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usually appear prior to the onset of clinical AIDS. Chronic gingivitis may present with band-like
or punctate erythema, though biopsy reveals only increased vascularity without inflammation,
and most are associated with Candida infection. Gingivostomatitis with Herpes simplex virus
infection is typically severe with multiple vesicles that can rupture, coalesce, and leave painful
irregular ulcers. The HIV-associated periodontitis may or may not have necrosis, but produces
severe pain in the jaw.[473,693,694]
Aphthous oral ulcers, though seen in non-immunocompromised persons, are more likely
to be severe and prolonged in patients with HIV infection. Aphthous oral ulcers can appear as a
complication of saquinavir therapy.[261,264] Recurrent aphthous stomatitis is more likely to
occur with declining immunologic status and be associated with nutritional deficiencies.[695]
Aphthous ulcers most commonly appear as painful lesions in the floor of the mouth, tonsillar
fossa, and epiglottis, particularly in patients with low CD4 lymphocyte counts, that lead to
weight loss from decreased oral intake. They may also occur in esophagus and colon.
Histologically, these ulcers demonstrate submucosal lymphocytic infiltration with overlying
acute inflammation, including eosinophils. Special stains are needed to exclude possible
infectious agents.[667] Oral analgesics for minor lesions and intralesional injection of
corticosteroids for major lesions may be helpful for pain relief, healing of the ulcers, and weight
gain.[696] The drug thalidomide has shown effectiveness in the treatment of oral aphthous
ulcers.[697] Drug therapy with foscarnet, interferon, and ddC may also be complicated by oral
ulceration.[698]
Neoplasms associated with HIV infection that involve the oral cavity are not common.
Oral Kaposi's sarcoma (KS) usually appears in two patterns. There can be small, well-delineated
macular lesions that histologically have inconspicuous patches of spindle cells containing ill-
defined vascular spaces and scattered lymphocytes. More often, KS appears as larger,
infiltrative, nodular lesions that have spindle cells lining vascular slits and bizarre-shaped
vessels. Both types of lesions have extravasated red blood cells, but hyaline globules and
hemosiderin are present only half the time.[699] A variant of a diffuse large cell non-Hodgkin
lymphoma known as plasmablastic lymphoma has been reported in the oral cavity.[578]
Oral hairy leukoplakia, (OHL) also known as oral condyloma planum, produces a white
lesion usually found on the lateral border of the tongue that is slightly raised, poorly demarcated
and variable in size. The mucosal surface is grossly corrugated or "hairy." Unlike the exudate of
oral thrush, the lesion of OHL cannot be scraped off. Epstein-Barr virus (EBV) has been
identified in epithelial cells with OHL. Microscopically, the squamous epithelium shows marked
acanthosis (which produces the grossly “hairy” appearance) with parakeratosis, koilocytosis, and
herpetic type intranuclear inclusions. Candidiasis is often present overlying the lesion.
However, fungal infections alone, or mechanical irritation, may produce gross and microscopic
appearances similar to OHL. OHL is not premalignant. The presence of OHL in an HIV-
infected person may presage development of AIDS.[700,701] The appearance of high grade T-
cell non-Hodgkin lymphomas has been reported in the oral cavity of patients with EBV infection
and OHL.[702] Though OHL is clinically apparent in only 2% of pediatric HIV-infected
patients, it can be detected cytologically in up to 17% of these patients.[703]
Oral condylomata can appear in several forms and may occur on any oral mucosal
surface and are associated with human papillomavirus infection (HPV). Oral HPV infection
occurs in approximately 1% of persons with HIV infection. Lesions that are flat, sessile, and
firm are associated with HPV genotypes 1, 2, and 7 similar to cutaneous warts. The spiked, soft,
or cauliflower-like lesions are associated with HPV genotypes 6 and 11 similar to genital warts.