Summary

This document provides information on viral infections, including classifications, symptoms, and diagnosis, focusing on viral hepatitis and HIV. It discusses DNA and RNA viruses. It also details some viral diseases related to dentistry.

Full Transcript

**Viral hepatitis and HIV** **What is a virus?**\ The simplest (and smallest) reproducing entities known are:\ The prions: composed entirely of protein (Special structural proteins assemble together with the progeny nucleic acid to form virion**s**)\ The viroids which are small single strands of...

**Viral hepatitis and HIV** **What is a virus?**\ The simplest (and smallest) reproducing entities known are:\ The prions: composed entirely of protein (Special structural proteins assemble together with the progeny nucleic acid to form virion**s**)\ The viroids which are small single strands of naked nucleic acid. Viruses can replicate only in living cells. Their nucleic acid contains information necessary for reprogramming the infected host cell to synthesise the virus macromolecules necessary for production of viral progeny. Virions of different viruses vary in size (from 20 to 400 nm) and complexity. They contain only one type of nucleic acid. The virion nucleic acid is encased in a protein coat, the capsid, to form a nucleocapsid. In many viruses, the nucleocapsid is further wrapped in a lipoprotein envelope. The function of these outer layers of the virion is to protect the nucleic acid. **Viruses can be classified into** +-----------------------------------+-----------------------------------+ | **DNA viruses** | **RNA viruses** | +===================================+===================================+ | These all have DNA in their | RNA Viruses have **RNA** as its | | virions | genetic material. This nucleic | | | acid is usually | | Example: The Herpesviruses, | single-stranded **RNA** (ssRNA) | | hepatitis B virus, and | but may be | | Parvoviruses, which cause a rash | double-stranded **RNA** (dsRNA). | | in infants and stillbirths are | | | single stranded | Example**:** Hepatitis C virus | +-----------------------------------+-----------------------------------+ +-----------------------------------------------------------------------+ | **Symptoms caused by viral infections related to dentistry** | | | | - Oral ulceration | | | | - Warts | | | | - Parotitis | | | | - Lymphadenopathy | | | | - Upper respiratory tract symptoms | | | | - HIV-related disorders such as hairy oral leukoplakia and Kaposi's | | sarcoma | +-----------------------------------------------------------------------+ +-----------------------------------------------------------------------+ | **Diagnosis of viral infection** | | | | - A virus diagnosis can be made on purely clinical grounds, but on | | other occasions the presentation may be atypical | | | | - Serological tests | | | | - Molecular techniques: PCR (diagnose active infections) | | | | - virus isolation in cell culture: less commonly used | +-----------------------------------------------------------------------+ Only a small number of viruses are treated with antiviral drugs in dental practice. Acyclovir and its derivatives are used with little or no toxicity. **Hepatotropic viruses** +-----------+-----------+-----------+-----------+-----------+-----------+ | **Virus** | **Hepatit | **Hepatit | **Hepatit | **Hepatit | **Hepatit | | | is | is | is | is | is | | | A** | B** | C** | D** | E** | +===========+===========+===========+===========+===========+===========+ | **Family* | Picornavi | Hepadnavi | Flaviviri | Unknown | Hepevirid | | * | ridae | ridae | dae | | ae | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Genome* | Single-st | Double-st | Single-st | Single-st | Single-st | | * | randed | randed | randed | randed | randed | | | RNA | DNA | RNA | | RNA | | | | | | RNA | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Transmi | Fecal-ora | Parentral | Parentral | Parentral | Fecal-ora | | ssion** | l, | | | | l | | | | Sexual | Sexual | Sexual | | | | May be | | | | | | | via | Peri-nata | Peri-nata | Peri-nata | | | | saliva | l | l | l | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Incubat | 2-7 weeks | 1-6 | 2-25 | 1-6 | 2-9 weeks | | ion | | months | weeks | months | | | period** | | | | | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Immunop | Active& | Active& | No | Active& | Active& | | rophylaxi | Inactive | Inactive | Vaccine | Inactive | Inactive | | s** | | | | | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Chronic | No | yes | yes | yes | No | | infection | | | | | | | ** | | | | | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Carrier | No | yes | yes | yes | No | | state\*** | | | | | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Fulmina | rare | Yes | rare | yes | yes | | nt | | | | | | | disease** | | However, | | | | | | | one-third | | | | | | | of | | | | | | | patients | | | | | | | have no | | | | | | | signs or | | | | | | | symptoms | | | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Long-te | \- | -liver | -liver | -liver | \- | | rm | | cirrhosis | cirrhosis | cirrhosis | | | Complicat | | | | | | | ion** | | -Hepatoce | -Hepatoce | -Hepatoce | | | | | ular | ular | ular | | | | | carcinoma | carcinoma | carcinoma | | | | | | | | | | | | -liver | -liver | -liver | | | | | failure | failure | failure | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Diagnos | Anti-HAV | HBV | -Anti-HCV | Anti-HDV | Anti-HEV | | is** | antibody | serology | IgG | antibody | antibody | | | | | | | | | | | PCR | -PCR | | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Treatme | Supportiv | Antiviral | Antiviral | Antiviral | -Supporti | | nt** | e | treatment | treatment | treatment | ve | | | | | | | | | | | | | | -Ribaviri | | | | | | | n | | | | | | | in severe | | | | | | | cases | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Risk of | Low | Possible | Possible | Possible | Low | | transmiss | | | | | | | ion | | | | | | | through | | | | | | | dental | | | | | | | treatment | | | | | | | ** | | | | | | +-----------+-----------+-----------+-----------+-----------+-----------+ | \*A | | | | | | | carrier | | | | | | | state in | | | | | | | which | | | | | | | hepatitis | | | | | | | B | | | | | | | persists | | | | | | | within | | | | | | | the body | | | | | | | for \> 6 | | | | | | | months | | | | | | | develops | | | | | | | in about | | | | | | | one-tenth | | | | | | | of | | | | | | | patients | | | | | | | | | | | | | | - Curre | | | | | | | nt | | | | | | | hepat | | | | | | | itis | | | | | | | B | | | | | | | vacci | | | | | | | ne | | | | | | | is a | | | | | | | recom | | | | | | | binant | | | | | | | vacci | | | | | | | ne | | | | | | | of | | | | | | | HBsAg | | | | | | |. | | | | | | | After | | | | | | | vacci | | | | | | | nation, | | | | | | | anti- | | | | | | | HBs | | | | | | | devel | | | | | | | ops | | | | | | | and | | | | | | | confe | | | | | | | rs | | | | | | | prote | | | | | | | ction. | | | | | | | This | | | | | | | vacci | | | | | | | nation | | | | | | | also | | | | | | | indir | | | | | | | ectly | | | | | | | prote | | | | | | | cts | | | | | | | again | | | | | | | st | | | | | | | hepat | | | | | | | itis D. | | | | | | | | | | | | | | - Hepat | | | | | | | itis | | | | | | | D | | | | | | | virus | | | | | | | (or | | | | | | | delta | | | | | | | agent | | | | | | | ) | | | | | | | is | | | | | | | carri | | | | | | | ed | | | | | | | withi | | | | | | | n | | | | | | | the | | | | | | | hepat | | | | | | | itis | | | | | | | B | | | | | | | parti | | | | | | | cle | | | | | | | and | | | | | | | as | | | | | | | such | | | | | | | is an | | | | | | | incom | | | | | | | plete | | | | | | | virus | | | | | | |. | | | | | | | It | | | | | | | can | | | | | | | only | | | | | | | repli | | | | | | | cate | | | | | | | in | | | | | | | the | | | | | | | prese | | | | | | | nce | | | | | | | of | | | | | | | HBsAg | | | | | | | | | | | | | | - All | | | | | | | clini | | | | | | | cal | | | | | | | medic | | | | | | | al | | | | | | | and | | | | | | | denta | | | | | | | l | | | | | | | stude | | | | | | | nts | | | | | | | shoul | | | | | | | d | | | | | | | be | | | | | | | immun | | | | | | | ized | | | | | | | again | | | | | | | st | | | | | | | hepat | | | | | | | itis | | | | | | | B | | | | | | | | | | | | | | - Anti- | | | | | | | HCV | | | | | | | IgG | | | | | | | is | | | | | | | not | | | | | | | usual | | | | | | | ly | | | | | | | detec | | | | | | | table | | | | | | | until | | | | | | | 3 | | | | | | | month | | | | | | | s | | | | | | | after | | | | | | | the | | | | | | | acute | | | | | | | infec | | | | | | | tion | | | | | | +-----------+-----------+-----------+-----------+-----------+-----------+ +-----------------------------------------------------------------------+ | When treating dental patients, providing that the platelet count and | | clotting times are normal, and cross-infection control measures are | | employed there is no reason why these patients when well should not | | be treated in dental practice | +=======================================================================+ | - **High risk groups for hepatitis B carriage**\ | | Patients who have received unscreened blood products\ | | People involved with long-stay institutions\ | | Occupations leading to exposure to human blood (particularly | | surgeons)\ | | Hemodialysis for end-stage renal disease\ | | Unscrupulous tattooing/body piercing activity\ | | Travel to areas with high infection rates\ | | Contact with someone who has had a chronic hepatitis B | | infection | +-----------------------------------------------------------------------+ **Serological markers of hepatitis B** **Acute HBV** **Chronic HBV** **Cleared HBV** **Vaccination** --------------- --------------- ----------------- ----------------- ----------------- **HBcAb IgM** **+** **-** **-** **-** **HBcAb IgG** **+** **+** **+** **-** **HBsAg** **+** **+** **-** **-** **Anti-HBs** **-** **-** **+** **+** **HBeAg** **+** **+/-** **-** **-** **Anti-HBe** **-** **+/-** **+/-** **-** **HBV DNA** Low/high Low/high **-** **-** ***Chronic hepatitis***\ Chronic hepatitis is defined as hepatitis persisting for longer than 6 months ---------------------------------------------------------------------------------------- Potential causes of chronic hepatitis\ Alcohol excess\ Hepatitis B or C infection\ Autoimmune disease\ As a complication of infl ammatory bowel disease\ Wilson's disease -- toxic accumulation of copper in liver and brain. Inherited.\ Alpha1 antitrypsin defi ciency -- in adults, associated with hepatocellular cancer.\ Drug-induced liver disease, e.g. aspirin, halothane, paracetamol ---------------------------------------------------------------------------------------- ***Clinical features of liver cell failure*** +-----------------------------------------------------------------------+ | Jaundice | | | | Fluid retention: Ascites, oedema | | | | Hepatic encephalopathy | | | | A bleeding tendency | | | | Clinical results of the altered metabolism of drugs | | | | Diabetes | | | | Endocrine disorders | +-----------------------------------------------------------------------+ **Other Viruses Related to Dentistry** +-------------+-------------+-------------+-------------+-------------+ | **Virus** | **I/P** | **Clinical | **Diagnosis | **Treatment | | | | features** | ** | ** | +=============+=============+=============+=============+=============+ | Herpes | 2-12 day | -Initially | -A swab | -Once | | simplex | | infect | from fresh | acquired, | | virus (HSV) | | oro/pharyng | vesicular | HSV | | | | eal | lesion | infection | | | | mucosa and | | is lifelong | | | | is usually | -Detection | | | | | asymptomati | of HSV by | -Acyclovir | | | | c | either | can be | | | | | virus | effective | | | | -fever, | isolation | | | | | sore | in cell | **-** In | | | | throat, | culture | herpes | | | | ulcerative | (approximat | labialis, | | | | and | ely | topical | | | | vesicular | 1--4 days), | administrat | | | | lesions, | IF (same | ion | | | | gingivostom | day) or PCR | of 5% | | | | atitis, | (next day). | aciclovir\ | | | | localized | | cream | | | | lymphadenop | -Virus | significant | | | | athy | culture\ | ly | | | | and malaise | and PCR are | reduces | | | | can occur | the most | pain and | | | | | sensitive | lesion | | | | -Occasional | techniques | duration | | | | ly | | | | | | severe\ | | -If | | | | mucous | | recurrence | | | | membrane | | is very | | | | disease, | | frequent or | | | | Stevens--Jo | | severe, | | | | hnson | | then | | | | syndrome. | | long-term | | | | | | oral | | | | -latent | | prophylaxis | | | | infection | | is | | | | in the | | recommended | | | | trigeminal | |. | | | | ganglion | | | | | | | | | | | | -A variety | | | | | | of factors | | | | | | can lead\ | | | | | | to | | | | | | reactivatio | | | | | | n | | | | | | of HSV, | | | | | | including | | | | | | stress, UV | | | | | | light and | | | | | | steroid | | | | | | therapy. | | | +-------------+-------------+-------------+-------------+-------------+ | Varicella | 10 to 23 | **-**Very | -IF | -Aciclovir | | zoster | days | contagious | | | | virus (VZV) | | virus | -PCR | -Famciclovi | | | | | | r | | | | -Transmissi | | | | | | on | | | | | | occurs via | | | | | | the | | | | | | airborne | | | | | | route | | | | | | | | | | | | \- Primary | | | | | | infection: | | | | | | characteris | | | | | | tic | | | | | | vesicular | | | | | | rash of | | | | | | chickenpox | | | | | | occurs, may | | | | | | appear on | | | | | | oral | | | | | | mucosa. | | | | | | | | | | | | -latent | | | | | | infection | | | | | | in | | | | | | posterior | | | | | | root | | | | | | ganglia and | | | | | | is life- | | | | | | long. | | | | | | | | | | | | -Zoster is | | | | | | a | | | | | | reactivatio | | | | | | n | | | | | | of VZV, may | | | | | | occur after | | | | | | the rash | | | | | | has healed. | | | +-------------+-------------+-------------+-------------+-------------+ | Cytomegalov | 4 and 8 | **-**Primar | -PCR. for a | Antiviral | | irus | weeks | y | urine or | therapy | | (CMV) | | infection | blood | with either | | | | is | sample. | ganciclovir | | | | predominant | | or | | | | ly | \- CMV IgM | foscarnet | | | | asymptomati | antibodies | may be | | | | c. | in serum | required in | | | | | denotes\ | immunocompr | | | | \- | recent or | omised\ | | | | Infectious | current | patients, | | | | mononucleos | infection. | although | | | | is | | the drugs | | | | (glandular | | are toxic; | | | | fever) | | myelosuppre | | | | syndrome\ | | ssive\ | | | | can occur | | and | | | | | | nephrotoxic | | | | -Congenital | | , | | | | infections | | respectivel | | | | occur in | | y. | | | | approximate | | | | | | ly | | | | | | 1% of all | | | | | | live births | | | | | | transmitted | | | | | | by infected | | | | | | genital | | | | | | secretions | | | | | | or breast | | | | | | milk. | | | | | | | | | | | | -CMV may | | | | | | also cause | | | | | | Guillain--B | | | | | | arré | | | | | | syndrome, | | | | | | an acute | | | | | | flaccid | | | | | | paralysis. | | | +-------------+-------------+-------------+-------------+-------------+ | Epstein--Ba | 4--6 weeks | \- The most | **-** EBV | \- | | rr | | well-known | IgM, IgG | Antiviral | | virus (EBV) | | clinical | antibody | therapy is | | | | presentatio | | not usually | | | | n | -Blood | warranted | | | | is the | film: | in | | | | infectious | atypical | immunocompe | | | | mononucleos | lymphocytos | tent | | | | is | is | patients. | | | | syndrome | | \-- Chronic | | | | | | active EBV | | | | -This | | infection | | | | presents | | has been | | | | with | | treated | | | | malaise, | | with | | | | low fever, | | aciclovir | | | | proceeding | | and | | | | to | | steroids | | | | tonsillitis | | | | | | and/or | | | | | | pharyngitis | | | | | | , | | | | | | cervical | | | | | | lymph node | | | | | | enlargement | | | | | | or | | | | | | tenderness\ | | | | | | -Latent | | | | | | infection | | | | | | of B | | | | | | lymphocytes | | | | | | is | | | | | | lifelong. | | | | | | | | | | | | -EBV is | | | | | | thought to | | | | | | have a role | | | | | | in the | | | | | | pathogenesi | | | | | | s | | | | | | of | | | | | | | | | | | | classic | | | | | | Hodgkin's | | | | | | disease, | | | | | | Nasopharyng | | | | | | eal | | | | | | carcinoma | | | | | | and | | | | | | Burkitt's | | | | | | lymphoma | | | | | | which is | | | | | | the most | | | | | | common | | | | | | childhood | | | | | | malignancy | | | | | | in | | | | | | equatorial | | | | | | Africa, | | | | | | mainly | | | | | | presenting | | | | | | as a Jaw | | | | | | tumour. | | | +-------------+-------------+-------------+-------------+-------------+ | Enterovirus | Variable | -These | -Diagnosis | Supportive | | es | | include | is usually | treatment | | | | polioviruse | clinical. | | | | | s, | -PCR or\ | | | | | coxsackie | virus | | | | | viruses, | isolation | | | | | echo | | | | | | viruses. | | | | | | | | | | | | **-** | | | | | | Transmissio | | | | | | n | | | | | | occurs via | | | | | | direct | | | | | | contact | | | | | | with nose | | | | | | and throat | | | | | | discharges | | | | | | and by | | | | | | aerosol | | | | | | spread. | | | | | | | | | | | | \- | | | | | | Enterovirus | | | | | | es | | | | | | cause a | | | | | | wide | | | | | | variety of | | | | | | diseases; | | | | | | myocarditis | | | | | | , | | | | | | pericarditi | | | | | | s, | | | | | | aseptic | | | | | | meningitis | | | | | | and | | | | | | respiratory | | | | | | infections. | | | | | | | | | | | | \- In | | | | | | dental | | | | | | practice, | | | | | | the two | | | | | | most | | | | | | commonly | | | | | | encountered | | | | | | enteroviral | | | | | | diseases | | | | | | are: | | | | | | | | | | | | 1.Vesicular | | | | | | pharyngitis | | | | | | | | | | | | ***(Herpang | | | | | | ina):*** | | | | | | an acute | | | | | | self-limiti | | | | | | ng | | | | | | disease | | | | | | caused by | | | | | | Coxsackie | | | | | | viruses, | | | | | | characteris | | | | | | ed | | | | | | by fever, | | | | | | sore throat | | | | | | and small | | | | | | (1--2 mm) | | | | | | discrete, | | | | | | papulovesic | | | | | | ular | | | | | | pharyngeal | | | | | | lesions, | | | | | | which | | | | | | progress to | | | | | | larger | | | | | | ulcers. | | | | | | | | | | | | 2\. Hand, | | | | | | foot and | | | | | | mouth | | | | | | disease. | | | | | | | | | | | | Hand, foot | | | | | | and mouth | | | | | | disease is | | | | | | a vesicular | | | | | | stomatitis | | | | | | with skin | | | | | | rash. The | | | | | | oral | | | | | | lesions are | | | | | | more | | | | | | diffuse | | | | | | compared | | | | | | with | | | | | | herpangina | | | | | | | | | | | | -Occasional | | | | | | ly | | | | | | palmar and | | | | | | plantar | | | | | | lesions | | | | | | appear, | | | | | | especially | | | | | | in young | | | | | | children. | | | +-------------+-------------+-------------+-------------+-------------+ | Mumps | 12--25 days | -Transmissi | -Diagnosis | **-Prophyla | | | | on | is | xis:** | | | | occurs via\ | principally | Measles, | | | | droplet | clinical | mumps, | | | | spread and | | rubella | | | | by direct | -PCR | (MMR) | | | | contact | | vaccine | | | | with the | -Isolation | | | | | saliva of\ | in cell | **-Treatmen | | | | an infected | culture | t:** | | | | person. | | | | | | | -Mumps IgM | Uncomplicat | | | | -Enlargemen | antibody | ed | | | | t | | mumps is | | | | of one | | treated | | | | parotid | | supportivel | | | | gland | | y | | | | followed | | using | | | | 1--5 days | | analgesics, | | | | later by | | antipyretic | | | | enlargement | | s, | | | | of the | | rest and | | | | contralater | | hydration | | | | al | | | | | | gland. | | | | | | | | | | | | \- There is | | | | | | a prodrome | | | | | | of 1--2 | | | | | | days of | | | | | | malaise, a, | | | | | | headache | | | | | | and low | | | | | | grade- | | | | | | fever. | | | | | | | | | | | | -A variety | | | | | | of | | | | | | complicatio | | | | | | ns | | | | | | may occur; | | | | | | Orchitis, | | | | | | oophoritis. | | | | | | Sterility | | | | | | occurs only | | | | | | very | | | | | | rarely.\ | | | | | | Aseptic | | | | | | meningitis | | | | | | occurs | | | | | | frequently. | | | +-------------+-------------+-------------+-------------+-------------+ | Adenovirus | | -Transmissi | -Throat | -In | | | | on | swab | immunocompe | | | | occurs via | examined | tent | | | | direct | for the | patients, | | | | contact, | presence of | treatment | | | | small | adenovirus\ | is purely | | | | droplet | either by | supportive. | | | | aerosols | PCR or, | | | | | and the | less | -Infection | | | | faecal--ora | commonly, | in | | | | l | by virus | pediatric | | | | route.\ | isolation | bone marrow | | | | -Clinical | in cell | transplant | | | | manifestati | culture. | patients | | | | ons | | may require | | | | depend on | | antiviral | | | | the host | | therapy | | | | and | | | | | | adenovirus | | | | | | serotype | | | | | | including | | | | | | acute | | | | | | respiratory | | | | | | infection | | | | | | of both the | | | | | | upper and | | | | | | lower | | | | | | respiratory | | | | | | tract, | | | | | | tonsillitis | | | | | | and | | | | | | pharyngocon | | | | | | junctival | | | | | | fever | | | | | | | | | | | | -In | | | | | | severely | | | | | | immunocompr | | | | | | omised\ | | | | | | children | | | | | | (e.g. | | | | | | post-bone | | | | | | marrow | | | | | | transplanta | | | | | | tion), | | | | | | disseminate | | | | | | d | | | | | | adenovirus | | | | | | infection | | | | | | can occur | | | | | | and may be | | | | | | life | | | | | | threatening | | | | | |. | | | +-------------+-------------+-------------+-------------+-------------+ **Infection with** **immunodeficiency virus** +-----------------------------------------------------------------------+ | - The virus is now known to cause AIDS | | | | - Inoculation can occur either directly into the bloodstream | | (intravenous drug use with needle sharing, a needlestick injury | | or receipt of HIV-contaminated blood products) or by exposure of | | an open wound or mucous membranes to HIV-contaminated body | | fluids. Inoculation may also occur by perinatal transmission from | | infected mother to infant or sexual transmission. | | | | - The risk of transmission of HIV to healthcare workers is | | increased when the device causing the injury is visibly | | contaminated with blood, when the device has been used for | | insertion into a vein or artery, when the device caused a deep | | injury or when the source patient died within 2 months after the | | exposure. | | | | - Circulating CD4 lymphocytes (T helper cells) and macrophages are | | the main targets. | | | | - During the period of primary HIV infection (or acute | | seroconversion illness), the patient often experiences a few days | | of clinical symptoms suggestive of a viral illness. | | | | - The majority of patients become asymptomatic for a period that | | ranges from weeks to years and are identified by screening of | | serum for HIV antibody. | +-----------------------------------------------------------------------+ +-----------------------------------------------------------------------+ | Clinical Manifestations | | | | HIV infection may present in any of the following ways as: | | | | - An acute viral syndrome often resembling glandular fever | | | | - An asymptomatic state characterised only by laboratory evidence | | of HIV infection | | | | - A lymphadenopathy syndrome termed 'persistent generalised | | lymphadenopathy' (PGL), as chronic constitutional symptoms, often | | systemic and non-specific (weight loss, fever, night sweats) | | | | - A chronic diarrhea illness | | | | - A syndrome resulting from opportunistic infection or malignancy | | | | - Any combination of these. | | | | - The two main clinical manifestations of AIDS are tumours | | (Kaposi's sarcoma (KS) is the most common) and a series of | | opportunistic infections; *Pneumocystis carinii (jiroveci)* | | pneumonia | | | | - The best laboratory parameters that have been shown to correlate | | with disease progression are CD4 lymphocyte count and HIV viral | | load. | +-----------------------------------------------------------------------+ +-----------------------------------------------------------------------+ | **Oral/head and neck manifestations of HIV disease** | | | | Early recognition, diagnosis and treatment of HIV-associated oral | | lesions may reduce morbidity. These lesions may be an early | | diagnostic indicator of immunodeficiency and is a predictor of the | | progression of HIV disease. | | | | - Fungal infections\ | | Candidiasis\ | | Erythematous candidiasis\ | | Angular cheilitis\ | | Hyperplastic candidiasis. | | | | - Histoplasmosis | | | | - *Cryptococcus neoformans* | | | | - Oral hairy leukoplakia | | | | - Bacterial lesions | | | | - Kaposi's sarcoma | | | | - Oral ulceration | | | | - Lymphoma | | | | - Idiopathic thrombocytopaenic purpura | | | | - Salivary gland disorders | +-----------------------------------------------------------------------+ +-----------------------------------------------------------------------+ | Candidiasis | | | | Candidiasis is a common finding in HIV infected people and reflects | | falling CD4+ T 'cell count in the middle and late stages of HIV | | disease. Oral candidiasis is mostly associated with *[Candida | | albicans]*, although other species, such as *C. glabrata* | | and *C. tropicalis*, are frequently part of the normal oral flora. | | | | **[Risk Factors]** | | | | Infancy, old age, antibiotic therapy, steroid and other | | immunosuppressive drugs, xerostomia, anaemia, endocrine disorders, | | and primary and acquired immunodeficiency.\ | | ***[Clinical features]*** | | | | Variable Presentations. The most common presentations include | | pseudomembranous (creamy white, removable plaques on the oral mucosa, | | also termed as thrush) and erythematous candidiasis (flat, red | | patches of varying size. It commonly occurs on the palate and the | | dorsal surface of the tongue), which are equally predictive of the | | development of AIDS, and angular cheilitis (redness, ulceration and | | fissuring, either unilaterally or bilaterally at the corners of the | | mouth). | | | | Associated symptoms include a burning mouth and changes in taste.\ | | ***Hyperplastic candidiasis***. This type is unusual in persons with | | HIV infection. The lesions appear white and hyperplastic, cannot be | | removed by scraping, may be confused with hairy leukoplakia. | | | | [***Differential diagnosis***\ | | ]Erythematous candidiasis should be differentiated from | | other red lesions, such as KS or erythroplakia. Pseudomembranous | | candidiasis should be differentiated from the non-removable white | | lesions of hairy leukoplakia while the creamy white plaques of | | pseudomembranous candidiasis are removable. | | | | ***[Diagnosis]***\ | | *The* clinical appearance + detection of organisms on smears or | | growth from swabs on specific media, such as Sabouraud's agar.\ | | ***[Treatment]***\ | | Oral candidiasis may be treated either topically or systemically for | | 7 days.\ | | Response to treatment is good but relapses are common because of the | | underlying immunodeficiency.\ | | ***-Topical treatment***\ | | Topical medications require that the patient hold medications in the | | mouth for 20--30 min.\ | | Clotrimazole is an effective topical treatment | | | | Topical creams and ointments containing nystatin, miconazole, | | ketoconazole or clotrimazole may be useful in treating angular | | cheilitis.\ | | ***-Systemic treatment***\ | | Easy to administrate with rapid recovery rates. | | | | Fluconazole (Diflucan) is effective in treating candidiasis (50 mg | | tablet taken once daily for 2 weeks). Itraconazole and amphotericin | | may have to be used. | +=======================================================================+ | Histoplasmosis\ | | Ulcerative leisons that can affect any mucosal surface. Diagnosis | | requires biopsy | | | | *Cryptococcus neoformans*\ | | *Cryptococcus neoformans* causing an ulcerated mass in the hard | | palate has been described in the literature. Diagnosis requires | | biopsy | | | | Human papillomavirus lesions\ | | Oral warts, papillomas and skin warts are associated with the human | | papillomavirus (HPV).\ | | Lesions caused by HPV are common on the skin and mucous membranes of | | persons with HIV disease.\ | | *[Clinical features]*\ | | Oral leisons may appear as solitary or multiple nodules, | | smooth-surfaced raised masses or small papilliferous or | | cauliflower-like projections.\ | | *[Diagnosis]*\ | | A biopsy is necessary for histological diagnosis. | | | | *[Prognosis]*\ | | There is no known association between oral HPV lesions and more rapid | | progression of HIV disease,\ | | *[Treatment]*\ | | Oral HPV lesions can be removed surgically. | | | | Carbon dioxide laser surgery can remove multiple flat warts, but | | relapses are common | +-----------------------------------------------------------------------+ +-----------------------------------------------------------------------+ | **Hairy leukoplakia and EBV**\ | | - Oral hairy leukoplakia (OHL), which presents as a non-movable, | | corrugated or 'hairy' white lesion on the lateral margins of the | | tongue or buccal mucosa, occurs in all risk groups for HIV and | | becomes more common as the CD4+ T cell count falls. OHL correlates | | with a statistical risk for more rapid progression of HIV disease.\ | | - It should be differentiated from other white lesions, such as oral | | candidiasis, lichen planus, idiopathic leukoplakia, white sponge | | naevus, dysplasia and squamous cell carcinoma. | | | | **-***[Diagnosis]*\ | | OHL can be diagnosed by incisional biopsy. The typical microscopic | | appearance of OHL includes acanthosis with the formation of ridges | | and keratin projections. Definitive diagnosis of OHL requires | | demonstration of EBV in biopsy.\ | | *[Treatment]*\ | | HL usually is asymptomatic and does not require treatment. | | | | OHL has disappeared in patients receiving high dose acyclovir for | | herpes zoster, presumably because of the anti-EBV activity of | | acyclovir. | +-----------------------------------------------------------------------+ --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- **Bacterial lesions\ ***Periodontal disease*\ Periodontal disease is a fairly common problem in both asymptomatic and symptomatic HIV-infected patients. It can take the form of a rapid and severe condition called necrotising ulcerative periodontitis.\ *Mycobacterium avium intracellulare*\ *Mycobacterium avium intracellulare* presents as palatal and gingival granulomatous masses in the oral cavity. Biopsy should demonstrate the presence of acid-fast bacilli (AFB) and subsequent culture\ should grow *Mycobacterium avium intracellulare*. --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- +-----------------------------------------------------------------------+ | **Neoplastic lesions**\ | | *Kaposi's sarcoma (KS)*\ | | - KS may occur either intraorally alone or associated with skin and | | disseminated lesions principally occuring in men. | | | | \- KS can appear as a red, blue or purplish lesion. It may be flat or | | raised, solitary or multiple.\ | | - The most common oral site is the hard palate, but lesions may occur | | on any part of the oral mucosa. | | | | \- Oral KS lesions may enlarge, ulcerate and become infected. Good | | oral hygiene is essential to minimize these complications.\ | | ***[Differential diagnosis]***\ | | - KS must be distinguished from vascular lesions such as haematomas, | | haemangiomas, other vascular tumours, pyogenic granulomas and | | pigmented lesions such as oral melanotic macules. | | | | \- Diagnosis is made by histological examination. | | | | ***[Treatment]***\ | | - Treatment is determined based on the number, size and location of | | the oral KS lesions. | | | | -It is important to perform thorough dental prophylaxis before | | initiating therapy for KS lesions\ | | involving the gingiva. | | | | \- Oral KS can be tre0rcated surgically or with localized | | intralesional chemotherapy. | | | | \- Surgical removal is suitable for small, well-circumscribed lesions | | such as gingival or tongue\ | | lesions. It can be performed under local anesthesia with a blade or | | with the carbon dioxide laser. | | | | \- Intralesional vinblastine is useful for treating small lesions, | | particularly on the palate or gingiva. | | | | \- Radiation therapy may be indicated for large, multiple lesions. | | | | -Local application of sclerosing agents may reduce the size of oral | | lesions. | +=======================================================================+ | | +-----------------------------------------------------------------------+ +-----------------------------------------------------------------------+ | *Lymphoma*\ | | [***Clinical features***\ | | ]- Diffuse, undifferentiated non-Hodgkin's lymphoma (NHL) | | is a frequent HIV-associated malignancy. - Lymphoma can occur | | anywhere in the oral cavity, and there may be soft tissue involvement | | with or without involvement of underlying bone. | | | | The lesion may present as firm, painless swelling that may be | | ulcerated. | | | | ***[Differential diagnosis]***\ | | Oral NHL may be confused with major aphthous ulcers.\ | | Diagnosis of NHL must be made by histological examination of biopsy | | specimens.. | +-----------------------------------------------------------------------+ +-----------------------------------------------------------------------+ | Other oral lesions associated with HIV disease\ | | *Oral ulceration*\ | | Oral ulcers resembling recurrent aphthous ulcers (RAUs) in | | HIV-infected persons are frequent. The cause of these ulcers is | | unknown probably, stress and unidentified infectious agents. | | | | ***[Diagnosis]***\ | | - Herpetiform RAUs may resemble the lesions of coxsackie virus | | infection. | | | | -RAUs may require biopsy to exclude malignancy, such as lymphoma, or | | opportunistic infection, such as histoplasmosis. | | | | \- The ulcers usually occur on non-keratinised mucosa; this | | characteristic differentiates\ | | them from those caused by herpes simplex.\ | | ***[Treatment]***\ | | The RAU-type ulcers usually respond well to topical steroids such as | | fluocinonide (0.05%) ointment mixed with equal parts Orabase® applied | | six times daily, or clobetasol (0.05%) ointment mixed with equal | | parts Orabase® applied three times per day. | | | | -Dexamethasone elixir (0.5 mg/5 ml) used as a mouth rinse for | | multiple ulcers. | | | | \- For HIV-infected persons with oral and gastrointestinal RAUs, | | systemic steroid therapy (prednisone 40--60 mg/day for 7--10 days) | | has been reported as helpful. | | | | \- The risk of steroids should be considered in this population | +-----------------------------------------------------------------------+ +-----------------------------------------------------------------------+ | *Idiopathic thrombocytopaenic purpura*\ | | -Reports have described idiopathic thrombocytopaenic purpura (ITP) in | | HIV-infected patients. | | | | \- Oral lesions may be the first manifestation of this condition.\ | | -Petechiae, ecchymoses and haematomas can occur anywhere on the oral | | mucosa. | | | | -Spontaneous bleeding from the gingiva can occur. | | | | ***[-]*** The clinician must distinguish ITP from other | | vascular lesions and KS. | | | | \- Because of potential bleeding risk, blood and platelet counts | | should be done before performing other diagnostic procedures. | +-----------------------------------------------------------------------+ +-----------------------------------------------------------------------+ | *Salivary gland disease and xerostomia*\ | | -Salivary gland enlargement is described in patients with HIV usually | | involving the parotid gland. | | | | -The enlarged salivary glands are soft but not fluctuant, may be due | | to lymphoepithelial cysts. | | | | ***Management***\ | | - For individuals with xerostomia: salivary substitutes and salivary | | stimulants such as sugarless gum or sugarless sweets are helpful. | | | | \- Fluoride rinses to prevent against caries; should be used daily, | | and visits to the dentist should\ | | occur 2--3 times per year. | | | | -Removal of the enlarged parotid glands is rarely recommended. | +-----------------------------------------------------------------------+

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