acoustic enhancement. Features differentiating LAs from LECs have not been previously described. Parotid FI (lipodystrophy) was noted in patients on highly active antiretroviral therapy, who showed lesser prevalence of LECs after 12 months of treatment.

CONCLUSIONS

Our study of 200 patients is probably the largest such study in the English language literature. The wide spectrum of diagnostic ultrasound patterns was categorized into four main groups (ten subgroups).

Effects of long-term use of HAART on oral health status of HIV-infected subjects

BACKGROUND

The aim of this study was to determine the effects of long-term use of highly active antiretroviral therapy (HAART) on oral health status of HIV-infected subjects.

METHODS

Oral examination and measurement of saliva flow rate of both unstimulated and wax-stimulated whole saliva were performed in HIV-infected subjects with and without HAART, and in non-HIV individuals. The following data were recorded; duration and risk of HIV infection, type and duration of HAART, CD4 cell count, viral load, presence of orofacial pain, oral dryness, oral burning sensation, oral lesions, cervical caries, and periodontal pocket. Multiple logistic regression analysis was performed to determine the effects of long-term use of HAART on oral health status of HIV-infected subjects.

RESULTS

One hundred and fifty-seven HIV-infected subjects - 99 on HAART (age range 23-57 years, mean 39 years) and 58 not on HAART (age range 20-59 years, mean 34 years) - and 50 non-HIV controls (age range 19-59 years, mean 36 years) were enrolled. The most common HAART regimen was 2 NRTI + 2 NNRTI. HIV-infected subjects without HAART showed greater risks of having orofacial pain, oral dryness, oral lesions, and periodontal pockets than those with short-term HAART (P < 0.01). The subjects with long-term HAART were found to have a greater risk of having oral lesions than those with short-term HAART (P < 0.05). The unstimulated and stimulated salivary flow rates of the subjects with HAART were significantly lower than in those without HAART (P < 0.05).

CONCLUSION

We conclude that long-term HAART has adverse effects on oral health status of HIV-infected subjects.

Effect of HAART on salivary gland function in the Women's Interagency HIV Study (WIHS)

OBJECTIVE

To determine the impact of highly active antiretroviral therapy (HAART) on salivary gland function in human immunodeficiency virus (HIV) positive women from the Women's Interagency HIV Study (WIHS).

DESIGN

Longitudinal cohort study.

SUBJECTS AND METHODS

A total of 668 HIV positive women from the WIHS cohort with an initial and at least one follow-up oral sub-study visit contributed 5358 visits. Salivary gland function was assessed based on a dry mouth questionnaire, whole unstimulated and stimulated salivary flow rates, salivary gland enlargement or tenderness and lack of saliva on palpation of the major salivary glands.

MAIN OUTCOME MEASURES

Changes in unstimulated and stimulated flow rates at any given visit from that of the immediate prior visit (continuous variables). The development of self-reported dry mouth (present/absent), enlargement or tenderness of salivary glands (present/absent), and absence of secretion on palpation of the salivary glands were binary outcomes (yes/no).

RESULTS

Protease Inhibitor (PI) based HAART was a significant risk factor for developing decreased unstimulated (P = 0.01) and stimulated (P = 0.0004) salivary flow rates as well as salivary gland enlargement (P = 0.006) as compared with non-PI based HAART.

CONCLUSIONS

PI-based HAART therapy is a significant risk factor for developing reduced salivary flow rates and salivary gland enlargement in HIV positive patients.

Diagnostic yield of fine-needle aspiration cytology in HIV-infected patients with lymphadenopathy in the era of highly active antiretroviral therapy

Fine-needle aspiration (FNA) cytology has an established role in the investigation of lymphadenopathy in HIV-infected patients. However, changes in the spectrum of disease have been observed since the introduction of highly active antiretroviral therapy (HAART). The aim of the study was to establish whether FNA cytology remains a useful investigative tool in the post-HAART era and to determine whether the cytology results reflect the changing patterns of disease. Retrospective search of the cytopathology database at University College London Hospitals identified 73 FNA cytology procedures performed in 62 patients between January 1998 and December 2006. FNA cytology showed significant disease in 90% of adequate samples. The most common diagnoses were persistent generalized lymphadenopathy (PGL, 50%), infection (22%) and malignancy (18%). Diagnoses could not be made in 31 % of patients because of inadequate sampling. An open lymph node biopsy was subsequently performed in 27% of patients. FNA cytology remains an important initial investigation in the post-HAART era, particularly in the diagnosis of PGL, infection and malignancy. Difficulties in diagnosis of Castleman disease and Hodgkin's lymphoma by FNA cytology are recognized.

Salivary dysfunction associated with systemic diseases: systematic review and clinical management recommendations

OBJECTIVES

The objective of this study was to identify systemic diseases associated with hyposalivation and xerostomia and develop evidence-based management recommendations for hyposalivation/xerostomia.

STUDY DESIGN

Literature searches covered the English language medical literature from 1966 to 2005. An evidence-based review process was applied to management studies published from 2002 to 2005.

RESULTS

Several systemic diseases were identified. From studies published 2002 to 2005, 15 were identified as high-quality studies and were used to support management recommendations: pilocarpine and cevimeline are recommended for treating hyposalivation and xerostomia in primary and secondary Sjögren's syndrome (SS). IFN-alpha lozenges may enhance saliva flow in primary SS patients. Anti-TNF-alpha agents, such as infliximab or etanercept, are not recommended to treat hyposalivation in SS. Dehydroepiandrosterone is not recommended to relieve hyposalivation or xerostomia in primary SS. There was not enough evidence to support any recommendations for the use of local stimulants, lubricants, and protectants for hyposalivation/xerostomia. However, professional judgment and patient preferences may support the use of a specific product for an individual patient.

CONCLUSIONS

These evidence-based management recommendations should guide the clinician's management decisions for patients with salivary dysfunction related to systemic disease. Future treatment strategies may include new formulations of existing drugs, e.g., local application of pilocarpine. Recent discoveries on gene expression and a better understanding of the etiopathogenesis of SS may open new treatment options in the future.

Mechanisms of autoantibody production and the relationship between autoantibodies and the clinical manifestations in Sjögren's syndrome

The major target organs of Sjögren's syndrome (SS) are lacrimal glands and salivary glands where prominent lymphocytic infiltration occurs, which may induce varying levels of autoantibody production. Multiple factors, including environmental stress, viral infection, hormonal imbalance, and apoptosis, are thought to be involved in the pathogenesis of SS. Production of anti-SS-A/Ro and anti-SS-B/La antibodies is thought to be regulated by the presentation of autoantigens in context with an aberrant expression pattern of human leukocyte antigen (HLA) in situ. Molecular mimicry with some viral sequences is also hypothesized. The apoptosis-resistance phenotype of B cells in labial salivary glands (LSGs) of SS is important in autoantibody production. CD40/CD40L (CD40 ligand) and Bcl-2 family proteins, in tandem with B cell-activating factor (BAFF), are supposed to protect infiltrating lymphocytes from apoptosis. Anti-muscarinic3 receptor antibody plays an important role in cholinergic hyperresponsiveness in SS. Fragmentation of autoantigens such as SS-B/La or alfa-fodrin during the process of apoptosis causes the redistribution of these autoantigens, leading to the production of autoantibodies in SS. In this review, the role of autoantibodies found in SS, corresponding to clinical aspects of each antibody as well as the mechanisms of production, is discussed.

Lymphocytic infiltration and enlargement of the lacrimal glands: a new subtype of primary Sjögren's syndrome?

PURPOSE

To review the clinical, radiologic, serologic, histopathologic, immunohistochemical, and molecular genetic features of patients having Sjögren's syndrome (SS) with lacrimal gland enlargement.

DESIGN

Retrospective case series review.

PARTICIPANTS

Fourteen patients histopathologically diagnosed with SS with lacrimal enlargement. Twenty-three age- and gender-matched controls were used for comparison on radiologic analysis.

METHODS

Clinical and serologic data were determined directly or by chart review. Computed tomography images from patients were compared with those from the control group. Histopathologic sections were reviewed and graded using the Chisholm-Mason scale, and quantitative immunohistochemical analysis was applied.

MAIN OUTCOME MEASURES

Clinically, patients were assessed for age, gender, onset, symptoms and signs, systemic features, treatment, and outcome. Existing histologic specimens were reviewed according to the Chisholm-Mason scale, and then the percentages of plasma cells containing immunoglobulin (Ig) A, IgG, and IgM were determined. Imaging was assessed for lacrimal gland thickness, prolapse, density, and margin contour; extraocular muscle size; orbital tissue displacement; and proptosis.

RESULTS

Clinical and histopathological data fulfilled the revised American-European criteria for primary SS in 79% of patients. Compared with other large series of primary SS patients, similarities were found with age, xerophthalmia, parotidomegaly, and articular involvement. Differences included a lower incidence of autoantibodies, xerostomia, and extraglandular features and a higher male-to-female ratio. In almost all patients (93%), the percentage of plasma cells positive for IgA was less than 70%, consistent with SS. Compared with controls, the lacrimal glands were enlarged significantly (P<0.0001) and prolapsed (P<0.001). Involved glands had blurred margins (P<0.007), caused displacement of adjacent tissues (P = 0.03), and were associated with hyperdense fat (P = 0.007). Lymphocytic infiltration of orbital fat was present in all patients for whom fat biopsy results were available. Three patients had monoclonal infiltrates, and 1 patient experienced subsequent extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue type, 4 years after presentation.

CONCLUSIONS

The criteria used to diagnose primary SS are controversial, but both diagnostic and quantitative immunohistochemical criteria suggest that these patients, with lacrimal gland enlargement resulting from lymphocytic infiltration, represent a new subtype of primary SS. This is clinically important in view of the increased risk of lymphoma associated with SS, compared with idiopathic nonspecific lacrimal inflammation.

Upper Respiratory Tract Involvement in the Course of Diffuse Infiltrative Lymphocytosis Syndrome in HIV‐1–Infected Patients: Report of 2 Cases

Diffuse infiltrative lymphocytosis syndrome (DILS) in patients with human immunodeficiency virus (HIV) infection is characterized by persistent CD8(+) lymphocytosis with visceral lymphocytic infiltration. DILS induces a large spectrum of clinical features. We describe 2 HIV-infected patients with upper respiratory tract involvement that occurred during the course of DILS.

Ultrasonographic contrast-enhanced study of sicca syndrome

OBJECTIVE

To assess the ability of US contrast-enhanced time-intensity curves to depict the changes connected with sicca syndrome, a fairly common condition that is often associated with autoimmune disorders such as Sjogren's syndrome or other diseases. Diagnostic criteria are complex and controversial and although no single test can be considered the gold standard, salivary gland scintigraphy and biopsy are reliable diagnostic methods.

MATERIALS AND METHODS

Sixty consecutive patients with sicca syndrome, 40 of whom had primary (n = 23) or secondary (n = 17) Sjogren's syndrome and 20 had non-Sjogren's sicca syndrome, selected according to European Community Study Group diagnostic criteria for Sjogren's syndrome and subjected to contrast-enhanced US imaging of the parotids using a second-generation contrast agent with analysis of time-intensity curves at rest and during salivary stimulation, Tc99m salivary gland scintigraphy and labial gland biopsy.

RESULTS

In the 40 Sjogren's patients, US enhancement values were significantly lower (P < 0.0001 and P < 0.00003, respectively) than in the 20 non-Sjogren's patients both at rest and during stimulation. In the 23 subjects with the primary syndrome, values during stimulation were significantly lower than in the 17 subjects with the secondary syndrome (P < 0.0006), whereas at rest differences were not significant. Contrast-enhanced US imaging allowed to discriminate Sjogren's from non-Sjogren's sicca patients with 87.5% sensitivity, 85% specificity and 86.7% accuracy and the primary from the secondary syndrome with 78.2% sensitivity, 70.5% specificity and 75% accuracy. Interestingly, in eight patients with the primary syndrome, i.e. those with the more severe gland involvement, enhancement values were lower during stimulation than at rest.

CONCLUSION

Preliminary results indicate that contrast-enhanced US imaging can provide useful information on sicca characterisation and severity.

MR imaging of salivary glands

Diagnostic imaging of salivary glands has been revolutionized with the advent of cross-sectional imaging modalities like CT and MR imaging. In the era before CT, imaging of the salivary glands was relatively unrewarding and was used uncommonly by ear-nose-throat surgeons. Early diagnostic tests like plain films and sialography evaluated dilated parotid ducts and calculus disease within ducts or glands. Full evaluation of salivary glands, especially deep lobes of parotid gland and masses of minor salivary glands, was not possible by these methods, however. Imaging of the parotid glands has developed significantly since that time. CT and MR imaging greatly compliment physical and endoscopic examinations (and previous favorites like sialography) by direct visualization of previously blind areas of the salivary glands and extension of the disease process in surrounding tissue planes.

Salivary IgA to cariogenic bacteria in HIV-positive children and its correlation with caries prevalence and levels of cariogenic microorganisms

The interrelationship of HIV infection, dental caries and mucosal immune responses remains controversial. In our study population of 40 HIV-infected and 40 healthy control children (ages 2-5 years) there was a significantly higher prevalence of dental caries in HIV-infected children (P<0.05). The extent of caries correlated with the severity of HIV disease. To determine whether the immunosuppression that ensues after HIV infection could contribute to the increased caries prevalence, the concentrations of total IgA and IgA specific to cariogenic bacteria (Streptococcus mutans, Streptococcus sobrinus and Lactobacillus acidophilus) were determined in whole saliva by enzyme-linked immunosorbent assay. Levels of the same bacteria were also quantified in saliva using checkerboard DNA-DNA hybridization. A significantly increased level of total salivary IgA was found in the HIV-positive population (P < 0.05), but there were comparable titers of specific IgA to cariogenic bacteria in HIV-positive and healthy controls. The microbiological assessment also demonstrated similar levels of cariogenic microorganisms in both groups. We conclude that HIV-positive children appear to maintain the capacity to mount a mucosal immune response to cariogenic microorganisms, at least until late stages of disease.

Salivary gland disease in HIV/AIDS and primary Sjögren's syndrome: analysis of collagen I distribution and histopathology in American and African patients

BACKGROUND

Salivary gland disease (SGD) in HIV/AIDS is clinically and histopathologically very similar to Sjögren's Syndrome (SS), although the mechanism of tissue damage is unknown. The aim of this study is to determine the prevalence of SGD in primary SS and in HIV/AIDS in USA and in West African patients, and to seek distinguishing histopathologic features that may help to elucidate underlying mechanisms.

METHODS

Histologic sections of minor salivary glands from 164 HIV-positive and -negative patients from Cameroon and the US, and from 17 US patients with primary SS, were evaluated following salivary gland biopsy for inflammatory changes. To confirm the presence of fibrosis, collagen I, which is the most abundant collagen type, was assessed immunohistochemically in H&E-stained sections.

RESULTS

Forty-eight per cent of patients with HIV from Cameroon had severe SGD, while it was only in 6% of patients from the US. Patients with HIV in the US had less fibrosis and collagen I deposits than Cameroonians. Seventy-six per cent of US HIV-positive patients had received anti-retroviral therapy, while none of the African patients had. SS and AIDS patients had a tendency for lymphocytes to locate in a perivascular rather than in a periductal distribution.

CONCLUSIONS

The prevalence of SGD and the presence of fibrosis and collagen I in Cameroonians with HIV is significantly higher than in HIV-positive American patients, and is similar to US patients with primary SS. The impact of patient selection, anti-retroviral therapy, and pathogenic mechanisms on salivary gland pathology is discussed.

Histopathological analysis and demonstration of EBV and HIV p-24 antigen but not CMV expression in labial minor salivary glands of HIV patients affected by diffuse infiltrative lymphocytosis syndrome

BACKGROUND

The diffuse infiltrative lymphocytosis syndrome (DILS) in HIV patients is characterized by the persistence of CD8-circulating lymphocytes and lymphocytic infiltration, predominantly in salivary glands.

METHODS

We examined seven HIV-positive patients with bilateral parotid enlargement and sicca symptoms. Minor labial salivary gland biopsies were performed in all patients and submitted for histopathological analysis and immunohistochemistry for CD4, CD8, cytomegalovirus (CMV), LMP-EBV protein, and HIV p-24 protein.

RESULTS

In all cases, lymphocytic infiltration of the minor salivary glands, mainly periductal, was found. Acinar atrophy, ductal ectasia, and mild to moderate fibrosis were also observed. We noticed strong immunohistochemical reaction for LMP-EBV and p-24 proteins in ductal cells in all cases, while staining for CMV was consistently negative. The lymphocytes were positive for CD8, but consistently negative for CD4.

CONCLUSIONS

A role of Epstein-Barr virus (EBV) and HIV, but not CMV, in the pathogenesis of DILS, is suggested by our immunohistochemical findings.

Host pathogen interaction and the development of oral lesions

The aetiologies of oral ulceration, disseminated interstitial lymphocytosis syndrome and oral lymphomas have been reviewed, with emphasis on the role of HIV infection in the primary causation or modification of the presentation of these entities. There is a paucity of evidence to explain why oral ulceration is so severe in HIV infection, and why major ulceration affects the oropharynx. A number of mechanisms have been proposed to account for the development of lymphomas in patients with HIV infection, including a genetic predisposition, decreased immunosurveillance due to HIV infection, alteration of endothelial cell function and dysregulation of cytokine networks. From this review, it was concluded that there is a need for a prospective multicentre study, to elucidate the aetiological mechanisms involved in lymphomas of the oral regions in this patient group. It was concluded that, although there is anecdotal evidence implicating tobacco use in the aetiology of the lesions reviewed, this is insufficient to allow definitive statements to be made and further systematic evaluation is indicated.

MR imaging of salivary glands

In conclusion, if a parotid gland mass is bilateral, it is more likely to be Warthin's tumor, especially if it does not enhance. Less likely, it could be lymphoepithelial cyst or necrotic lymph node. A unilateral, non-enhancing mass with a high T2 signal is more likely to be a Warthin's tumor and less likely a necrotic lymph node or first branchial cleft cyst. If the mass is unilateral, shows postcontrast enhancement, has a high T2 signal, and does not invade surrounding tissue planes, it is more likely to be a pleomorphic adenoma. An intermediate to low T2 signal mass-with or without invasion of surrounding tissue planes--is more likely to be a malignant mass such as adenocystic or mucoepidermoid carcinoma. Biopsy is superior and the gold standard for diagnosis and cannot be replaced by MR imaging, however.

Regression of HIV parotid swellings after antiviral therapy: case reports with computed tomographic scan evidence

Parotid swellings have been noted in approximately 5% to 10% of patients with HIV-1. These swellings are a result of lymphoproliferative activity or lymphoepithelial cyst formation in response to a viral parotid presence. Two patients with cosmetic concerns regarding parotid swellings are presented before and after antiviral therapy. Regression of the swellings after treatment is substantiated with clinical photographs and computerized tomographic scans. The successful outcome was a reflection of a diminution in viral load and some degree of immune restoration.

Primary Sjögren's syndrome: oral aspects on pathogenesis, diagnostic criteria, clinical features and approaches for therapy

Primary Sjögren's syndrome (pSS) is a chronic inflammatory systemic autoimmune disease affecting the exocrine glands and predominantly the salivary and lacrimal glands. The impaired gland function is assumed to be a result of progressive lymphocyte-mediated destruction of the exocrine gland tissue leading to the cardinal manifestations, hyposalivation and keratoconjunctivitis sicca (KCS), as well as devastating symptoms of oral and ocular dryness. Although primarily characterised as an exocrine dysfunction, non-exocrine organs may also be affected. The onset and course of pSS is usually insidious but may develop into a disabling disease, which profoundly affects the patient's general well being and quality of life. Moreover, pSS may even evolve into a lymphoid malignancy. The aetiology of pSS remains unknown but the pathogenesis of exocrine cell damage is apparently multi-factorial, including immunological, genetic, hormonal and viral components. Recent research also includes neurogenic aspects of exocrine gland dysfunction, including the interference of immune mediators with glandular response to neurotransmitters released from nerve fibres. pSS usually affects middle-aged women and the female:male ratio is 9:1. The prevalence varies from 0.29-4.8%, depending on the population sampled and the diagnostic criteria used. At present, there are no specific diagnostic tests for pSS and no universally accepted diagnostic criteria. The current therapy is primarily symptomatic. This review focuses on the current oral clinical, diagnostic, pathogenic and therapeutic aspects of pSS.

Ultrasound findings in HIV-positive patients with parotid gland swellings

PURPOSE

This study aimed to determine the role that ultrasound might play in evaluating parotid swellings in patients with human immunodeficiency virus (HIV)-1 disease.

PATIENTS AND METHODS

The parotid glands of 13 HIV-positive patients, who were previously diagnosed as seropositive and who were referred because they had unilateral or bilateral parotid gland swellings, were examined sonographically.

RESULTS

All patients showed multiple and varied parotid sonolucent areas bilaterally. These patterns reflected the presence of lymphoepithelial cysts, intraparotid lymphadenopathies, and parenchymal lymphoproliferation.

CONCLUSION

Because parotid swellings can represent early clinical evidence of HIV disease, comprehensive gland evaluation is mandatory. Ultrasound offers a simple, rapid imaging technique to ascertain the nature of the glandular pathology.

Characteristics of salivary diffuse infiltrative lymphocytosis syndrome in West Africa

OBJECTIVE

To determine the prevalence of diffuse infiltrative lymphocytosis syndrome (DILS) in the minor salivary glands of 30 African Cameroonian adults with the acquired immunodeficiency syndrome (AIDS).

DESIGN

Salivary gland tissue was analyzed using a modified classification system that was developed to aid the diagnosis of Sjögren syndrome. The advantages and disadvantages of this approach are discussed.

MATERIALS AND METHODS

Formalin-fixed, paraffin-embedded, hematoxylin-eosin-stained biopsy sections were prepared for 30 patients with AIDS, 26 healthy individuals who declined human immunodeficiency virus (HIV) testing, and 4 seronegative healthy controls. Tissues were immunostained for CD4/CD8+ lymphocytes and cytomegalovirus (CMV), and transmission electron microscopy was performed to locate viral particles. Patients were tested for HIV-1 and HIV-2 by the HIV/Chek System 3 or CAMSTIX-HIV-1 and HIV-2 assay.

RESULTS

Severe salivary ductal atypia (96%) was the feature most strongly associated with AIDS, and the lymphocytic focus score was the second histologic feature most strongly correlated with AIDS. Forty-eight percent of patients with HIV-1 infection had more than 1 lymphocytic focus in a minor salivary gland. These lymphocytes were primarily CD8+. We report, to the best of our knowledge, the first case of multinucleated salivary duct epithelial cells in minor salivary glands also containing enveloped virus particles. All cases were negative for CMV.

CONCLUSIONS

The prevalence of DILS in West Africans with AIDS appears higher than the prevalence reported in whites from the United States and Europe and in blacks from the United States, a group that has been reported to have a greater incidence of DILS than whites. This discrepancy may be related to differences in patient selection criteria. The determination of lymphocytic focus score, as used in the diagnosis of Sjögren syndrome, with the adjunct of ductal atypia is useful for assessing DILS. The impact of patient selection, drug therapy, and parasites on salivary gland pathology is discussed.

The changing spectrum of rheumatic disease in human immunodeficiency virus infection

CONTEXT

Although it has been known for over 15 years that a number of rheumatic diseases occur in patients with human immunodeficiency virus (HIV) infection, increasing knowledge about these disorders and advances in HIV treatment need to be considered in approaching patients with HIV-associated rheumatic disease.

OBJECTIVE

To examine the clinical, pathologic, and therapeutic features of HIV-associated rheumatic diseases in the context of what is known about the immunology of HIV infection.

DATA SOURCES

The author's own extensive collection of references, supplemented by PubMed Medline searches for articles in English-language journals published between 1985 and 2000. The indexing term HIV and the following coindexing terms were used for searching: arthritis, Reiter's syndrome, psoriatic arthritis, rheumatoid arthritis, osteonecrosis, vasculitis, pulmonary hypertension, myositis, myopathy, fibromyalgia, septic arthritis, parotid enlargement, diffuse infiltrative lymphocytosis syndrome, systemic lupus erythematosus, septic arthritis, mycobacterial arthritis, fungal arthritis, autoantibodies, anti-cardiolipin antibodies, and anti-neutrophilic cytoplasmic antibodies.

STUDY SELECTION

All papers identified in the literature search were reviewed. Studies presenting data that merely confirmed previous studies were not included in the analysis.

DATA EXTRACTION

All identified papers were abstracted by the author. Letters to the editor were included only if a new observation had been made.

DATA SYNTHESIS

This was a qualitative review of papers published, with new knowledge about these disorders summarized and presented.

RESULTS

Despite new treatments for HIV, reports of rheumatic diseases presenting in AIDS patients persist, especially in HIV-associated arthritis, diffuse infiltrative lymphocytosis syndrome, HIV-associated vasculitis, and polymyositis. However, new HIV treatments may ameliorate these diseases.

CONCLUSIONS

The spectrum of HIV-associated rheumatic disease remains a diagnostic and therapeutic challenge for the clinician. The impact of changes in HIV treatment on these disorders requires further assessment.

Differentiating HIV-1 parotid cysts from papillary cystadenoma lymphomatosum

BACKGROUND

Patients with parotid cystic lesions may first be seen in the dental office. These conditions most often represent either papillary cystadenoma lymphomatosum, or PCL, or lymphoepithelial cysts associated with human immunodeficiency virus, or HIV, disease. The authors present a case report to illustrate the differential diagnosis.

CASE DESCRIPTION

PCL represents a benign, usually unilateral, circumscribed parotid tumor with cystic elements. HIV-associated lymphoepithelial cysts of the parotid gland usually are seen bilaterally, create cosmetic concerns and are hallmarked by an associated cervical lymphadenopathy. Therapy for PCL demands surgical excision, while patients with HIV-associated lymphoepithelial cysts may be treated with antiviral therapy and undergo periodic monitoring by a physician.

CLINICAL IMPLICATIONS

As a member of the health care team, the dentist must be familiar with head and neck swellings. Early clinical recognition of parotid swellings leads to successful treatment.

Salivary gland disease in human immunodeficiency virus-positive women from the WIHS study. Women's Interagency HIV Study

OBJECTIVE

To determine the prevalence of enlargement, tenderness, and absence of saliva on palpation as indicators of salivary gland disease in women who are human immunodeficiency virus (HIV)-positive.

STUDY DESIGN

The study subjects are participants in the Women's Interagency HIV Study (WIHS), a multicenter study examining HIV-seropositive women and at-risk HIV-seronegative women. A total of 576 HIV-positive women and 152 HIV-negative women were examined at their baseline oral visit for clinical markers of salivary gland disease. Viral load levels, CD4 counts, and CD8 counts were obtained as part of the related core study.

RESULTS

HIV-positive women had higher rates of salivary gland enlargement (4.3%), tenderness (6.9%), and absence of saliva on palpation (26.6%) compared with HIV-negative women, who had rates of 1.3%, 4.6%, and 13.2%, respectively. Absence of saliva was significantly different (P =. 001) between the 2 groups. When 2 of the 3 clinical findings were combined, comparisons between the HIV-positive women and HIV-negative women became significant at the P <.05 level for every combination, except for enlargement/tenderness for the submandibular/sublingual gland. For the HIV-positive women, the viral load was significantly related to enlargement (P =.019) and enlargement/absence of saliva on palpation (P =.037) for the parotids and enlargement (P =.046), absence of saliva (P =.043), and enlargement/absence of saliva (P =.022) for the submandibular/sublingual glands. Significant linear trends were found for increasing viral load and enlargement (P =.013) and enlargement/tenderness (P =.024) for the submandibular/sublingual glands. Significance was present for submandibular/sublingual absence of saliva and tenderness/absence of saliva for CD4 and CD8 medians.

CONCLUSIONS

Serostatus is related to salivary gland disease as assessed by glandular enlargement, tenderness, and absence of saliva on palpation. Furthermore, our findings indicate that a multidimensional approach to gland assessment may provide a more complete and perhaps more adequate description of glandular involvement with HIV infection.

Changing prevalence of oral manifestations of human immuno-deficiency virus in the era of protease inhibitor therapy

OBJECTIVE

The purpose of this study was to determine temporal trends in the prevalence of oral manifestations of human immunodeficiency virus (HIV).

STUDY DESIGN

Five hundred seventy HIV-infected adults recruited consecutively were examined by using established presumptive clinical criteria for HIV-associated oral lesions. Prevalence of oral lesions before the widespread use of HIV protease inhibitors (February 1995 through August 1996, 8% of the early sample, n = 271) was compared with lesion prevalence in a more recent period of greater protease inhibitor use (December 1996 through February 1999, 42% of the late sample, n = 299).

RESULTS

Overall prevalence of oral lesions significantly decreased from early to late periods, 47.6% to 37.5%, respectively (P =.01), with some variation by lesion type. Prevalence of hairy leukoplakia (25. 8% to 11.4%; P <.01) and necrotizing periodontal diseases (4.8% to 1. 7%; P =.03) decreased, whereas HIV salivary gland disease increased (1.8% to 5.0%; P =.04). Changes in prevalence of oral candidiasis (20.3% to 16.7%), aphthous ulcers (3.7% to 3.0%), oral warts (2.2% to 4.0%), herpes simplex virus lesions (1.8% to 2.0%), and Kaposi's sarcoma (1.1% to 0.3%) were not statistically significant (P >.20 for all comparisons).

CONCLUSION

The pattern of oral opportunistic infections is changing in the era of protease inhibitor use.

Oral infections and other manifestations of HIV disease

Oral lesions are important in the clinical spectrum of HIV/AIDS, arousing suspicion of acute seroconversion illness (aphthous ulceration and candidiasis), suggesting HIV infection in the undiagnosed individual (candidiasis, hairy leukoplakia, Kaposi's sarcoma, necrotizing ulcerative gingivitis), indicating clinical disease progression and predicting development of AIDS (candidiasis, hairy leukoplakia), and marking immune suppression in HIV-infected individuals (candidiasis, hairy leukoplakia, necrotizing periodontal disease, Kaposi's sarcoma, long-standing herpes infection, major aphthous ulcers). In addition, oral lesions are included in staging systems for HIV disease progression and as entry criteria or endpoints in clinical trials of antiretroviral drugs. Recognition and management of these oral conditions is important for the health and quality of life of the individual with HIV/AIDS. In keeping with this, the U.S. Department of Health Services Clinical Practice Guideline for Evaluation and Management of Early HIV Infection includes recommendations that an oral examination, emphasizing oral mucosal surfaces, be conducted by the primary care provider at each visit, a dental examination by a dentist should be done at least two times a year, and patients should be informed of the importance of oral care and educated about common HIV-related oral lesions and associated symptoms.

Epstein-Barr virus status and the histopathological changes of parotid gland lymphoid infiltrates in HIV-positive children

This study examined the EBV status and the morphology in parotid glands of a large cohort of HIV-positive pediatric patients. Nineteen children with vertically acquired HIV infection, ranging in age from three months to seven years and two months, were analyzed. Seventeen patients were assessed for serological evidence of EBV infection; nine showed evidence of past infection, one each re-activation and current infection and six did not have serological evidence of EBV. Immunohistochemistry and in situ hybridization for EBER 1 and 2 were performed on formalin-fixed, paraffin-embedded tissue. Fourteen of the 19 cases were classified as severe or established myoepithelial sialadenitis (MESA) and five were regarded as having mild MESA. The majority of intraepithelial lymphocytes were of B-cell lineage, while the pericystic infiltrate contained CD8-positive T-lymphocytes. p24 immunohistochemistry for HIV showed positive follicular dendritic cells, lymphoid cells and macrophages. Ten of 14 cases were positive for EBER 1 and 2. These included cases that were serologically negative for EBV. This study confirms that the morphology and immunophenotype of pediatric HIV-associated parotid lesions are similar to those seen in adults. Ten of 14 cases with evidence of EBV within the lymphoid infiltrate showed the same morphology and immunophenotype as cases in which EBV was not detected either by serology or by in situ hybridization. These findings indicate that EBV is not uniformly found in either the tissue or serum of these patients, and may not have a pathogenetic role in HIV-associated lymphoepithelial lesions in the pediatric age group.