Oral ulcers in HIV-infected patients: an update on epidemiology and diagnosis

A nonspecific ulcer on upper lip presented as the first and sole sign of syphilis

Syphilis, a sexually transmitted disease, can be categorized as acquired syphilis and congenital syphilis, manifesting diverse lesions involving multiple sites. Oral manifestations at the primary stage of acquired syphilis are usually characterized by its short period and non-specific varied presentations. And oral ulcers as initial and the only presentation of syphilis oral lesions are infrequent and occur in less than 2% of patients. Because of its transient nature and variable manifestations which could mimic other oral ulcerative lesions, oral syphilis presenting as sole ulceration at early stage can be easily neglected and rather difficult to diagnose. Herein, we report a 35-year-old female patient manifested a sole atypical ulceration on her upper lip for approximately 1 month. We highlighted the importance of early and accurate diagnosis, focused on the characteristics of oral chancre, and gave an insight to the differential diagnoses, which would be enlightening and useful in clinical practice.

Candida is a protractive factor of chronic oral ulcers among usual outpatients

Although many oral ulcers have similar clinical appearances, their etiologies can range from reactive to neoplastic to oral manifestations of dermatological diseases. In patients with an HIV infection, fungal diseases may cause ulceration in the oral cavity; however, there have been few studies of oral ulcerative lesions associated with Candida in patients without an HIV infection. Nevertheless, we encountered chronic oral ulcer associated with Candida among our frequent outpatients without an HIV infection. The present article reviews the causes of oral ulcers, focusing on Candida as a protractive factor for chronic oral ulcers, and it is recommended that Candida involvement be considered in diagnosis of a certain chronic oral ulcer, that remains of unknown origin even if some examinations have been performed.

Topical treatments for HIV-related oral ulcers

BACKGROUND

In HIV-infected adults, oral ulcers occur more frequently, last longer and produce more painful symptoms than in immunocompetent people. Oral aphthous ulcers observed during the course of HIV infection may be severe and can result in significant morbidity in these patients. Such manifestations may interfere with oral functions and alter patients' quality of life.

OBJECTIVES

To evaluate the efficacy and side effects of topical agents used in the treatment of HIV-related oral aphthous ulcers in adults.

SEARCH METHODS

The following electronic databases were searched from the year 1980 to May 2011 for randomised controlled trials involving managements of oral ulcers, apthouses in HIV infected adults: EMBASE, PUBMED, the Cochrane Central Register of Controlled Trials (CENTRAL).

SELECTION CRITERIA

Only randomised controlled trials that evaluated the efficacy of any topical agent in treating HIV oral aphthous ulcerations in HIV positive adults were considered.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the potentially eligible studies for inclusion. We did not find any studies that meet our eligibility criteria. Therefore, no analysis was performed.

MAIN RESULTS

A total of 233 abstracts were retrieved from the databases searched. None of the identified studies met our inclusion criteria. Ten of the studies identified were reports of systemic rather than topical treatment. Therefore, no studies were included in this review.

AUTHORS' CONCLUSIONS

There is a need for well designed studies to evaluate the efficacy and safety of topical agents for the treatment of HIV related oral aphthous ulcers.

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.

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.

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 manifestations of HIV infection]

Oral manifestations of HIV infection are sometimes the first sign of the disease and often indicate its progression to acquired immune deficiency syndrome (AIDS), thus it is important for health professionals (physicians and dentist) to possess adequate knowledge of these lesions. Improvements in antiretroviral treatments, especially with the incorporation of HAART therapy, have produced a gradual reduction in the prevalence of HIV-associated oral lesions. On the other hand, the increased life expectancy of HIV-positive patients has led to their greater presence at our clinics, implying the need for continuous updating in the diagnosis and treatment of these processes. Using the consensus classification (EEC-Clearinghouse, 1993) we reviewed the diagnostic criteria and current treatment protocols for the different HIV infection related oral lesions in both adults and children.

Estomatite aftosa recorrente: revisão bibliográfica

A estomatite aftosa recorrente (EAR) é a afecção mais comum da mucosa oral. Apesar das constantes pesquisas e preocupação clínica, sua causa permanece obscura. Possui três formas principais. A mais comum é a EAR menor, com pequenas ulcerações definidas, arredondadas, que são dolorosas e cicatrizam em 10 a 14 dias. Na forma maior são maiores, duram de 6 semanas a mais e freqüentemente deixam cicatriz. A terceira forma é a herpetiforme com múltiplas lesões que podem coalescer e duram de 7 a 10 dias. O diagnóstico é feito após exame clínico. Alguns fatores locais e sistêmicos podem estar associados a doença e se tem evidência de que uma base imunogenética pode estar presente. O controle da doença depende de sua apresentação clínica e inclui drogas imunossupressoras, corticosteróides tópicos e sistêmicos e soluções anestésicas e antimicrobianas.

Oral manifestations of an HIV positive cohort in the era of highly active anti-retroviral therapy (HAART) in South London

BACKGROUND

Human Immunodeficiency Virus (HIV) infection is associated with oral manifestations of diagnostic and prognostic importance. With the advent of Highly Active Anti-retroviral Therapy (HAART) there is anecdotal evidence to suggest that the prevalence of oral lesions has declined. The number of prevalence studies, carried out in the era of HAART is, however, meagre. Our aim was to study the prevalence of the oral manifestations of HIV in a population, predominantly on HAART, attending a Genito-Urinary Medicine Centre in South London.

METHODS

This cross sectional study included 203 adult volunteers, comprising 76% males and 24% females. One third of the subjects were from the predominantly African or Afro- Caribbean ethnic minority groups resident in London. The relationship between the prevalence of oral lesions and demographic variables, therapeutic regimes, viral load and CD4 counts were evaluated.

RESULTS

One hundred (49%) of the patients had no detectable oral lesions. Oral lesions detected most frequently included oral hairy leukoplakia (9.9%), HIV associated periodontal diseases (9.9%) and oral candidiasis (4.9%). Three subjects had multiple papillomatous growths. Most cases (n = 17/20) of oral hairy leukoplakia were in individuals with a detectable (> 400 copies/ml) plasma RNA viral load. The majority (n = 8/10) of our patients with oral candidiasis had a plasma RNA viral load > 10,000 copies/ml and half (n = 5/10) had a CD4 count < 200 cells/mm3. Logistic regression analysis suggested that the presence of an oral lesion was not associated with any demographic features except for periodontal diseases which were associated with tobacco smoking (P = 0.023).

CONCLUSIONS

The prevalence of so called 'strongly associated' oral lesions of HIV is low in this South London HIV-infected population on HAART, and the relative frequency is different from that cited in the literature from the pre-HAART era. The oral lesions detected were found mostly in people with low CD4 counts and high HIV-1 RNA viral loads, suggesting they were very immunocompromised, not on, or declining therapy, or that their therapy was failing.

Aphthous ulcers: a difficult clinical entity

Recurrent aphthous ulcers (RAU) are the most common oral ulcerative disease, affecting 10% to 20% of the population. There are 3 clinical subtypes-minor, major, and herpetiform. Minor aphthous ulcers are the most common subtype, representing 80% to 90% of all recurrent aphthous ulcers. Clinically, RAU present as extremely painful, shallow ulcerations with an erythematous halo on unattached oral mucosa. The primary differential diagnosis is oral herpes simplex. The etiology of RAU is unknown. Topical corticosteroids are the mainstay of therapy.

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.