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

Human Cytomegalovirus Replication and Infection-Induced Syncytia Formation in Labial, Foreskin, and Fetal Lung Fibroblasts

Only a handful of cell types, including fibroblasts, epithelial, and endothelial cells, can support human cytomegalovirus (CMV) replication in vitro, in striking contrast to the situation in vivo. While the susceptibility of epithelial and endothelial cells to CMV infection is strongly modulated by their anatomical site of origin, multiple CMV strains have been successfully isolated and propagated on fibroblasts derived from different organs. As oral mucosal cells are likely involved in CMV acquisition, we sought to evaluate the ability of infant labial fibroblasts to support CMV replication, compared to that of commonly used foreskin and fetal lung fibroblasts. No differences were found in the proportion of cells initiating infection, or in the amounts of viral progeny produced after exposure to the fibroblast-adapted CMV strain AD169 or to the endothelial cell-adapted strain TB40/E. Syncytia formation was, however, significantly enhanced in infected labial and lung fibroblasts compared to foreskin-derived cells, and did not occur after infection with AD169. Together, these data indicate that fibroblast populations derived from different tissues are uniformly permissive to CMV infection but retain phenotypic differences of potential importance for infection-induced cell-cell fusion, and ensuing viral spread and pathogenesis in different organs.

Viral infections of oral cavity

Viral infections of the oral cavity usually manifest as either ulceration or blistering presentation of oral tissues. Oral viral infections are encountered in dental practice but received less clinical interest due to the lesser frequency of patients and diagnostic challenges. The clinical presentation, pathogenic mechanism, investigations, and management of oral viral infections are integrated into the article which will enable general dentists to develop critical thinking processes on differential diagnosis and management through a multidisciplinary approach with specialist dentists.

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.

Detection of Herpes Simplex Virus and Varicella-Zoster Virus by Traditional and Multiplex Molecular Methods

Objectives

To compare multiplex nucleic acid amplification tests (NAATs) that detect and differentiate herpes simplex virus (HSV) and varicella-zoster virus (VZV) with traditional virologic assays.

Methods

The HSV ELVIS Test System (Quidel, San Diego, CA) and/or Light Diagnostics VZV direct fluorescent antibody (DFA) kit (Millipore Sigma, Billerica, MA), as well as an ARIES HSV 1&2/VZV assay (Luminex, Austin, TX) and the Solana HSV1 + 2/VZV Assay (Quidel), were performed on non-cerebrospinal fluid specimens.

Results

The sensitivities/specificities for the ELVIS, Aries, and Solana assays for HSV were 71.1%/93.2%, 94.9%/93.2%, and 94.7%/100%, respectively. The sensitivities/specificities for the DFA, Aries, and Solana assays for VZV were 71.4%/100%, 100%/96.0%, and 95.3%/100%, respectively. HSV and VZV were detected but clinically unsuspected in 5.4% and 4.2% of the specimens, respectively.

Conclusions

Both NAAT assays were comparable and more sensitive than traditional methods. The recovery of unsuspected HSV and VZV from clinical specimens supports the implementation of a combined HSV/VZV assay.

Human Cytomegalovirus Productively Replicates In Vitro in Undifferentiated Oral Epithelial Cells

Human cytomegalovirus (HCMV) productive replication in vitro is most often studied in fibroblasts. In vivo, fibroblasts amplify viral titers, but transmission and pathogenesis require the infection of other cell types, most notably epithelial cells. In vitro, the study of HCMV infection of epithelial cells has been almost exclusively restricted to ocular epithelial cells. Here we present oral epithelial cells with relevance for viral interhost transmission as an in vitro model system to study HCMV infection. We discovered that HCMV productively replicates in normal oral keratinocytes (NOKs) and telomerase-immortalized gingival cells (hGETs). Our work introduces oral epithelial cells for the study of HCMV productive infection, drug screening, and vaccine development.IMPORTANCE The ocular epithelial cells currently used to study HCMV infections in vitro have historical significance based upon their role in retinitis, an HCMV disease most often seen in AIDS patients. However, with the successful implementation of highly active antiretroviral therapy (HAART) regimens, the incidence of HCMV retinitis has rapidly declined, and therefore, the relevance of studying ocular epithelial cell HCMV infection has decreased as well. Our introduction here of oral epithelial cells provides two alternative in vitro models for the study of HCMV infection that complement and extend the physiologic relevance of the ocular system currently in use.

Cytomegalovirus Co-infection in AIDS-associated Oral Kaposi’s Sarcoma

The increasing appearance of AIDS-associated oral Kaposi’s sarcoma (KS) in South Africa may be ascribed to the later start of the HIV epidemic, more patients reaching stages III and IV, and the inaccessibility of most patients to anti-retroviral therapy. The objective of this study was to demonstrate cytomegalovirus (CMV) co-infection in oral KS and to consider its possible significance. We reviewed 20 cases of oral KS in known HIV-positive patients without active CMV disease. HHV8 PCR and CMV immunohistochemistry were performed. HHV8 DNA was present in all cases. CMV inclusions were detected in five cases. The significance of CMV co-infection in oral KS is unclear. The inclusions suggest active infection, although there is no evidence to support CMV in the pathogenesis of KS. Nonetheless, it is vital that physicians be alerted to active CMV infection, so that timely intervention and careful observation can be instituted, ensuring early diagnosis and treatment.

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.

Cutaneous cytomegalovirus infection on multi dermatomal herpes zoster scars: an isotopic immune response

As more patients with human immunodeficiency virus (HIV) are surviving, despite severe immune suppression, clinicians are faced with atypical manifestations of both common and uncommon dermatoses. A 30-year-old black South African woman presented with a 10-month history of multiple chronic ulcers appearing on a multidermatomal herpes zoster (HZ) scar. The woman was infected with HIV, and her CD4 count was 45 cells/μL. Histology and PCR revealed cytomegalovirus (CMV) infection. This case highlights an unusual presentation of cutaneous CMV occurring as an isotopic immune response on a pre-existing multidermatomal HZ scar.

Update on oral herpes virus infections

Oral herpes virus infections (OHVIs) are among the most common mucosal disorders encountered by oral health care providers. These infections can affect individuals at any age, from infants to the elderly, and may cause significant pain and dysfunction. Immunosuppressed patients may be at increased risk for serious and potential life-threatening complications caused by OHVIs. Clinicians may have difficulty in diagnosing these infections because they can mimic other conditions of the oral mucosa. This article provides oral health care providers with clinically relevant information regarding etiopathogenesis, diagnosis, and management of OHVIs.

Salivary shedding of Epstein-Barr virus and cytomegalovirus in people infected or not by human immunodeficiency virus 1

The purpose of this study is to determine the frequency of EBV and CMV DNA detection in saliva of HIV infected and non-HIV individuals and their siblings. The study group comprised 240 individuals. Group 1 comprised of 40 HIV-infected patients, group 2 40 non-HIV individuals, group 3 two siblings for each patient from group 1 (n = 80), and group 4 two siblings for each individual from group 2 (n = 80). Non-stimulated whole saliva was collected, DNA was extracted, and amplification was performed using a nested PCR protocol. EBV and CMV DNA was detected in 7/40 (17.5%) and 5/40 (12.5%) individuals from group 1, 8/40 (20%) and 3/40 (7.5%) from group 2, 11/80 (13.8%) and 2/80 (2.5%) from group 3, and 8/80 (10%) and 1/80 (1.3%) from group 4, respectively. Five (71.4%) out of seven HIV/EBV coinfected individuals of group 1 had a relative also infected with EBV (OR = 11.25, CI [1.75-72.5], p = 0.011). Regarding group 2, among the eight non-HIV and EBV-infected individuals, three (37.5%) had a relative also positive to EBV (p = 0.320). No individual HIV/CMV coinfected had a relative CMV infected (p = 1.00). Also, only one non-HIV and CMV-infected individual had a relative also positive to CMV (p = 0.075). EBV and CMV DNA was detected mainly in those who had HIV viral load counts <400/mL (71%, p = 0.2 and 100%, p = 1, respectively) and those who had CD4 T cells counts between 200 and 400/mm(3) (57%, p = 0.544 and 60%, p = 0.249, respectively). HIV-infected individuals and healthy controls showed a similar frequency of viral DNA detection. EBV DNA was significantly amplified in saliva of household members of HIV/EBV coinfected individuals.

Oral ulcers in HIV-positive Peruvian patients: an immunohistochemical and in situ hybridization study

BACKGROUND

This study describes the histopathological, immunohistochemical (IHC) and in situ hybridization (ISH) data of 25 cases of oral ulcers in HIV-positive patients, with clinical and microscopical features similar to ulcers not otherwise specified (NOS)/necrotizing ulcerative stomatitis (NUS).

METHODS

Sex, age and clinical history were obtained from the clinical records. Histological analysis for H&E, Gomori-Grocott and Ziehl-Neelsen stains, IHC analysis to detect infectious agents and to characterize inflammatory cellular infiltrate, and ISH for cytomegalovirus (CMV) and EBER1/2 were performed.

RESULTS

Twenty-one patients were men and four were women (mean age of 34.6 years). The tongue was preferentially affected. Microscopically, the lesions showed extensive necrosis, leukocytoclasia, vasculitis with luminal fibrin clots and an intense inflammatory cellular infiltrate predominated by CD68(+) atypical large cells, normal-sized and crescent-shaped nuclei macrophages, interspersed by CD8(+) T lymphocytes. Mast cells were also observed in all samples studied. CD4(+) T lymphocytes, CD20(+) B lymphocytes and VS38c(+) plasma cells were practically absent. CMV and EBER1/2 were identified in scarce cells of 3 and 16 of 25 cases respectively.

CONCLUSION

These results show that CD68(+) macrophages, followed by CD8(+) T lymphocytes, were the predominant inflammatory cells, indicating they are relevant to the pathogenesis of the ulcers, possibly reflecting an abnormal immune response in the oral mucosa. The clinicopathological and immunoprofile features of the present cases are similar to NOS ulcers/NUS in HIV-positive patients.

Recurrent oral ulceration: aphthous-like ulcers in periodic syndromes

Recurrent oral ulceration that clinically resembles recurrent aphthous stomatitis but presents atypically, including commencement after adolescence, with fever, with a strong family history, or failing to resolve with age, has been termed aphthous-like ulceration (ALU). It may be seen in some immunodeficiency states, chronic viral infections, rheumatologic disorders, skin diseases, and the periodic syndromes. The periodic syndromes, considered to be the prototypic autoinflammatory diseases, present with recurrent short attacks of myalgia, arthralgia, rashes, abdominal pain, lymphadenopathy, and fever. Several of the syndromes can result in amyloidosis. Genetic studies have enhanced the clinical characterization of these conditions and elucidation of their molecular etiopathogenesis. This paper describes 2 patients with periodic syndromes presenting with ALU and reviews the present understanding of the syndromes.

Ulcerative lesions of the mouth: an update for the general medical practitioner

Oral ulceration is a common complaint of patients attending out-patient clinics. Because of the diversity in causes of oral ulceration, patients presenting with oral mucosal disease can be challenging to diagnose and manage. Patients with signs or symptoms of oral ulcers are sometimes referred to gastroenterology clinics; however, in most instances the ulcers do not result from gastrointestinal disease. The aim of the present article is to review aspects of the etiology, diagnosis and management of common ulcerative disorders of the oral mucosa. A search in the National Library of Medicine computerized bibliographic database MEDLINE was performed. Selection of publications, extraction of data, and validity assessment were then performed by the authors. Based upon the searched literature, it is concluded that there are several systemic disorders that can present with similar clinical signs and symptoms, and knowledge of each disease is necessary for the clinician to provide proper management.

Herpesviral-bacterial synergy in the pathogenesis of human periodontitis

PURPOSE OF REVIEW

Periodontitis is an infectious disease, but the specific mechanisms by which tooth-supportive tissues are lost remain obscure. This article proposes an infectious disease model for periodontitis in which herpesviral-bacterial interactions assume a major etiopathogenic role.

RECENT FINDINGS

Epstein-Barr virus type 1, cytomegalovirus and other herpesviruses occur at a high frequency in aggressive periodontitis lesions. Also, herpesvirus-infected periodontitis lesions tend to harbor elevated levels of classic periodontopathic bacteria, including Porphyromonas gingivalis, Dialister pneumosintes, Prevotella intermedia, Prevotella nigrescens, Campylobacter rectus, Treponema denticola and Actinobacillus (Aggregatibacter) actinomycetemcomitans.

SUMMARY

Conceivably, a herpesvirus active infection in the periodontium impairs local defenses, thereby permitting overgrowth and increased aggressiveness of periodontopathic bacteria. In turn, periodontal pathogenic bacteria may augment the virulence of periodontal herpesviruses. It is suggested that interactions among herpesviruses and specific bacterial species constitute an important pathogenetic feature of periodontitis and maybe also of various non-oral infections.

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.

Endothelial cell- and lymphocyte-based in vitro systems for understanding KSHV biology

Kaposi sarcoma (KS), the most common AIDS-associated malignancy, is a multifocal tumor characterized by deregulated angiogenesis, proliferation of spindle cells, and extravasation of inflammatory cells and erythrocytes. Kaposi sarcoma-associated herpesvirus (KSHV; also human herpesvirus-8) is implicated in all clinical forms of KS. Endothelial cells (EC) harbor the KSHV genome in vivo, are permissive for virus infection in vitro, and are thought to be the precursors of KS spindle cells. Spindle cells are rare in early patch-stage KS lesions but become the predominant cell type in later plaque- and nodular-stage lesions. Alterations in endothelial/spindle cell physiology that promote proliferation and survival are thus thought to be important in disease progression and may represent potential therapeutic targets. KSHV encodes genes that stimulate cellular proliferation and migration, prevent apoptosis, and counter the host immune response. The combined effect of these genes is thought to drive the proliferation and survival of infected spindle cells and influence the lesional microenvironment. Large-scale gene expression analyses have revealed that KSHV infection also induces dramatic reprogramming of the EC transcriptome. These changes in cellular gene expression likely contribute to the development of the KS lesion. In addition to KS, KSHV is also present in B cell neoplasias including primary effusion lymphoma and multicentric Castleman disease. A combination of virus and virus-induced host factors are similarly thought to contribute to establishment and progression of these malignancies. A number of lymphocyte- and EC-based systems have been developed that afford some insight into the means by which KSHV contributes to malignant transformation of host cells. Whereas KSHV is well maintained in PEL cells cultured in vitro, explanted spindle cells rapidly lose the viral episome. Thus, endothelial cell-based systems for studying KSHV gene expression and function, as well as the effect of infection on host cell physiology, have required in vitro infection of primary or life-extended EC. This chapter includes a review of these in vitro cell culture systems, acknowledging their strengths and weaknesses and putting into perspective how each has contributed to our understanding of the complex KS lesional environment. In addition, we present a model of KS lesion progression based on findings culled from these models as well as recent clinical advances in KS chemotherapy. Thus this unifying model describes our current understanding of KS pathogenesis by drawing together multiple theories of KS progression that by themselves cannot account for the complexities of tumor development.

Noma (cancrum oris)

Noma is an opportunistic infection promoted by extreme poverty. It evolves rapidly from a gingival inflammation to grotesque orofacial gangrene. It occurs worldwide, but is most common in sub-Saharan Africa. The peak incidence of acute noma is at ages 1-4 years, coinciding with the period of linear growth retardation in deprived children. Noma is a scourge in communities with poor environmental sanitation. It results from complex interactions between malnutrition, infections, and compromised immunity. Diseases that commonly precede noma include measles, malaria, severe diarrhoea, and necrotising ulcerative gingivitis. The acute stage responds readily to antibiotic treatment. The sequelae after healing include variable functional and aesthetic impairments, which require reconstructive surgery. Noma can be prevented through promotion of national awareness of the disease, poverty reduction, improved nutrition, promotion of exclusive breastfeeding in the first 3-6 months of life, optimum prenatal care, and timely immunisations against the common childhood diseases.

Tongue disease in advanced AIDS

OBJECTIVE

This study describes the involvement and the histological alterations found in the tongues of 92 autopsied patients who died with AIDS.

MATERIALS AND METHODS

Sex, age, CD4 cell count and clinical history were obtained from the files of 92 patients who died with AIDS. All the tongues were examined for macroscopical alterations and stained using H&E, Gomori-Grocott, Ziehl-Neelsen, PAS, Brow-Hopps and Mucicarmine. Histological autopsy findings were grouped based on a protocol that was designed following the World Health Organization recommendations.

RESULTS

The mean age of the patients who died of AIDS and CD4 cell count were 36 years and 82 cells microL(-1), respectively. Histological alterations of the tongues were found in 75% of the cadavers. The most common lesions were hairy leukoplakia (HL) (42 cases), candidosis (31 cases) and non-specific chronic glossitis (29 cases), followed by concomitant lesions (28 cases), non-specific chronic ulceration (17 cases), melanotic pigmentation (13 cases), herpes simplex (10 cases), lymphoepithelial cysts (two cases), cryptococcosis (two cases), mycobacteriosis (one case), histoplasmosis (one case), cytomegalovirus infection (one case) and non-Hodgkin Lymphoma (one case). HL with oral candidosis (n = 13) were the most common concomitant lesions.

CONCLUSION

These findings indicate that the tongue is a favorite site to occurrence of reactive, infectious and concurrent lesions in the end-stage of AIDS patients.

Review article: oral ulcers and its relevance to systemic disorders

Oral ulceration is a common problem, and is sometimes a marker of gastroenterological disease. Patients with signs or symptoms of oral ulcers are sometimes referred to gastroenterology clinics, however, in most instances the ulcers does not reflect gastrointestinal disease. Indeed, a spectrum of disorders other than those of the gut can give rise to oral mucosal ulcers ranging from minor local trauma to significant local disease such as malignancy or systemic illness. This present article reviews aspects of the aetiology, diagnosis and management of common ulcerative disorders of the oral mucosa.

Oral herpetic infections (HSV 1-8)

Oral herpes virus infections are commonly seen by the dental practitioner. Saliva is a reservoir for the herpes virus, and a variety of infections, both localized and systemic, may be induced by the virus. Patients who are immunocompromised may be at risk for serious and potentially life-threatening complications of herpes virus infections. This article highlights the basic virology and clinical manifestations of herpetic infections and the differential diagnosis and management of oral herpes virus infections.

Imatinib-induced regression of AIDS-related Kaposi's sarcoma

PURPOSE

Activation of the platelet-derived growth factor (PDGF) and c-kit receptors has been proposed as important in mediating the growth of AIDS-related Kaposi's sarcoma (KS). We investigated the response of KS to the PDGF receptor (PDGFR)/c-kit inhibitor, imatinib mesylate, and investigated the effect of this therapy on critical signal transduction intermediates.

PATIENTS AND METHODS

Ten male patients with AIDS-related cutaneous KS, which progressed despite chemotherapy and/or highly active antiretroviral therapy, received imatinib mesylate administered orally, 300 mg twice daily. Clinical response was determined by serial tumor measurements. To determine biologic and histologic response, skin lesion biopsies were obtained at baseline and following 4 weeks of therapy.

RESULTS

Five of 10 participants had a partial response by tumor measurements. Biopsies after 4 weeks of therapy demonstrated histologic regression in four of six patients. Four patients' tumor biopsies were assessable for immunohistochemistry end points pre- and post-therapy. These demonstrated inhibition of PDGFR and its downstream effector, extracellular receptor kinase, which is a member of the mitogen-activated protein kinase family. The most common adverse event was diarrhea, which led to dose reduction in six patients.

CONCLUSION

Imatinib mesylate administered orally twice daily for AIDS-related KS results in clinical and histologic regression of cutaneous KS lesions within 4 weeks. These promising results demonstrate that inhibition of the c-kit and/or PDGF receptors may represent an effective strategy for treating KS.

Update on herpesvirus infections

Herpesviruses are responsible for many illnesses that affect the oral and maxillofacial region. The most common of these are primary or recurrent HSV infection, but knowledge of the manifestations of the eight herpesviruses that cause infections in humans will provide clinicians with a better understanding and basis for diagnosing and managing patients with these diseases. Immunocompromised patients are at greater risk for serious illness: therefore, clinicians treating transplant patients, patients receiving cancer chemotherapy, or HIV-infected individuals should be aware of the various clinical manifestations of infection with herpesviruses.

Management strategies for HIV-associated aphthous stomatitis

Recurrent aphthous stomatitis (RAS) is the most common oral mucosal disorder found in men and women of all ages, races, and geographic regions. There are three forms of the lesions (minor, major, and herpetiform), with major aphthous ulcers causing significant pain and potential for scarring. In HIV-infected individuals, these ulcers occur more frequently, last longer, and produce more painful symptoms than in immunocompetent persons. In addition, they may be associated with similar ulcerations involving the esophagus, rectum, anus, and genitals. The diagnosis of HIV-induced RAS requires a careful history of the condition, and a thorough extra- and intra-oral examination. Oral mucosal biopsies are required for non-healing ulcers in order to exclude the possibility of deep fungal infections, viral infections, and neoplasms. The cause of the ulcers in HIV-positive persons has not been elucidated--local diseases, genetic, immunologic, and infectious factors all probably play a role. The goals of current treatments are to promote ulcer healing, to reduce ulcer duration and pain while maintaining nutritional intake, and to prevent or diminish the frequency of recurrence. Initial therapy for infrequent RAS recurrences includes over-the-counter topical protective and analgesic products. Initial therapy for frequent RAS outbreaks requires topical anesthetics, binding agents, and corticosteroids. Major RAS and non-healing minor or herpetiform RAS may require intralesional corticosteroids and systemic prednisone. Second-line immunomodulators for frequent and non-healing ulcers includes thalidomide and other immunomodulators.

Synergism between HIV and other viruses in the mouth

The HIV family replicate in and are shed from the mouth. Oral sexual practices potentially contribute to the overall extent of HIV transmission, particularly if high-risk practices are not restricted. Herpesviruses and papillomaviruses that appear in the oral cavity can determine oral HIV replication. The mechanisms probably include heterologous transactivation, enhanced expression of HIV receptors and co-receptors in target cells, release of cytokines and chemokines, and production of superantigens. Oral diseases peculiar to, or more common in, the HIV-infected patient further predispose to heightened oral HIV replication and trafficking. Defining the mechanisms by which oral viruses interact with HIV in the co-infected host should permit intervention measures against oral HIV transmission to be more precisely targeted.

Herpesviruses in HIV-periodontitis

BACKGROUND/AIMS

Human herpesvirus-associated diseases exhibit elevated morbidity and mortality in patients infected with human immunodeficiency virus (HIV). This study aimed to investigate the occurrence of herpesviruses in HIV-periodontitis.

METHOD

Gingival biopsies from periodontitis lesions of 21 HIV-patients and 14 non HIV-patients were studied. Nested-polymerase chain reaction methods were employed to detect human cytomegalovirus, Epstein-Barr virus type 1 and 2 (EBV-1, EBV-2), herpes simplex virus, human herpes virus (HHV)-6, HHV-7 and HHV-8.

RESULTS

Gingival biopsies from HIV-periodontitis lesions showed on average 4.0 herpesvirus species and gingival biopsies from HIV periodontitis lesions of non-HIV patients revealed an average of 1.9 herpesvirus species (p<0.001). Occurrence of 4 to 6 different herpesviruses was more common in HIV- than in non HIV-gingival biopsies (71% vs. 7%) (p<0.001). EVB-2 was detected in 12 (57%) biopsies from HIV-periodontitis but was absent in non HIV-periodontitis biopsies (p= 0.002). HHV-6 also occurred in significantly higher frequency in HIV-periodontitis (71%) than in non HIV-periodontitis (21%) (p=0.01). HHV-8 was detected only in biopsies from HIV-periodontitis lesions..

CONCLUSION

HIV-periodontitis seems to be associated with elevated occurrence of EBV-2, HHV-6 and herpesvirus co-infections compared to periodontitis in non-HIV-patients. The periodontopathic significance of herpesviruses in HIV-periodontitis constitutes a research topic of considerable interest.

Necrotizing ulcerative stomatitis in human immunodeficiency virus-seropositive individuals: a review of the histopathologic, immunohistochemical, and virologic characteristics of 18 cases

OBJECTIVE

The purpose of this retrospective study was to delineate the histopathologic, immunohistochemical, and virologic characteristics of 18 cases of necrotizing ulcerative stomatitis.

STUDY DESIGN

Eighteen examples or oral ulcerations in human immunodeficiency virus-seropositive individuals were identified that displayed unique histopathologic features. Immunohistochemic staining for CD1a, CD3, CD23, CD68, HLA-DR, p24, cytomegalovirus, HSV-1, and HSV-2 was performed, along with in situ hybridization for Epstein-Barr virus RNA and special staining for bacteria and fungi.

RESULTS

The lesions demonstrated ulceration, extensive necrosis, leukocytoclasia, histiocytic vasculitis with luminal fibrin clots, and a prominent infiltrate of large atypical cells with amphophilic cytoplasm, vesicular nuclei, and prominent nucleoli, interspersed with crescentic histiocytes, a histologic picture resembling extranodal Kikuchi's disease. Immunohistochemical findings suggested that the large atypical cells were histiocytes. Fifty-six percent (10/18) of the cases were immunoreactive for human immunodeficiency virus p24 within focal histiocytes, whereas Epstein-Barr virus RNA was identified in 1 (6%) of 17 cases.

CONCLUSIONS

Necrotizing ulcerative stomatitis is an inflammatory disease characterized by specific, reproducible microscopic features. We postulate that the histopathologic resemblance of necrotizing ulcerative stomatitis to extranodal Kikuchi's disease reflects a similar immune response to differing pathogens.

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.

Oral ulcers in AIDS patients frequently associated with cytomegalovirus (CMV) and Epstein-Barr virus (EBV) infections

Oral ulcers are common in AIDS patients, with a wide spectrum of underlying causes, including different viruses. In the present study, the presence of cytomegalovirus (CMV), Epstein-Barr virus (EBV) and human herpesvirus-8 (HHV-8) DNA was analysed in 21 biopsies from oral ulcers of 17 male homosexual AIDS patients. The methods used were in situ hybridization (ISH) and the polymerase chain reaction (PCR) with subsequent non-radioactive Southern blot hybridization to confirm the specificity of PCR products. With ISH, 4 biopsies were CMV DNA-positive and 11 contained EBV-DNA. Using PCR, an additional 4 CMV- and 7 EBV-positive samples were detected, and HHV-8 DNA was present in three oral ulcers. Six of the patients (35%) had oral ulcers co-infected by two or three viruses. The overall figures for patients with the detectable EBV-, CMV-, and HHV-8 DNA were 82% (14/17), 35% (6/17) and 18% (3/17), respectively. This is the first study to show the frequent presence of EBV-DNA in oral ulcers of AIDS patients. Because ISH-positivity signifies active virus replication, these results implicate an etiological role of EBV in AIDS-associated oral ulcers. The causal role of HHV-8 has to be considered as well, because this virus was detected in three such ulcers, which were not associated with Kaposi's sarcoma. To conclude, three common members of the herpesvirus family (CMV, EBV, HHV-8) were detected in all but three ulcers in AIDS patients, warranting the inclusion of these viral analyses in the diagnosis of ulcerative lesions of the oral mucosa in all immunosuppressed individuals.

Noma (cancrum oris): questions and answers

Noma (cancrum oris) is an infectious disease which destroys the oro-facial tissues and other neighboring structures in its fulminating course. It affects predominantly children aged 2-16 years in sub-Saharan Africa where the estimated frequency in some communities may vary from one to seven cases per 1000 children. The key risk factors are poverty, malnutrition, poor oral hygiene, deplorable environmental sanitation, close residential proximity to livestock, and infectious diseases, particularly measles. Malnutrition acts synergistically with endemic infections in promoting an immunodeficient state, and noma results from the interaction of general and local factors with a weakened immune system as the common denominator. Acute necrotizing gingivitis (ANG) is considered the antecedent lesion. Current studies suggest that evolution of ANG to noma requires infection by a consortium of microorganisms with Fusobacterium necrophorum and Prevotella intermedia as the suspected key players. Without appropriate treatment, mortality rate is 70-90%. Survivors suffer the two-fold affliction of oro-facial disfigurement and functional impairment. Reconstructive surgery of the resulting deformity is time-consuming and financially prohibitive for the victims who are poor.

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.

Relationship of cytomegalovirus to salivary gland dysfunction in HIV-infected patients

In a previous retrospective study of HIV-infected patients we detected a relationship between xerostomia and the presence of cytomegalovirus in saliva. This prospective study compares 13 patients with HIV and a complaint of xerostomia and low salivary flow rates with a control group of 7 patients with HIV without xerostomia and normal salivary flow rates. Both groups were evaluated for the presence of cytomegalovirus in saliva, peripheral blood mononuclear cells, and labial minor salivary glands. Viral cultures, polymerase chain reaction, and histopathologic examination were used to detect cytomegalovirus. Xerostomia and low salivary flow rates were associated with the presence of CMV in saliva. The virus was detected in 10 of 13 xerostomia patients and 2 of 7 controls (p = 0.05, Fisher's exact test). Cytomegalovirus was detected in the saliva of patients who did not also have it in their blood suggesting a local source of virus replication such as the salivary glands. The minor salivary glands were not a major site of cytomegalovirus. Culture was more sensitive then polymerase chain reaction in detecting salivary cytomegalovirus as a result of the presence of inhibitors to the reaction in saliva. These results suggest a link between cytomegalovirus in saliva and salivary gland dysfunction in HIV-infected patients.