Covid-19 and oral diseases: Crosstalk, synergy or association?

The coronavirus disease 2019 (Covid-19) is a viral infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that clinically affects multiple organs of the human body. Cells in the oral cavity express viral entry receptor angiotensin-converting enzyme 2 that allows viral replication and may cause tissue inflammation and destruction. Recent studies have reported that Covid-19 patients present oral manifestations with multiple clinical aspects. In this review, we aim to summarise main signs and symptoms of Covid-19 in the oral cavity, its possible association with oral diseases, and the plausible underlying mechanisms of hyperinflammation reflecting crosstalk between Covid-19 and oral diseases. Ulcers, blisters, necrotising gingivitis, opportunistic coinfections, salivary gland alterations, white and erythematous plaques and gustatory dysfunction were the most reported clinical oral manifestations in patients with Covid-19. In general, the lesions appear concomitant with the loss of smell and taste. Multiple reports show evidences of necrotic/ulcerative gingiva, oral blisters and hypergrowth of opportunistic oral pathogens. SARS-CoV-2 exhibits tropism for endothelial cells and Covid-19-mediated endotheliitis can not only promote inflammation in oral tissues but can also facilitate virus spread. In addition, elevated levels of proinflammatory mediators in patients with Covid-19 and oral infectious disease can impair tissue homeostasis and cause delayed disease resolution. This suggests potential crosstalk of immune-mediated pathways underlying pathogenesis. Interestingly, few reports suggest recurrent herpetic lesions and higher bacterial growth in Covid-19 subjects, indicating SARS-CoV-2 and oral virus/bacteria interaction. Larger cohort studies comparing SARS-CoV-2 negative and positive subjects will reveal oral manifestation of the virus on oral health and its role in exacerbating oral infection.

Serum levels of IgG antibodies against alpha-enolase are increased in patients with Behçet's disease and are associated with the severity of oral ulcer, erythrocyte sedimentation rates, and C-reactive protein

OBJECTIVES

Behçet's disease (BD) is a chronic inflammatory disease of unknown etiology, characterised by recurrent oral and genital ulcers, skin lesions, uveitis, and arthritis. It is regarded as vasculitis and anti-endothelial cell antibodies (AECA) are found in patients with BD. One of the endothelial cell antibodies was reported to recognise alpha-enolase. This study aimed to investigate expression of alpha-enolase in the surface of peripheral blood cells and serum anti-alpha-enolase antibody (AEA), and their association with clinical manifestations or disease activity of BD.

METHODS

Cell surface alpha-enolase expression was examined from several cell types of peripheral blood, including lymphocytes, monocytes, and neutrophils using flow cytometry in patients with BD and healthy controls (HCs). IgG AEA levels were measured by enzyme-linked immunosorbent assay (ELISA) in sera from 110 patients with BD, and age/sex matched 110 HCs. Association of alpha-enolase or AEA with clinical manifestation was analysed.

RESULTS

The frequency of surface alpha-enolase-expressing cells was increased in BD in lymphocytes and monocytes. Serum AEA levels were in- creased in BD patients (median [IQR], 0.360 [0.268-0.482], p < 0.0001), particularly with mucocutaneous involvement (0.367 [0.273-0.490], p < 0.0001) compared to HCs (0.274 [0.231-0.357]). The levels of AEA were correlated with the number of oral ulcer, ESR, and CRP. There was no association between serum levels of AEA and other clinical manifestations.

CONCLUSIONS

Serum AEA was increased in BD patients and correlated with oral ulcer, ESR and CRP.

[Study on the changes of iron metabolism in patients with recurrent oral ulcer and its relationship with cellular immune function]

PURPOSE

To study the relationship between abnormal iron metabolism and cellular immune dysfunction and recurrent oral ulcer.

METHODS

A cross-sectional analysis of serum iron, ferritin and cellular immune function in 100 patients with recurrent oral ulcer and 100 healthy cases as control were performed. Logistic regression analysis was conducted to evaluate the relationship between serum ferritin and cellular immunity and recurrent oral ulcer using SPSS 19.0 software package.

RESULTS

Serum iron, ferritin, CD3⁺, CD4⁺ and CD4⁺/CD8⁺ concentration significantly decreased in Rou group compared with the control group (P<0.01). Multiple logistic regression analysis showed serum iron, ferritin and CD3⁺, CD4⁺ decrease were the independent risk factors for the onset of ROU, whereas CD4⁺/CD8⁺ were the protective factors in the pathogenesis of ROU(P<0.05).

CONCLUSIONS

Iron deficiency and cellular immune function is closely related to the pathogenesis of ROU.

Chronic granulomatous disease as a risk factor for cutaneous lupus in childhood

Chronic granulomatous disease (CGD) is a primaryimmunodeficiency disorder that affects the phagocyticcells of the innate immune system. It is characterizedby recurrent or persistent infections with granulomaformation. Lupus-like lesions have been reported incarriers of CGD and less frequently, in patients withCGD. Immunological study in these patients areusually negative. We describe the case of an 8-yearoldboy with CGD who developed chronic and acutecutaneous lupus erythematous with angular cheilitis,oral ulcers, Raynaud phenomenon, and positiveserologies for antinuclear, anticentromere, and anti-Saccharomyces cerevisiae antibodies.

Multiple mucocutaneous ulcers associated with cocaine-induced midline destructive lesions

Cocaine-induced midline destructive lesions (CIMDL) occur in a small subset of cocaine users, who clinically present with inflammation and necrosis of facial midline structures such as the palate, nasal septum, turbinates, and sinuses. We present a patient with CIMDL occurring concomitantly with ulcers on the cheek and upper trunk. Multiple biopsy specimens from the cutaneous and mucosal lesions consistently showed a dense dermal/submucosal infiltrate of neutrophils and plasma cells, without vasculitis or thrombosis. The ulcers resolved following cessation of cocaine use.

Role of salivary tumour necrosis factor α in HIV-positive patients with oral manifestations

In HIV-1-infected patients, oral manifestations such as recurrent apthous ulcers are often seen. A total of 29 HIV-infected patients were examined to determine salivary tumour necrosis factor α (TNF α) concentrations by enzyme-linked immunosorbent assay, the amount of HIV-1 RNA copy by Amplicor HIV-1 Monitor test, number of CD4 cells by flow cytometry and oral manifestations by oral examination. TNF α concentration was significantly correlated with the amount of HIV-1 RNA, however, not with the number of CD4 cells in HIV-1-infected patients. Further, patients with oral manifestations showed significantly higher concentrations of TNF α in saliva and HIV-1 RNA copies in serum than those without oral manifestations. Following recovery from oral ulcers, TNF α concentration was decreased by half to 20 times lower than the level of that during ulcer incidence. Our results suggest that salivary TNF α is a good indicator for oral manifestations and HIV RNA amounts in HIV-1-infected patients.

[Local immunomodulating agents in complex treatment of oral lichen planus]

The paper presents the results of local immunity status assessment in patients with erosive-ulcerous form of oral lichen planus by etiopatogenetic treatment including imudone and derinate. The positive dynamics of immunological parameters under imudone and derinate is demonstrated.

Long-term remission of ocular and extraocular manifestations in Behçet's disease using infliximab

OBJECTIVES

To investigate the long-term effect of infliximab on ocular and extraocular manifestations in patients with Behçet's disease.

METHODS

Seven patients with active Behçet's disease and treated with infliximab at Aichi Medical University Hospital for more than 18 months were included in the study. We evaluated visual acuity, the average number of uveitis attacks involving the posterior segment, and general disease activity every 2 months. The Behçet's Disease Current Activity Form (BDCAF) was used for an overall index of disease activity. Anti-infliximab antibody levels were examined in the patients' sera.

RESULTS

The follow-up period after initial introduction of infliximab ranged from 19 to 40 months (mean ± SD, 32 ± 8.7 months). The number of infliximab infusions ranged from 12 to 24 (19 ± 4.4). By the 2-month follow-up, the frequency of uveitis attacks involving the posterior segment and the BDCAF scores were significantly improved compared to the 2 months before introducing infliximab. Anti-infliximab antibodies were detected in the sera of all examined patients.

CONCLUSIONS

Significant long-term improvement in both the frequency of uveitis attacks involving the posterior segment and overall disease activity was provided by the administration of infliximab to patients suffering from Behçet's disease, despite the presence of anti-infliximab antibodies.

Skin prick test with self-saliva in patients with oral aphthoses: a diagnostic pathergy for Behcet's disease and recurrent aphthosis

There may be some difficulties to differentiate Behcet's disease (BD), recurrent aphthosis (RA), and herpetic aphthous ulceration, from other mimicking oral disorders. Despite of unexpected sensitivity and responsiveness, the skin pathergy test regarding a non specific hypersensitivity has long been thought as one of auxiliary diagnostic benefits for BD. To determine the potential usefulness and disease specificity of the prick reaction with saliva, a skin prick test with neat and filter-sterilized saliva was performed on the forearm skin of 26 individuals; 10 patients with BD (8 incomplete type without uveitis, 1 complete type, and 1 neurological type), 5 with RA, 3 with herpetic oral aphthosis, 2 with erythema nodosum alone, and 6 healthy controls. We assessed the skin reaction at 48 hours after pricking, and the pricked skin lesions were biopsied and analyzed immunohistologically. Nine of 10 BD patients (90 %) exhibited an indurative erythema at the skin site pricked with self-saliva, whereas 3 of 5 RA patients (60%) were relatively weak reaction. Pricking with filter-sterilized saliva failed to recapitulate any of positive skin reactions, albeit a faint erythematous dot appeared in a few BD patients, implicating the involvement of causative microorganism(s) in oral bacterial flora. Culture of saliva from 3 randomly chosen BD patients revealed numerous streptococcal colonies on Mitis-Salivarius agar. Histology of the pricked skin sites showed perivascular inflammatory infiltrates, composed of CD4+ T cells and CD68+ monocyte/macrophage lineage, a feature consistent with a delayed type hypersensitive reaction. Our results suggested that skin prick test using self-saliva (a new diagnostic pathergy) can be a simple and valuable in vivo diagnostic approach for differentiating BD and RA from other mimicking mucocutaneous diseases. The positive skin prick may be triggered by resident intra-oral microflora, particularly streptococci, and may in part address the underlying immunopathology in BD.

An ulcerated lesion due to HSV-2 infection with a CD56+ cell predominant inflammatory infiltrate

CD56+ rich inflammatory infiltrates have been described in several cutaneous inflammatory conditions. However, CD56+ cells rarely account for more than 10% of the cells in such infiltrates. In certain conditions, such as insect bites or infection with herpes virus, CD56+ cells can be up to 43% of the cells in the infiltrate. This contrasts with what is observed in natural killer (NK)-cell lymphomas, which show a diffuse, atypical infiltrate in which most of the cells are CD56+. In this report, we describe a lymphocytic infiltrate in an ulcerated lesion on the lip of a 53-year-old man resulting from infection with herpes simplex virus type 2. CD56+ cells represented 80 to 90% of the infiltrate, showing atypical morphologic features, and clusters of CD56 positive cells were also observed.

[Linear IgA disease of the oral mucosa with pharyngeal and esophageal involvement]

A 69-year-old man presented with multiple recurrent oral ulcerations for about 20 years. After he began having difficulty in breathing and swallowing, esophagogastroscopy was performed and showed ulcerations, erosions and scars on the mucous membrane of the pharynx as well of the esophagus. Linear IgA disease (LAD) was diagnosed based on histopathological and immunofluorescence examinations. In this patient with LAD, the buccal, pharyngeal and esophageal mucosa was affected without involvement of the skin.

Clinical and immunopathologic findings in oral lichen planus pemphigoides

Lichen planus pemphigoides (LPP) is a rare, acquired, immunobullous disorder of skin that occasionally involves oral mucous membranes. Clinical, histologic, and immunopathologic findings of the oral manifestations of LPP are described. Clinical features are lichenoid striae, erosions, and ulcerations involving gingiva and buccal mucosae. Histopathologic features are similar to those of ora lichen planus. Direct immunofluorescence demonstrates linear deposits of immunoglobulin G and complement component C3 along the basement membrane with fibrillar deposits of fibrin at the epithelial/lamina propria junction. Fluorescence overlay antigen mapping and laser scanning confocal microscopy of the biopsy specimen exhibits colocalization of in situ antibodies with beta4 integrin, a marker of the keratinocyte basal plasma membrane and upper lamina lucida, consistent with the location of the bullous pemphigoid antigens. This case report describes a case of LPP that presented exclusively as an oral condition. Lichen planus pemphigoides should be considered in the clinical differential diagnosis of vesiculoerosive oral mucosal diseases.

Successful treatment of oral linear IgA disease using mycophenolate

Linear IgA disease (LAD) is a rare acquired autoimmune bullous disorder, characterized by linear deposition of IgA along the dermoepidermal basement membrane zone. The clinical presentation of LAD consists of vesiculobullous lesions affecting the skin and mucosal surfaces. The present case report presents a rare presentation of this vesiculobullous disorder. Although more than 50% of LAD patients present with oral lesions, there are few reported cases of involvement of the mouth as the sole manifestation. A 79-year-old female presented with a sore mouth and erosions affecting the palate. The symptoms resolved following the provision of mycophenolate, an antiproliferative immunosuppressant which has not previously appeared to have been reported in the long-term successful management of linear IgA disease limited to the mouth. We found that mycophenolate is a useful adjunct to the successful treatment of oral linear IgA when the uses of other immunosuppressants are contraindicated.

Traumatic ulcerative granuloma with stromal eosinophilia of the oral mucosa: histological and immunohistochemical analysis of three cases

Traumatic ulcerative granuloma with stromal eosinophilia is an ulcerated oral lesion which pathogenesis is still unclear. Clinically, this disease is characterized by the presence of chronic ulcerative lesions with elevated and indurated borders in the oral mucosa. It usually develops rapidly and persists for several weeks or months, it presents mainly on the tongue but other areas such as gingival, cheek and vestibular mucosa may also be involved. We report three cases showing their clinical, histological and immunohistochemical analysis. In this study the authors underline the importance of a correct differential diagnosis and monitoring of these patients in order to prevent the development of possible serious complications.

Diversity of gammadelta T cells in patients with Behcet's disease is indicative of polyclonal activation

OBJECTIVE

Behcet's disease (BD) is a multisystemic disease, with vasculitic lesions in the oral and genital mucosa, eyes, joints, skin and brain. We have previously found that gammadelta T cells are increased in peripheral blood of BD patients. The aim of this study was to investigate the extent of gammadelta T cells in oral biopsies from BD patients with special emphasis on the restriction of Vgamma and Vdelta usage.

PATIENTS AND METHODS

Expression of Vgamma and Vdelta chains on peripheral blood gammadelta T cells from 31 BD patients and 19 healthy controls was analysed by flow cytometry and the expression of Vgamma and Vdelta chains in nine ulcerated and eight non-ulcerated oral mucosa from BD patients and non-ulcerated oral mucosa from three healthy controls was analysed by immunohistochemistry.

RESULTS

Vgamma9 and Vdelta2 were the predominant chains expressed in peripheral blood of BD patients, although other Vgamma and Vdelta chains were also expressed. The presence of gammadelta T cells was only observed in the ulcerated oral mucosa but not in the non-ulcerated mucosa from the BD patients, and not in the non-ulcerated mucosa from the healthy controls. These gammadelta T cells showed no preferential expression of any of the Vgamma or Vdelta chains.

CONCLUSION

These data suggest a polyclonal rather than oligoclonal activation of the gammadelta T cells. This may indicate that during repeated inflammation of the oral mucosa, the gammadelta T cells are responding to a wide variety of antigenic stimuli with consequent expansion of gammadelta T cells expressing various Vgamma and Vdelta chains and that different antigenic stimuli or responses may be responsible for the clinical heterogeneity of the disease.

Eosinophilic ulcer of the oral mucosa: another histological simulator of CD30+ lymphoproliferative disorders

Eosinophilic ulcer of the oral mucosa (EUOM), also known as traumatic ulcerative granuloma with stromal eosinophilia or Riga-Fede disease, is an uncommon benign self-limited lesion poorly described in the dermatological literature. It probably includes a spectrum of related disorders presenting as an ulcer with elevated indurated borders affecting the tongue, oral mucosa or lip. Histopathological findings are characteristic and consist of eosinophil-rich mixed infiltrates accompanied by a population of large mononuclear cells whose origins have been a matter of debate. Immunohistochemical studies of these cells have suggested a myofibroblastic or histiocytic origin. We present a 93-year-old woman with two episodes of self-healing ulcers on the upper lip and on the lingual mucosa, respectively. Histopathological findings on both biopsies were consistent with EUOM and showed the presence of large atypical CD30+ lymphocytes. Some recent reports have also shown positivity for the CD30 antigen, raising the possibility that a subset of EUOM could be included within the spectrum of CD30+ lymphoproliferative disorders. This finding most likely suggests that EUOM can represent another histological simulator of CD30+ lymphoproliferative disorders.

Anti-Ro/SSA antibodies in rheumatoid arthritis: clinical and immunologic associations

OBJECTIVE

To assess the prevalence of anti-Ro/SSA in RA and to analyse clinical and serological features of anti-Ro/SSA positive patients with RA.

METHODS

195 consecutive patients affected by RA were studied by counterimmunoelectrophoresis and ELISA for the detection of anti-Ro/SSA antibodies. Anti-Ro were found in 12 patients, with a prevalence of 6%. These 12 patients were pooled with other 15 patients known to have anti-Ro/SSA antibodies and RA, in order to evaluate their clinical and laboratory features.

RESULTS

Anti-Ro positive patients showed a common pattern of joint involvement at onset and a comparable progression of disease compared to anti-Ro negative subjects. In addition, extra-articular manifestations (such as xerophthalmia, xerostomia, scleritis, oral ulcers and amyloidosis) and peculiar autoantibody profile (hypergammaglobulinemia, anti-dsDNA and AMA) were found significantly associated to anti-Ro/SSA positivity. Even though DMARDs withdrawals were more frequently detected in anti-Ro/SSA patients, especially when using gold salts, no statistical difference between the two groups was detected. In addition, anti-TNFalpha treatment did not cause further progression of autoimmunity neither on laboratory nor on clinical ground.

CONCLUSION

Anti-Ro/SSA can be detected in about 6% of patients affected by RA. These patients presented a peculiar clinical picture characterised by extra-articular manifestations some of which are known to be anti-Ro/SSA correlated, while others are more disease-specific (amyloidosis, episcleritis). Anti-Ro/SSA are significantly associated with other autoantibodies not specific for RA such as anti-dsDNA and AMA. Treatment with anti-TNF drugs did not cause further progression of autoimmunity neither on laboratory nor on clinical ground.

Neuro-immunity in stress-related oral ulcerations: a fractal analysis

By testing archival paraffinized biopsy blocks obtained from the oral pathology library with immunohistochemistry, we tested the hypothesis that substantial alterations are demonstrable in the cross-talk between sympathetic (VMAT) and para-sympathetic innervation (VAchT), and resident CD3+ T cells in the mucosa from oral lichen planus (OLP), compared to recurrent aphthous stomatitis (RAS) and control biopsies. We quantified fractal dimension and Euclidean dimension of CD3+ cells between the two pathologies, and across the set of CD3+ cells proximal to the vesicles of monoamines transport (VMAT)+ or the vesicles of acetylcholine transport (VAchT)+ innervation, compared to cells relatively distal to the nerve endings. The data show exquisite organization of the punctuate sympathetic and para-sympathetic staining about the resident CD3+ T cells in the OLP lesions, but not in the aphthous lesions or in control mucosa. Fractal analysis reveals that aphthous lesions are characterized by CD3+ T cells of larger size (Euclidean dimensional map), compared to control mucosa. CD3+ T cells in OLP lesions are also found to be significantly larger than those found in control lesions, when they are not proximal to sympathetic or para-sympathetic vesicles. The membrane of CD3+ T cells is overall more complex (fractal dimension) in aphthous lesions, compared to control sections. A similar trend is apparent, albeit not statistically significant, in CD3+ T cells resident in OLP lesions, whether or not they are located proximal to nerve endings. An overall decrease in the ratio of fractal dimension-over-topological dimension was also observed across the pathological lesions, compared to control. Taken together, these data indicate that as CD3+ T cells grow larger in the pathological conditions, they, in effect, stretch their plasma membrane, and that the cells may be at different stage of the cell cycle, relative to their position vis a' vis nerve endings. Because fractal analysis is performed on individual cells, it has the potential of being developed in a novel diagnostic test, as well as a prognostic tool for monitoring the etiology and the course of treatment at the individual cellular level. Our findings also open new frontiers of fundamental, clinical and translational biosciences of OLP.

Oral ulcers in children under chemotherapy: clinical characteristics and their relation with Herpes Simplex Virus type 1 and Candida albicans

OBJECTIVE

The objective of this study was to determine the clinical characteristics of oral ulcers in pediatric oncology patients undergoing chemotherapy and their relation with the presence of Herpes Simplex Virus (HSV) type 1 and Candida albicans.

STUDY DESIGN

The sample consisted of 20 ulcerative lesions from 15 children treated with chemotherapy in the Pediatric Service of the Regional Hospital of Concepción, Chile. Two calibrated clinicians performed clinical diagnosis of the ulcers and registered general data from the patients (age, general diagnosis, absolute neutrophil count, and number of days after chemotherapy) and clinical characteristic of the ulcers: number, size, location, presence or absence of pain and inflammatory halo, edge characteristics, and exudate type. Additional to clinical diagnosis, culture for Candida albicans (C) and polymerase chain reaction (PCR) for Herpes Simplex Virus type 1 was performed.

RESULTS

Ten ulcers occurred in patients with acute lymphoblastic leukemia, five in patients with acute myeloblastic leukemia and five in patients with other neoplastic diseases. Eight ulcers were HSV (+) / C (-), 6 HSV (-) / C (-), 4 HSV (+) / C (+) and 2 HSV (-) / C (+). Preferential location was the hard palate. Most lesions were multiple, painful, with inflammatory halo, irregular edges and fibrinous exudate. The average size was 6,5 millimeters, and the mean number of days after chemotherapy was 7.5 days.

CONCLUSIONS

Oral ulcers in children with oncological diseases did not present a specific clinical pattern. They were strongly associated with HSV.

Linear IgA Disease Presenting as Desquamative Gingivitis

Linear IgA disease is a subepidermal blistering disorder of unknown cause. Along with dermatologic blistering, other manifestations include oral ulceration and desquamative gingivitis. We present a case of linear IgA disease that manifested simply as oropharyngeal ulceration and desquamative gingivitis, resulting in considerable delay in diagnosis and treatment. This article (1) highlights the difficulties of diagnosing linear IgA disease when the predominant presenting features are mucosal and (2) reviews the current literature regarding linear IgA disease.

Two cases of linear IgA disease with clinical manifestations limited to the gingiva

Linear IgA disease (LAD) is a chronic, subepithelial blistering disease that is associated with the presence of linear deposits of IgA along the basement membrane zone. Etiopathogenic aspects of LAD are only partially known. LAD is clinically characterized by vesiculobullous skin and mucous lesions. Although more than half of LAD patients present oral mucosal lesions, there are only a few cases reported of oral lesions as the only manifestation of LAD. This study presents 2 of these uncommon cases.

Levamisole and Chinese medicinal herbs can modulate the serum interleukin-6 level in patients with recurrent aphthous ulcerations

BACKGROUND

Recurrent aphthous ulcerations (RAU) are common oral inflammatory lesions. Interleukin-6 (IL-6) is a pro-inflammatory cytokine that has effects on cellular and humoral immunities. Previous studies have shown that the high serum IL-6 levels in some RAU patients can be reduced by drug treatment. This finding suggests that IL-6 may be a useful marker in evaluating therapeutic effects of RAU.

METHODS

In this study, we used a solid phase, two-site sequential chemiluminescent immunometric assay to determine the baseline serum levels of IL-6 in a group of 228 patients with RAU, erythema multiforme (EM), traumatic ulcers (TU), oral submucous fibrosis (OSF), pemphigus vulgaris (PV), or Sjögren's syndrome (SS), and in 77 normal control subjects. Some RAU patients were treated with levamisole plus Chinese medicinal herbs or levamisole only for 0.5-5 months and their serum IL-6 levels were measured after treatment.

RESULTS

We found that about 99% of the normal control subjects and the patients with EM, TU, or OSF had a serum IL-6 level within the normal limit of 5.0 pg/ml. However, 24% (48/197) RAU patients, 14% (1/7) EM patients, 43% (3/7) PV patients, and 100% (6/6) SS patients had a serum level of IL-6 greater than 5.0 pg/ml. The mean serum level of IL-6 in patients with RAU (3.6 +/- 3.5 pg/ml, P < 0.001), minor type RAU (2.7 +/- 2.0 pg/ml, P < 0.05), major type RAU (5.2 +/- 4.6 pg/ml, P < 0.001), or herpetiform type RAU (4.1 +/- 3.8 pg/ml, P < 0.01) was higher than that in normal control subjects. The mean serum level of IL-6 in major type (P < 0.001) or in herpetiform type RAU patients (P < 0.05) was higher than that in minor type RAU patients. The mean reduction of serum IL-6 level (10.0 +/- 7.1 pg/ml) in RAU patients after treatment with levamisole plus Chinese medicinal herbs was significantly higher than that (5.1 +/- 3.7 pg/ml) in RAU patients after treatment with levamisole only (P < 0.005), suggesting that the combination therapy is superior to the single therapy of levamisole only.

CONCLUSION

We conclude that levamisole and levamisole plus Chinese medicinal herbs can modulate the serum IL-6 level in RAU patients. Although the therapeutic effect of RAU can be assessed by a decrease in the frequency, duration and number of the oral ulcerations, it can also be monitored by a reduction of serum IL-6 level in RAU patients.

Linear IgA dermatosis induced by a new angiotensin-converting enzyme inhibitor

A 68-year-old female patient treated with benazepril for arterial hypertension developed oral and cutaneous blistering. Biopsy of the oral and cutaneous lesions showed neutrophilic microabscesses in the mesenchymal papillae, with epitheliomesenchymal separation. Direct immunofluorescence revealed linear immunoglobulin deposits at the epithelial basement membrane zone, consisting predominantly of IgA. The histologic results supported the clinical diagnosis of drug-induced linear IgA disease. The substitution of benazepril with a beta blocker resulted in complete resolution of all mucocutaneous lesions.

Modification to the approach of the diagnosis of mucous membrane pemphigoid: A case report and literature review

Mucous membrane pemphigoid (MMP) is a subepithelial blistering disease predominantly involving the mucosal surfaces. Distinct subgroups of MMP have recently been identified by using advanced immunopathologic and immunochemical techniques and are described in the literature on the basis of their clinical features and antigenic specificities. Antiepiligrin MMP has been described as an immunochemically distinct entity. Evidence of an existing relationship between malignancy and antiepiligrin MMP has been well documented in the medical literature. This case report illustrates a case of antiepiligrin MMP in a patient with an advanced cancer of the bladder.

Pemphigus vulgaris: update on etiopathogenesis, oral manifestations, and management

Pemphigus is a group of potentially life-threatening diseases characterized by cutaneous and mucosal blistering. There is a fairly strong genetic background to pemphigus with linkage to HLA class II alleles. Certain ethnic groups, such as Ashkenazi Jews and those of Mediterranean origin, are especially liable to pemphigus. Pemphigus vulgaris (PV), the most common and important variant, is an autoimmune blistering disease characterized by circulating pathogenic IgG antibodies against desmoglein 3 (Dsg3), about half the patients also having Dsg1 autoantibodies. Oral lesions are initially vesiculobullous but readily rupture, new bullae developing as the older ones rupture and ulcerate. Biopsy of perilesional tissue, with histological and immunostaining examinations, is essential to the diagnosis. Serum autoantibodies to either Dsg1 or Dsg3 are best detected by both normal human skin and monkey esophagus or by enzyme-linked immunosorbent assay (ELISA). Before the introduction of corticosteroids, pemphigus vulgaris was typically fatal mainly from dehydration or secondary systemic infections. Current treatment is largely based on systemic immunosuppression using systemic corticosteroids, with azathioprine, dapsone, methotrexate, cyclophosphamide, and gold as adjuvants or alternatives, but mycophenolate mofetil and intravenous immunoglobulins also appear promising.

Expansion of gammadelta T-cells in Behçet's disease: role of disease activity and microbial flora in oral ulcers

Gammadelta T-cells participate in the immune response to infections and in autoimmunity by recognizing bacteria-derived and autologous antigens. The goal of this study was to evaluate the involvement of gammadelta T-cells in Behçet's disease (BD). Gammadelta T-cells in the peripheral-blood mononuclear cells (PBMCs) of Israeli patients with definite BD (n = 23), normal controls (n = 16), and patients with familial Mediterrranean fever (FMF; n = 20) were evaluated by means of flow cytometry. The responses of patient and control gammadelta T-cells to medium conditioned by microorganisms cultured from an oral ulcer of a patient with active BD were compared. The proportions of CD3(+) and CD8(+) cells in the PBMCs were not significantly different between groups. In contrast, gammadelta-T-cells accounted for 7.01% +/- 4.42% of the PBMCs in BD compared with 3.56% +/- 3.45% in FMF (P < .005) and 3.7% +/- 3.15% in normal individuals (P < .009). Their numbers were significantly higher during active disease than in remission (9.45% +/- 5.08% versus 2.27% +/- 3.3%; P < .009). The number of T-cell-receptor gammadelta(+) and Vdelta2(+) cells of BD patients, but not of controls, increased after 96 hours of culture in medium containing supernatant of microorganisms cultured from an oral ulcer in a patient with BD relative to their proportions in control medium: 58.2% vs 13.9% (P < .05) and 28% vs 9% (P < .04), respectively, of the cultured T-cells (n = 4).gammadelta T-cells are expanded in BD PBMCs during active disease. An exaggerated proliferative response to products released by microorganisms present in oral ulcers may play a role in this phenomenon.

[Mucocutaneous lesions in patients with systemic lupus erythematosus]

The objective was to analyze the prevalence of mucocutaneous lesions in patients with systemic lupus erythematosus (SLE). During a 3-year period, we analyzed 77 patients with a diagnosis of SLE. The mucocutaneous lesions were classified into specific and non-specific. We defined skin type, sunlight exposure and photoprotection and correlated these lesions with serology and disease activity. Acute specific lesions were found in 67.5% of the patients, subacute lupus in 6.5% and chronic lesions in 26.0%. The most prevalent non-specific lesions were alopecia (59.7%), photosensitivity (57.1%), Raynaud's syndrome (46.7%), oral ulcerations (15.6%) and livedo reticularis (11.7%). Skin type 3 (35%) and exposure to mild ultraviolet radiation (74%) were seen in the majority of the patients. Appropriate sunlight protection was only used by 47% of the patients. When dermatological lesions and serology were compared, we found a significant association between malar rash, photosensitivity, livedo reticularis and alopecia with the presence of anti-Ro and Raynaud's phenomenon in patients with positive anti-Sm. The presence of malar rash, photosensitivity, Raynaud's phenomenon, diffuse alopecia and livedo reticularis was more frequent among patients with active disease. The prevalence of mucocutaneous manifestation in our population was slightly higher than data reported in other series. The presence of malar rash, diffuse alopecia, photosensitivity and livedo reticularis significantly related with the presence of anti-Ro and Raynaud's phenomenon with anti-Sm. All these lesions were more frequently seen in patients with active disease.

[Antigens of antineutrophil cytoplasmic autoantibodies in recognizing a novel neutrophil granule antigen in lupus nephritis and its association with photosensitivity and oral ulceration]

OBJECTIVE

To investigate whether there are some unknown target antigens of antineutrophil cytoplasmic autoantibodies (ANCA) in patients with lupus nephritis (LN) and the prevalence and the clinical significance of these unknown target antigens.

METHODS

Serum was collected from 72 renal-biopsy-proven lupus nephritis (LN) patients. Mixed neutrophil granules were separated from normal human peripheral neutrophils and soluble acid extracts in non-reducing conditions were used as antigens in Western-blot analysis to detect ANCA in the serum sample of LN patients.

RESULTS

Serum from seme LN patients could blot a few bands. Interestingly, serum from 14/72 (19.4%) of the patients recognized a novel 69,000 protein band and that from 10/72 (13.9%) sera recognized a 55,000 protein band that might be the bactericidal/permeability-increasing protein (BPI). The 69,000 target antigen was different from the known target ANCA antigens such as cathepsin G and lactoferrin. Further study revealed that the percentages of patients with photosensitivity and oral ulcer in anti-69,000 autoantibody positive group were significantly higher than those in the anti-69,000 autoantibody negative group (57.1% vs 12.1%, P < 0.005, and 50.0% vs 17.2%, P < 0.05, respectively).

CONCLUSIONS

A novel 69,000 protein in human neutrophil granules is identified as a target antigen of ANCA in LN patients. The anti-69,000 autoantibodies may be associated with photosensitivity and oral ulcer in LN patients.

Fevers and mouth ulcers

Mouth ulcers are commonly caused by infection but may be due to neutropenia. The most common form of hyper-IgM syndrome is of X-linked inheritance and caused by CD40 ligand gene mutations. Consider hyper-IgM syndrome in a male child with recurrent bacterial or opportunistic infections, neutropenia, hypogammaglobulinaemia (IgG and IgA) and normal T- and B-cell counts. In X-linked hyper-IgM syndrome: - the serum IgM concentration is normal in about 50% of cases. - transient or persistent neutropenia occurs in 70% of cases. First-line therapeutic options for hyper-IgM syndrome include regular intravenous immunoglobulin and prophylactic trimethoprimsulphamethoxazole.

Topical azathioprine in the treatment of immune-mediated chronic oral inflammatory conditions: a series of cases

OBJECTIVES

After hematopoietic cell transplantation, a variety of complications can occur, including chronic graft-versus-host disease (GVHD), with 25% to 70% of these involving the oral cavity. Those lesions, as well as oral involvement of autoimmune mucocutaneous diseases, might present as painful, erythematous, and ulcerative oral lesions. Management includes topical and systemic immunosuppressive agents, including systemic azathioprine (AZA). The purpose of this study was to evaluate the efficacy of topical AZA in chronic oral GVHD and in oral autoimmune diseases in a series of patients.

METHODS

Four men and 2 women with GVHD and 2 men with autoimmune vesiculo-ulcerative oral lesions were treated with topical AZA. A rinse of 5 mL of 5 mg/mL AZA in methylcellulose were rinsed 3 to 4 times daily for over 1 minute and expectorated, or a gel in the same concentration in 3% methylcellulose was topically applied. The outcome was evaluated separately for total ulcer size, assessment of the erythema, and severity of pain by using a visual analogue scale. Global estimated improvements represented a proportional combined improvement of ulcers, erythema, and pain.

RESULTS AND CONCLUSIONS

The mean estimated global improvement for 6 patients with GVHD who used AZA rinse was 60% in a mean of 16.67 weeks. Ulcers improved by 58%, erythema by 55%, and pain was reduced by 63%. Two patients with oral lesions of vesiculo-ulcerative diseases (1 AZA rinse and 1 topical gel) improved by 95% and 96%, respectively, in 3 months. One patient with GVHD applied topical AZA gel in addition to mouthrinses, and a 29% estimated global improvement was achieved in addition to 50% of improvement achieved with AZA mouthrinses. The observed effect of topical AZA suggests that it can be used for management of oral immune-mediated inflammatory conditions, and for patients who are provided with systemic immunosuppressives it can allow control of oral findings with lower systemic dosing. The therapeutic potential of topical AZA as mouthrinse versus topical applications and the most effective concentration should be further investigated.

Sensitivity, specificity, and positive predictive value of oral opportunistic infections in adults with HIV/AIDS as markers of immune suppression and viral burden

OBJECTIVES

The purpose of this study was to assess the use of human immunodeficiency virus (HIV)-related oral opportunistic infections as markers of immune suppression and viral burden in adults with HIV/acquired immunodeficiency syndrome (AIDS).

METHODS

The population consisted of a single institution observational cohort involving 606 patients with HIV/AIDS with CD4 count data and 277 with plasma viral load measurements examined between 1995 and 1999 for the presence of oral manifestations of HIV. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value is reported for the association of specific oral lesions and lesion sets with CD4 counts <200 cells/mm(3) and with plasma HIV RNA >/=20,000 copies/mL.

RESULTS

Lesions with moderate-to-high PPVs for CD4 <200 cells/mm(3) were as follows: Kaposi's sarcoma (100%; P =.035), pseudomembranous candidiasis (82. 2%; P <.001), linear gingival erythema (70.0%; P =.015), hairy leukoplakia (66.3%; P <.001), angular cheilitis (60.0%; P =.128), and erythematous candidiasis (58.3%; P =.061). Necrotizing ulcerative periodontal diseases, HIV salivary gland disease, oral ulcers, and oral warts had PPVs below 50%. Concurrent infection with candidiasis and hairy leukoplakia had the highest PPV of 89.3%; P <. 001. PPVs for HIV RNA >/=20,000 copies/mL ranged from 27.3% to 100%, with significant association only for pseudomembranous candidiasis.

CONCLUSIONS

Specific common oral lesions are strongly associated with immune suppression, as measured by CD4 cell counts, and are modestly associated with high viral burden, thus serving as potential clinical markers of HIV viremia and the consequent destruction of the immune system with progressive HIV disease.

Thalidomide for the treatment of acquired immunodeficiency syndrome-associated refractory oral ulcers

A case of severe, oral, not otherwise specified ulcers in a human immunodeficiency virus-infected patient is described. The lesions did not respond to acyclovir, prednisone, pentoxifylline, or foscarnet sodium therapy. Dramatic clinical improvement and progressive ulcer healing were observed after starting oral thalidomide therapy. Clinicians should be aware of the usefulness of thalidomide for the treatment of acquired immunodeficiency syndrome-associated not otherwise specified ulcerations.

Salivary immunoglobulin A levels of persons who have stopped smoking

OBJECTIVE

The aim of this study was to determine salivary immunoglobulin A levels in people who stopped smoking for at least 2 weeks. Salivary immunoglobulin A is a primary antibody at mucosal surfaces.

STUDY DESIGN

Salivary immunoglobulin A levels of each of 20 subjects were determined on 3 occasions: first, while the subject was still smoking; second, 7 days after cessation of smoking; third, on the 14th day after cessation. Two control groups (with 20 people in each group) were also used: the members of the first had never smoked, and the members of the second were current smokers. Results were analyzed through use of a repeated-measures analysis of variance and the t test.

RESULTS

Seven days after cessation of the smoking habit, a transient decrease in salivary immunoglobulin A levels was observed. However, within 14 days the levels returned to normal.

CONCLUSIONS

Salivary immunoglobulin A levels transiently decrease in people who have stopped smoking for 7 days, but they recover to normal values within 2 weeks after cessation of the habit.

Treatment of oral chronic graft-versus-host disease with PUVA therapy: case report and literature review

Chronic graft-versus-host disease commonly appears with oral manifestations subsequent to allogeneic bone marrow transplantation. These manifestations include leukoplakia, mucosal atrophy, erythema, ulcers, and xerostomia. Some lesions are resistant to treatment with immunosuppressive medications. Ultraviolet A irradiation therapy with oral psoralen has been shown to be effective in treating these resistant lesions. This article presents a review of the literature and a case report.

Behçet's disease: an immune-mediated vasculitis involving vessels of all sizes

Behçet's disease is an immune-mediated vasculitis affecting both small and large vessels. Small-vessel vasculitis is the pathological basis of the multiorgan involvement that results in protean clinical features. However, relapsing aphthous ulcers in the mouth are considered the clinical hallmark and are often also observed over the genitalia. Both manifestations, in association with uveitis, form the typical clinical triad. In addition, skeletal muscles, joints, gastrointestinal, cardiopulmonary, and central nervous systems can be involved. Heterogeneity in incidence, clinical manifestations, course, and severity are observed according to ethnic background. The natural course is chronic with relapses and remissions, gradually abating over the years, but the illness can also be life or sight threatening. Its origin and cause are still obscure: genetic, infectious, environmental, and immunological factors have been proposed. Owing to the lack of a specific test, diagnosis still relies on recognition of the typical clinical pattern. Treatment usually includes corticosteroids and immunosuppressive drugs. A better understanding of the pathogenesis will hopefully improve both diagnosis and therapy. In addition, the development of tests aimed at monitoring disease activity and response to therapy is certainly desirable.

Immunopathogenesis of oral lichen planus and recurrent aphthous stomatitis

Oral mucosal bullous/desquamative/ulcerative diseases involve immunopathological mechanisms that account for loss of adhesion between contiguous keratinocytes or to structures within the basal lamina. Some are antibody mediated, in which specific adhesion molecules of the desmosome, hemidesmosome, and basement membrane become antigenic targets. Oral lichen planus and recurrent apthous ulcers, although manifesting disparate clinical appearances and natural history, share immunopathological features that involve T cell-mediated immunity. Although the antigens, haptens, or autoantigens are not usually apparent, current research poses the hypothesis that both of these common oral mucosal diseases are a delayed-type hypersensitivity or cell-mediated response to an antigenic stimulus residing within the epithelium. This article reviews the research evidence for this hypothesis.

Serum IgG antibodies to Helicobacter pylori in patients with recurrent aphthous stomatitis and other oral disorders

OBJECTIVES

To compare the frequency of serum anti-Helicobacter pylori IgG antibodies in patients with recurrent aphthous stomatitis with patients with other oral ulcerative and nonulcerative disorders.

STUDY DESIGN

Prospective study of serum IgG antibodies to H. pylori in 75 patients with recurrent aphthous ulcers, 15 patients with other oral ulcerative disorders, 41 patients with other oral mucosal lesions, 27 patients with oral dysaesthesia, and 25 healthy control patients without oral lesions.

RESULTS

The frequency of anti-H, pylori seropositivity was not significantly greater in patients with recurrent aphthous stomatitis (30.6%) compared with patients with other ulcerated oral mucosal lesions (33.0%) and controls (24%).

CONCLUSIONS

Helicobacter pylori does not appear to be of etiologic significance in the development of recurrent aphthous stomatitis.

Oral lesions as markers of severe immunosuppression in HIV-infected homosexual men and injection drug users

OBJECTIVES

We examined the diagnostic utility of the presence of oral lesions, individually and in combination, in identifying severe immunosuppression, defined as CD4 cell count under 200.

STUDY DESIGN

Data were collected on 82 HIV-seropositive homosexual men and 82 HIV-seropositive injection drug users who volunteered to participate in a longitudinal study of HIV infection. CD4 cell counts were measured within 24 hours of oral examination.

METHODS

Sensitivity, specificity, positive predictive value, negative predictive value, and the odds ratio were computed to assess the association between oral lesions and CD4 less than 200. In addition to the individual lesions, we studied the diagnostic properties of sets of three to six lesions. For each set of lesions, a patient was classified as positive for the set if he or she had one or more lesions in that set.

RESULTS

In homosexual men and injection drug users, individual lesions had low sensitivity, high specificity, and moderate positive and negative predictive values. Odds ratios reflected weak correlation to immunosuppression. When lesion sets were considered in homosexual men, sensitivity rose dramatically with only modest decreases in specificity. The positive and negative predictive values remained almost the same. Similar results for lesion sets were obtained in injection drug users, with greater reduction in specificity but stable positive and negative predictive values. Odds ratios indicated that for homosexual men, the more lesions included in the set, the stronger the correlation with immunosuppression. For injection drug users, strong correlations were observed for all lesion sets.

CONCLUSIONS

Analysis of sensitivities and odds ratios in homosexual men suggest that it may be valid to note the occurrence of a greater number of oral lesions than is currently done in staging patients with HIV infection. Among injection drug users, monitoring a larger number of lesions neither improves nor reduces the correlation to severe immunosuppression.

Lack of TGF-alpha and TGF-beta 1 synthesis by human eosinophils in chronic oral ulcers

We recently demonstrated that eosinophils infiltrate prominently into cutaneous wounds in the Syrian hamster and represent a source of transforming growth factor-alpha and transforming growth factor-beta. In this study, we assessed the role of the eosinophil and eosinophil-derived transforming growth factors in human oral ulcers that exhibit delayed healing, descriptively termed traumatic ulcerative granuloma with stromal eosinophilia. Our aim was to determine whether eosinophils, which characteristically infiltrate traumatic ulcerative granuloma with stromal eosinophilia lesions, produced transforming growth factor-alpha or transforming growth factor-beta. Twelve cases of traumatic ulcerative granuloma with stromal eosinophilia were examined for transforming growth factor-alpha and transforming growth factor-beta mRNA and cellular protein by in situ hybridization and immunohistochemistry. Eosinophils in 92% of the cases did not express detectable cellular levels of mRNA for either of the transforming growth factors. In addition, only a small percentage of the many eosinophils infiltrating these lesions produced transforming growth factor-alpha or transforming growth factor-beta. The lack of significant synthesis of transforming growth factors by eosinophils in most of the cases of traumatic ulcerative granuloma with stromal eosinophilia is in striking contrast to the expression of transforming growth factors by the eosinophils that infiltrate the animal wound-healing model. Our findings may help to explain the delayed healing that is typical of TUGSE lesions.