Page 166 - AIDSBK23C

Page 166

Lesions with epithelial hyperplasia in small, flat papules on the lower lip are associated with
HPV genotypes 13 and 32. Microscopically, both acanthosis and koilocytosis are present.
Treatment of larger lesions is difficult, with surgical excision and laser ablation being applied
with some success. Treatment is difficult because of the extent of disease and the likelihood for
recurrences.[667,704]
Herpetic gingivostomatitis can be accompanied by systemic flu-like symptoms along
with painful gingival inflammation and multiple oral ulcers. Most commonly, this is manifested
as herpes labialis which is characterized by a prodrome of itching and burning followed by the
development of a crop of vesicles that crusts and then heals spontaneously in a week to 10 days.
Herpes labialis typically occurs along the vermillion border of the lips. With HIV infection,
herpes viral infections can be more extensive and severe and difficult to treat.[705]
Human papillomavirus (HPV) may cause the appearance of exophytic, papillary oral
lesions. With HIV infection, these lesions are often multiple and difficult to treat because of a
high rate of recurrence. Excision and cauterization or topical podophyllin have been used as
therapies.[705]
Bacillary angiomatosis, which produces proliferative vascular lesions, can rarely involve
the oral cavity. The lesions can resemble oral Kaposi’s sarcoma. Grossly, they are most often
bluish to purplish macules, but papules and nodules may also be seen, and there can be ulceration
and exudation. Histologically, lesions of bacillary angiomatosis may have similarities to
pyogenic granuloma and epithelioid hemangioma. A characteristic feature is vascular
proliferation with epithelioid-like endothelial cells that project into vessel lumens to give a
tombstone-like appearance.[706]
Noma, or cancrum oris, can be seen in association with HIV infection. Noma is an
opportunistic infection by anaerobic bacteria, staphylococci, streptococci, coliforms, and
Borrelia organisms. It often begins as a necrotizing gingivitis and progresses rapidly to orofacial
gangrene that requires antibiotic therapy and facial reconstruction. Though it has a worldwide
distribution, it is most common in sub-Saharan Africa, with a peak age incidence of 1-4 years.
Noma is most likely to occur in persons who are immunocompromised and who live in areas
with poverty, malnutrition, and poor environmental sanitation.[707]
Patients receiving antiretroviral therapy (ART) may develop a variety of exfoliative
cheilitis characterized by exfoliation, crater formation, fissuring, erosions and/or the formation of
papules, vesicles and blisters associated with erythema and edema. Microscopically, the lesions
consist of ulcerations with adjacent hyperkeratosis and suprabasal vacuolization accompanied by
a dense lymphocyte infiltrate.[708]
Lesions involving the tongue, which is easily accessible for examination, are common in
advanced HIV infection. Hairy leukoplakia and candidiasis are present in over a third of
patients, and can occur concomitantly. Non-specific glossitis can appear in a third of patients.
Disseminated infections, including mycobacteriosis, histoplasmosis, cryptococcosis, and
cytomegalovirus can involve the tongue.[709]
Tooth extraction is the dental treatment most commonly carried out in HIV infected
patients. The most frequent post extraction complications are delay in wound healing, alveolitis,
and wound infection. These complications are uncommon and not too severe.[710]

ANORECTAL SQUAMOUS INTRAEPITHELIAL LESIONS (ASIL).— This condition
is also known as anal intraepithelial neoplasia (AIN). Persons with HIV infection may develop
ASIL that can progress to high-grade squamous intraepithelial lesions (HSIL) that can progress