Oral hairy leukoplakia in an HIV-seronegative heart transplant patient

The role of viruses in oral mucosal lesions

The mucosa of the oral cavity is exposed to a large number of different microorganisms such as archaea, bacteria, fungi, parasites, and viruses. Among those, viruses cause specific infections, which can easily be transmitted from one person to another. The infectious route may not only include patients and their relatives but also the dental professional team. Thus, a wide knowledge regarding specific viral infections is crucial for the daily routine. Signs and symptoms of oral viral infections can be completely absent or develop into a pronounced clinical picture, so that early detection and information determine the further course of the infection and its influence on other inflammatory diseases, such as periodontitis, as well as the safety of family members and the social environment. As the clinical manifestation of viral infections may be highly variable leading to heterogenous mucosal lesions it is, in most cases, mandatory to differentiate them by specific microbiological tests in addition to clinical examination procedures. This article will give an overview of the role of viruses infecting the oral mucosa, and in addition, describe their clinical manifestation and management.

Oral hairy leukoplakia in a child using a corticosteroid nasal spray

We report a case of atypical oral hairy leukoplakia (OHL) in a 9-year-old immunocompetent girl treated with fluticasone propionate nasal spray for allergic rhinitis. The OHL in childhood is uncommon and should be included in a differential diagnosis of white lesions in the oral mucosa.

Epstein-Barr virus: dermatologic associations and implications: part I. Mucocutaneous manifestations of Epstein-Barr virus and nonmalignant disorders

Epstein-Barr virus (EBV) is a ubiquitous virus that has been implicated in a wide range of human diseases, many of which have mucocutaneous manifestations. As a member of the herpesviridae family, EBV causes lifelong infection by establishing latency in B lymphocytes. An intact immune response is critical in preventing progression of EBV disease, and the clinical manifestations of infection are dependent on the intricate relationship between virus and host immune system. This review provides a comprehensive overview of the epidemiology, pathophysiology, and diagnostic testing in EBV infection. In part I of this continuing medical education article, the mucocutaneous manifestations of EBV infection are reviewed with an emphasis on pathophysiology and management.

Oral hairy leukoplakia in patients without HIV: presentation of 2 new cases

OBJECTIVE

We report 2 cases of oral hairy leukoplakia (OHL) in patients without HIV and present a comprehensive review of OHL in HIV-negative individuals.

STUDY DESIGN

Two cases of non-HIV-associated OHL are described. A PubMed search identified previously reported cases. The attributes of those cases were ascertained.

RESULTS

OHL was confirmed in both of our cases. Both patients used inhaled steroids for pulmonary disorders, and were found to have depressed levels of immunoglobulin M. Additionally, 76 cases were identified in the literature. The condition occurred in association with various medical conditions, with the majority of patients on immunosuppressant medications (67 of 76). Systemic drugs were implicated most frequently. The condition has also been reported in healthy individuals (6 of 76).

CONCLUSIONS

Although thought of as an HIV/AIDS-associated condition, OHL can develop in patients without HIV, including healthy individuals. There is a strong correlation between the use of immunosuppressants and development of OHL in these patients.

Oral Hairy Leukoplakia in HIV-Negative Patients: Report of 10 Cases

Ten cases of oral hairy leukoplakia (OHL) in HIV- negative patients are presented. Eight of the 10 patients were on steroid treatment for chronic obstructive pulmonary disease, 1 patient was on prednisone as part of a therapeutic regimen for gastrointestinal stromal tumor, and 1 patient did not have any history of immunosuppression. There were 5 men and 5 women, ages 32-79, with mean age being 61.8 years. Nine out of 10 lesions were located unilaterally on the tongue, whereas 1 lesion was located at the junction of the hard and soft palate. All lesions were described as painless, corrugated, nonremovable white plaques (leukoplakias). Histologic features were consistent with Epstein—Barr virus—associated hyperkeratosis suggestive of OHL, and confirmatory in situ hybridization was performed in all cases. Candida hyphae and spores were present in 8 cases. Pathologists should be aware of OHL presenting not only in HIV-positive and HIV-negative organ transplant recipients but also in patients receiving steroid treatment, and more important, certain histologic features should raise suspicion for such diagnosis without prior knowledge of immunosuppression.

Oral hairy leukoplakia: an ultrastructural study and review of the literature

A 39-year-old, homosexual, Caucasian man with a 9-month history of acquired immunodeficiency syndrome by reduced CD4 lymphocyte count alone was found to have extensive, asymptomatic, nonremovable, corrugated, white patches on the lateral borders and ventral aspects of the tongue typical of oral hairy leukoplakia (OHL). Histologically, irregular hyperparakeratosis, acanthosis, and clusters of ballooned keratinocytes in the stratum spinosum were present in the biopsied lateral tongue. Some of the superficial ballooned keratinocytes had peripherally beaded nuclei, whereas others had ground glass intranuclear inclusions. Ultrastructurally, the ballooned keratinocytes had three important findings of diagnostic significance. First, frequent herpesvirus nucleocapsids were largely confined to superficial ballooned keratinocytes having marginated and condensed chromatin. In searching for herpesvirus nucleocapsids, the marginated and condensed chromatin was an invaluable marker for cells harboring the virions. Second, the marginated and condensed chromatin frequently had a distinctive punched-out or cribriform appearance. Third, the ground glass intranuclear inclusion bodies consisted of central, medium electron-dense, finely granular material containing frequent herpesvirus nucleocapsids and partially surrounded or capped by prominent, clumped chromatin. The patient died with progressive multifocal leukoencephalopathy 24 months after OHL was diagnosed.

Oral hairy leukoplakia in a patient with acute lymphocytic leukemia

The first case of oral hairy leukoplakia (OHL) in an HIV-negative 56-year-old patient with acute lymphocytic leukemia (ALL) is reported. A white plaque was observed while the patient was in complete remission which followed the chemotherapeutic scheme. The clinical and histopathologic findings were typical for OHL and the polymerase chain reaction method was positive for Epstein-Barr virus DNA. Underdiagnosis and underreporting of OHL in patients with a malignant haematological disease and the apparent different environmental factors to which these non-AIDS patients have been exposed, probably constitute some of the reasons for the very few OHL cases reported in these patients.

Detection of Epstein-Barr virus (EBV) DNA and antigens in oral mucosa of renal transplant patients without clinical evidence of oral hairy leukoplakia (OHL)

The use of the polymerase chain reaction (PCR) to detect the presence of Epstein-Barr virus (EBV) DNA in oral mucosa in the absence of specific lesions gives rise to the problem of identifying the real viral replication sites. To verify whether the detection of EBV is due to salivary contamination or its true replicative capacity in oral mucosa, saliva samples and exfoliated cells from four different oral mucosa sites were taken from 40 renal transplant patients and 20 normal subjects for examination by PCR using two pairs of primers specific for the BamHI-L and BamHI-K genomic regions. EBV-specific sequences were detected in one or more of the oral mucosa samples from 29 transplant patients (72.5%) and six healthy controls (30%), and in the saliva samples of 16 transplant patients (40%) and three healthy controls (15%). A total of 89 oral mucosa smears from 29 transplant patients, and 13 from healthy subjects, were EBV-positive. The positive samples were also investigated by means of in situ hybridization in order to confirm the intracellular presence of the viral genome, and by means of immunofluorescence testing with monoclonal antibodies to assess the possible expression of viral antigens. Hybridization with the EBV-specific probe was observed in 40/ 89 and 2/13 samples, respectively. Latent antigens (with or without lytic antigens) were detected in only 23 of the 40 samples (collected from eight different transplant patients) that were positive by in situ hybridization. Our data show that EBV is more frequently present in the oral mucosa of immunodeficient patients (where it can efficiently replicate) than in normal subjects.

Oral lesions in organ transplant patients

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

Epstein-Barr virus: biology and disease

Epstein-Barr virus is a human herpes virus which, whilst found as a widespread asymptomatic infection, is also associated with certain tumours of lymphoid and epithelial origin including Burkitt's lymphoma (BL), immunoblastic lymphoma (IBL), Hodgkin's Disease (HD) and nasopharyngeal carcinoma (NPC). A unique characteristic of EBV is its ability to infect and transform primary resting B lymphocytes in vitro into permanently growing lymphoblastoid cell lines (LCLs); this effect is associated with constitutive expression of a limited set of viral genes. Interestingly, the pattern of EBV gene expression observed in LCLs in vitro is also a feature of IBLs, a tumour associated with immunosuppression. The other EBV associated tumours display a more restricted pattern of EBV latent protein expression. B cell lines can be activated in vitro into the virus replicative cycle, where a large number of viral genes associated with EBV DNA replication and virus assembly are synthesised. Whilst EBV can be detected in throat washings from seropositive individuals, the only in vivo situation where full virus replication can be reliably observed in hairy leukoplakia (HL), a benign lesion of lingual epithelium frequently found in AIDS patients. Thus, the relative contribution of lymphoid cells and epithelial cells to latent EBV infection/persistence vs replication in vivo remains controversial. Recent studies suggest that HL represents a focus of EBV replication in the absence of a truly latent infection and this supports the contention that EBV persistence resides in the lymphoid compartment. These aspects together with the role of EBV in oral diseases and the effect of certain EBV genes on the control of epithelial cell growth and differentiation will be discussed.

Oral hairy leukoplakia in a patient with multiple myeloma

The first case of oral hairy leukoplakia in an HIV-negative patient with multiple myeloma is reported. The patient is a 56-year old man who has had monoclonal gammopathy of undetermined significance since 1986 and has been treated for a symptomatic multiple myeloma since 1993. The clinical and histopathologic findings are typical for oral hairy leukoplakia, and Epstein-Barr virus was demonstrated with polymerase chain reaction technique. Although a relatively large number of cases of oral hairy leukoplakia has been reported in HIV-negative patients, both immunocompromised and immunocompetent, only a few of these patients have had a malignant hematologic disease.

Oral hairy leukoplakia in an HIV-negative woman with Behçet's syndrome

The first case of oral hairy leukoplakia in an HIV-negative patient with Behçet's syndrome is reported. The patient was a 47-year-old woman with bilateral lesions on the tongue. The clinic and histologic appearances were typical of hairy leukoplakia, and Epstein-Barr virus was demonstrated in the epithelial cells by DNA in situ hybridization. The patient had been on systemic steroid therapy for 15 years to control lesions of Behçet's syndrome. The literature now records 30 HIV-negative patients with hairy leukoplakia.

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

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

Oral hairy leukoplakia in a patient with ulcerative colitis

A 30-year-old man with ulcerative colitis developed oral hairy leukoplakia (OHL). Serological examination for human immunodeficiency virus (HIV)-1 and HIV-2 infection showed no abnormalities. Biopsy specimen of the lateral tongue showed ballooned prickle cells, and electron microscopy revealed herpes-type viruses. Immunologic investigation of the patient showed a marked decrease in T-helper cells as a result of immunosuppressive regimen. The present report appears to be the first well-documented case of OHL in an HIV-negative patient with ulcerative colitis. OHL may be a marker for severe immunosuppression but is not necessarily associated with HIV infection. Patients with iatrogenic immunosuppression should be monitored for OHL. Concerning the marked decrease in T-helper cells in this case, the presence of OHL may imply the examination of T-lymphocyte subsets in patients such as HIV-infected individuals or in organ transplant recipients.

Use of exfoliative cytology in the diagnosis of oral hairy leukoplakia

The possibility of diagnosing oral hairy leukoplakia by means of exfoliative cytology and the Papanicolaou stain was investigated. Exfoliative cytology and punch biopsy specimens were obtained from 10 lesions that demonstrated clinical features of hairy leukoplakia. All biopsy specimens demonstrated the characteristic histopathologic features of hairy leukoplakia whereas all Papanicolaou-stained cytologic smears demonstrated condensation and margination of the nuclear chromatin (nuclear beading). All biopsy specimens and cytologic smears displayed positive Epstein-Barr virus deoxyribonucleic acid in situ hybridization. We conclude that routine exfoliative cytology may be a reliable, noninvasive, and inexpensive technique for the diagnosis of hairy leukoplakia.

Epstein-Barr virus in lingual epithelium of liver transplant patients

Thirty-three liver transplant patients and 20 controls were examined for the presence of EBV in epithelium of the lateral border of the tongue by negative staining electron microscopy. Five of the specimens (15%) showed particles typical of the herpes virus family, while all controls were negative for EBV. In 3 of the 5 patients moderate oral hairy leukoplakia was observed clinically. Our results indicate that EBV may be expressed at the lateral border of the tongue of liver transplant patients, who in some cases show oral hairy leukoplakia clinically.

Detection of Epstein-Barr virus and human papillomavirus type 16 DNA in hairy leukoplakia by in situ hybridisation and the polymerase chain reaction

Demonstration of Epstein-Barr virus (EBV) is considered desirable for the accurate diagnosis of hairy leukoplakia (HL). Previous studies have reported possible associations with human papillomavirus (HPV) infection although this is not a universal finding. Presence of EBV and HPV 16 was examined in biopsy specimens from 18 cases of HL and ten control specimens by in situ hybridisation using digoxigenin-labelled synthetic oligonucleotide probes and by the polymerase chain reaction (PCR). The presence of EBV was demonstrated in 12 cases by both techniques. Of the remaining six cases EBV could be detected in three by in situ hybridisation but not by PCR; EBV was not detected by either method in a further three cases. All samples were negative for HPV 16 by both techniques under conditions of high stringency, although when stringency of in situ hybridisation was reduced, four samples appeared to harbour HPV DNA sequences. This study provides further evidence to support the role of EBV in the pathogenesis of HL and suggests that HPV 16 is not regularly encountered.

Hairy leukoplakia in an HIV-negative, nonimmunosuppressed patient

Oral hairy leukoplakia is an Epstein-Barr virus-associated lesion that is considered to be a marker of immunosuppression. We report a case of oral hairy leukoplakia in a healthy nonimmunosuppressed elderly patient with no evidence of HIV infection on repeated investigation. This report has important implications on our understanding of the significance of this lesion.

Epstein-Barr virus DNA detection in gingival tissues of patients undergoing surgical extractions

The main oral manifestation of Epstein-Barr virus (EBV) infection is hairy leukoplakia, a lesion associated with the acquired immunodeficiency syndrome (AIDS) and occasionally in other immunocompromised patients. However, the recent literature describes the presence of viral genome in clinically normal oral tissues. The purpose of this work was to investigate these occult EBV infections in gingival epithelium. The Southern blot method with 32P-radiolabelled DNA probes under stringent conditions was applied to 20 interproximal gingival papillae specimens and revealed homologous EBV sequences in 4 of 10 AIDS patients as well as in 4 of 10 HIV negative patients. In order to determine whether EBV has a predilection for the gingival tissues, samples of nasal, laryngeal and oral mucosa, other than gingival mucosa, were collected from 10 HIV-negative patients undergoing surgical treatment for a variety of clinical conditions. None of these extra-periodontal mucosal specimens contained homologous EBV DNAs, except an edentulous palatal gingival specimen. With the present detection of EBV DNAs in the gingival tissues of patients undergoing surgical extractions, it would be of interest to investigate more systematically these subclinical infections in order to determine their exact implications in oral disease.

Significance of oral hairy leukoplakia

Since the original description of oral hairy leukoplakia among homosexual men in San Francisco in 1984, this white lesion of the tongue has been seen in the mouths of persons infected with the human immunodeficiency virus (HIV) worldwide. Its presence in HIV-positive persons usually but not always indicates fairly rapid progression to acquired immunodeficiency syndrome in the absence of antiretroviral therapy. Although the lesion appears to be common in HIV-positive persons, it is also, albeit rarely, seen in other conditions associated with immunosuppression. Epstein-Barr virus is associated with and presumably causes hairy leukoplakia, and the lesion offers insights into the biology of this ubiquitous DNA-oncogenic virus.

Recurrent oral condylomata acuminata and hairy leukoplakia: an early sign of myelodysplastic syndrome in an HIV-seronegative patient

Oral hairy leukoplakia (OHL) has been observed in all risk groups seropositive for HIV infection. Recently, this lesion has also been described in HIV-seronegative patients with immunosuppression of iatrogenic origin. We report on a HIV-1 and HIV-2 seronegative, heterosexual man affected by refractory anemia with ringed sideroblasts (myelodysplastic syndrome), who developed recurrent oral condylomata acuminata and OHL as an early clinical manifestation. The diagnosis of OHL was confirmed by identifying Epstein-Barr viral particles by electron microscopy and by in situ DNA hybridization. HIV infection was ruled out using polymerase chain reaction and testing for HIV-1 and HIV-2 antibodies.

Hairy leukoplakia--a histological study

Hairy leukoplakia is a recently described oral mucosal condition seen in immunosuppressed individuals, usually in association with HIV infection, when it is thought to be a sign of decreasing immunocompetence. It probably results from reactivation of infection by Epstein-Barr virus (EBV) and usually presents as bilateral white patches on the lateral borders of the tongue. From a histological study of 20 cases we have found that the typical appearance of hairy leukoplakia is of acanthotic, hyperparakeratinized epithelium with Candida hyphae sometimes present in the parakeratin. A band of EBV infected, koilocyte-like cells is present in the upper part of the prickle cell layers, these cells being swollen and pale staining, with prominent cell borders and perinuclear vacuoles. There is a paucity of inflammation in both the epithelium and lamina propria. An atypical appearance shows the koilocyte-like cells lying isolated or in small groups, irregularly arranged in the prickle cell layer and without a hyperparakeratinized surface. Diagnosis of hairy leukoplakia should normally be confirmed by demonstrating EBV in the koilocyte-like cells by immunocytochemistry or DNA in situ hybridization.

Demonstration of Epstein-Barr virus in scrape material of lateral border of tongue in heart transplant patients by negative staining electron microscopy

Scrape material from the lateral border of the tongue of 50 heart transplant patients and 20 controls was studied for the presence of EBV by negative staining electron microscopy. Mild oral hairy leukoplakia was observed in two cases. Particles of the herpes virus were found in 20% of the specimens. Controls were negative for EBV. The study has shown that EBV may be expressed at the lateral border of the tongue during immunosuppression, occasionally resulting in the clinical appearance of hairy leukoplakia.

Negative staining EM for the detection of Epstein-Barr virus in oral hairy leukoplakia

The performance of two different EM techniques applied for the detection of Epstein-Barr Virus (EBV) in oral hairy leukoplakia (HL) was assessed, i.e. the conventional two-step method of negative staining (CNS) and negative staining after Airfuge enrichment (ANS). Scrape specimens from the lateral borders of tongue of 66 HIV-positive patients with or without HL, of 3 patients with infectious mononucleosis and of 10 HIV-negative patients were evaluated. While CNS resulted in virus detection only in 25% of clinically diagnosed HL cases, EBV was detected by ANS in 85% of clinically suspected cases of HL. Scrape specimens of individuals negative for HIV were negative in EM while 2 of 3 mononucleosis patients were positive without clinical evidence for HL. Due to this high sensitivity the method of negative staining after Airfuge enrichment appears to be useful in the diagnosis of HL. The finding of EBV in clinically normal oral mucosa in HIV-seropositive individuals is interesting and indicates that EBV expression may precede the clinical appearance of HL.