Natural history of HIV-associated salivary gland disease

Prevalence of oral mucosal lesions in human immunodeficiency virus-infected children attending the Pediatric Infectious Diseases Clinic in Cape Town

Objective

Investigation of the prevalence of oral mucosal lesions in human immunodeficiency virus (HIV)‐infected children undergoing highly active antiretroviral therapy (HAART).

Materials and Methods

Cross‐sectional study of 66 HIV seropositive children, comprised of 28 (42.4%) females and 38 (57.6%) males (average age of 6 years). Study participants all required data regarding CD4+ T‐helper cell counts and the viral load. All participants underwent an orofacial clinical examination by calibrated clinicians. Associations between the presence of oral mucosal lesions, CD4+ cell counts, and viral load were analyzed using Poisson regression.

Results

The prevalence of oral manifestations was detected in 21 children (31.8%). Oral lesions were detected in 16 children with viral load copies <50 cells/mm³ and 22 children with CD4+ counts >500 cells/mm³. Predominant lesions identified included angular cheilitis (36.7%), candidiasis (13.3%) and atypical oral ulcers (13.3%). The presence of one lesion was the most prevalent represented by 19 children. Oral lesions in relation to the CD4+ counts >500 resulted in; 14 children with one oral lesion, 5 with two lesions and 3 with three oral mucosal lesions. The other half of this CD4+ count patient group presented with no oral mucosal lesions. Oral lesions in relation Viral load copies <50 resulted in; 9 children with one oral lesion, 3 with two oral mucosal lesions and 4 with three oral mucosal lesions. The other half of this Viral load patient group presented with no oral mucosal lesions. No significant correlations were established between the presence of oral mucosal lesions and low CD4+ counts (p = 0.715) nor with high viral load counts (p = 0.638).

Conclusion

HIV‐related oral mucosal lesions still presented in the participants despite management with HAART. Based on the results, CD4+ counts and viral load does not appear to be suitable markers of orofacial involvement in children.

Clinical analysis of 12 patients with primary lymphoepithelial carcinoma of the parotid gland

BACKGROUND AND PURPOSE

The WHO recently designated salivary gland lymphoepithelial carcinoma as a unique malignant tumor that most commonly occurs in the parotid gland. This is a rare cancer and there are few reports in the literature. Among 854 patients with parotid gland tumors who were admitted to our institution, we diagnosed 12 patients (1.41%) with parotid lymphoepithelial carcinoma.

METHODS

Retrospective analysis of 12 patients with parotid lymphoepithelial carcinoma diagnosed by the Department of Pathology, Xiangya Hospital of Central South University.

RESULTS

All 12 patients had unilateral parotid gland disease and 8 had cervical lymph node metastasis. Five patients received PCR testing for the Epstein-Barr virus and two were positive. All patients received surgical treatment, two received surgical resection alone, nine received surgery and postoperative radiotherapy and chemotherapy, and one received surgery and postoperative chemotherapy. The postoperative follow-up time ranged from 13 to 77 months. As of the last follow-up, eight patients were tumor-free, one patient was lost to follow-up, and three patients died. The main cause of death was local tumor recurrence and multiple metastases throughout the body.

CONCLUSION

Parotid lymphoepithelial carcinoma is a malignant neoplasm characterized by proliferation, invasion, and inclusion of poorly differentiated or undifferentiated carcinoma, and a high rate of metastasis to ipsilateral cervical lymph nodes. The comprehensive treatment method consists of radical resection combined with postoperative radiotherapy and chemotherapy. After this comprehensive treatment, the 1-year, 3-year, and 5-year overall survival rates of our patients were 100%, 78.8%, and 39.4%.

Radioiodine therapy induced sialadenitis versus chronic idiopathic sialadenitis-Presentation and outcomes

BACKGROUND

This study explores the unique characters of high dose radioactive iodine (RAI) induced chronic sialadenitis.

METHODS

A retrospective study of patients having received salivary endoscopy and followed in our outpatient clinic.

RESULTS

A total of 100 patients met the inclusion criteria, 75 were diagnosed with chronic idiopathic sialoadenitis and 25 with radio-iodine induced sialoadenitis (RIS). The main complaint in both groups was swelling of the parotid gland. Pain, dysphagia, and xerostomia were observed considerably more in the RIS group. During sialo-endoscopy, fibrosis of the Stensen's duct was more common in the RIS group (p = 0.003). RIS patients group generally managed better with interventional endoscopic treatment alone (80% vs. 46%).

CONCLUSION

RIS patients have distinct clinical characteristics. There may be a collateral muscular damage to the masticatory muscles. Fibrosis and parenchymal damage are major findings during sialendoscopy. Sialendoscopy is a safe and efficient treatment for RAI induced sialadenitis.

Rare Diseases of the Salivary Glands and of Facial Nerve

Salivary gland diseases are rare. In the European Union (EU) a disease is considered to be rare if not more than 5 of 10,000 people are affected by it. According to estimates in Germany are about 4 million people with a rare disease. In the EU are about 30 million people with rare diseases [1]. In the present work most of the described diseases of salivary glands and of the facial nerve fall in this category. They form a very heterogeneous group whose treatment takes place mainly in specialized centers. Still, it is essential for the otolaryngologist to identify and to diagnose these diseases in order to initiate the right therapeutic steps. The work is a compilation of innate andacquired rare salivary gland disorders and of rare facial nerve disorders. The etiologies of inflammatory diseases, autoimmune disorders and tumors are taken into account. For the individual topics, the current literature, if available, was evaluated and turned into summarized facts. In this context the development of new processes, diagnostics, imaging and therapy are considered. Genetic backgrounds of salivary gland tumors and the trends in the treatment of tumorous lesions of the facial nerve are picked up. Furthermore, also rare diseases of the salivary glands in childhood are described. Some of them can occur in adults as well, but differ in frequency and symptoms. Due to the rarity of these diseases, it is recommended to tread these in centers with special expertise for it. Finally, the difficulties of initiation of studies and the problems of establishing disease registries concerning salivary gland disorders are discussed. This is very relevant because these pathologies are comparatively seldom.

Salivary flow, amylase, and total protein in hospitalized patients with HIV infection / AIDS complications

BACKGROUND

Saliva is a complex secretion produced daily by the salivary glands. Saliva consists mainly of water, enzymes, ions and amino acids and performs several important functions in oral health.

OBJECTIVE

The aim of this study was to investigate the flow rate and concentrations of amylase and total proteins in the saliva of hospitalized patients due to AIDS complications.

METHODS

Ninety-three men and women (20-64 years of age) were divided into two groups (46 HIV-infected patients and 47 controls) and had salivary flow rate and levels of amylase enzyme and total proteins evaluated.

RESULT

The mean salivary flow rate was lower in individuals with HIV when compared to controls (P < 0.05). No significant difference between amylase enzyme levels and total proteins were observed in the saliva of patients with HIV infection when compared to controls.

CONCLUSION

Individuals with HIV / AIDS infection (in hospital treatment) suffer no interference in levels of amylase and total salivary proteins, but they have significantly reduced salivary flow.

Clinical implications of aberrant neurovascular structures coursing through the submandibular gland

Background

Variation within the submandibular triangle, including variant paths of facial neurovasculature, could increase risk of neurovascular derangement during submandibular gland (SMG) dysfunction, enlargement, interventions, or removal.

Methods

Frequency of anatomical variants enveloped within or piercing the SMG, including facial artery, vein, or branches of CN VII, were assessed in 70 cadaveric submandibular glands (39M/31F).

Results

Eighteen of 70 SMGs (25.7%) were pierced by at least one aberrant neurovasculature structure: Facial artery most frequently (n = 13), followed by facial vein (n = 2), inferior labial artery and vein (n = 1), and CN VII cervical branch (n = 1). This study demonstrated the high variability of neurovasculature within submandibular parenchyma. These aberrant neurovascular structures, especially facial artery, are in danger of compromise during surgical and other medical procedures on the SMG. To avoid potential neurovascular compromise, ultrasonographic or other imaging is recommended prior to procedures involving the SMG.

Human immunodeficiency virus and salivary gland pathology: an update

Salivary gland disease is a common manifestation of human immunodeficiency virus (HIV) infection, with a significant increase in prevalence over the last two decades. This review summarizes contemporary knowledge of non-neoplastic salivary gland disease in HIV infection. The aim is to update information on and bring attention to those lesions, which are almost exclusive to the salivary glands in the HIV setting. The associated conditions include xerostomia or salivary gland hypofunction; Sjögren syndrome-like illness; salivary gland enlargements, including benign lymphoepithelial cysts (cystic lymphoid hyperplasia); diffuse infiltrative CD8+ lymphocytosis syndrome; and mucous extravasation phenomena, especially ranula. Many of these conditions show considerable overlap, and thus, the term HIV-associated salivary gland disease is used to designate HIV infection with xerostomia or salivary gland hypofunction, enlargement of one or more of the major salivary glands, or both. These manifestations may be related to HIV infection, and therefore, prompt recognition is invaluable in the diagnosis and treatment of both the salivary gland disease and HIV infection.

Nonsurgical management of human immunodeficiency virus-associated parotid cysts: A systematic review and meta-analysis

BACKGROUND

The purpose of this clinical review was to analyze the effectiveness of nonsurgical management options for human immunodeficiency virus (HIV)-associated parotid cysts.

METHODS

We conducted systematic and meta-analysis reviews. Primary outcomes were complete or partial responses.

RESULTS

Systematic review identified 12 relevant studies. The average rates of complete response for antiretroviral therapy (ART), sclerotherapy, and fine-needle aspiration (FNA) were 52.8%, 55.5%, and 33.3%, respectively. Three radiotherapy studies, totaling 104 patients, were included in a meta-analysis. Patients receiving high-dose therapy achieved complete and partial response rates of 65.8% (95% confidence interval [CI] 54.3%-76.2%) and 25.2% (95% CI 16.1%-36.3%), respectively. Patients receiving low-dose therapy achieved complete and partial response rates of 23.2% (95% CI 1.2%-60.9%) and 22.3% (95% CI 5.2%-87.8%), respectively. The rate of complete response was significantly greater for high-dose radiotherapy compared to low-dose (P < .001).

CONCLUSION

Among nonsurgical treatment modalities for HIV-associated parotid cysts, radiotherapy has the highest number of reported outcomes in the literature and our analysis suggests that higher dose radiotherapy has higher rates of achieving complete response.

Distinct BK polyomavirus non-coding control region (NCCR) variants in oral fluids of HIV- associated Salivary Gland Disease patients

HIV-associated Salivary Gland Disease (HIVSGD) is among the most common salivary gland-associated complications in HIV positive individuals and was associated with the small DNA tumorvirus BK polyomavirus (BKPyV). The BKPyV non-coding control region (NCCR) is the main determinant of viral replication and rearranges readily. This study analyzed the BKPyV NCCR architecture and viral loads of 35 immunosuppressed individuals. Throatwash samples from subjects diagnosed with HIVSGD and urine samples from transplant patients were BKPyV positive and yielded BKPyV NCCR sequences. 94.7% of the BKPyV HIVSGD NCCRs carried a rearranged OPQPQQS block arrangement, suggesting a distinct architecture among this sample set. BKPyV from HIV positive individuals without HIVSGD harbored NCCR block sequences that were distinct from OPQPQQS. Cloned HIVSGD BKPyV isolates displayed active promoters and efficient replication capability in human salivary gland cells. The unique HIVSGD NCCR architecture may represent a potentially significant oral-tropic BKPyV substrain.

A Pilot Study on the Treatment of Posterior Cheek Enlargement in HIV+ Patients With Botulinum Toxin A

BACKGROUND

Posterior cheek enlargement in human immunodeficiency virus (HIV)+ individuals can lead to significant cosmetic disfigurement. Both parotid gland and masseter muscle overlie the mandibular ramus, contributing to lower facial contour. However, posterior cheek enlargement has not been well characterized anatomically. There are also limited treatment options. Botulinum toxin is a highly efficacious minimally invasive option for improving the shape of the lower face.

OBJECTIVE

A pilot study was undertaken to better characterize posterior cheek enlargement in HIV+ patients and explore treatment with botulinum toxin A.

MATERIALS AND METHODS

Five HIV+ patients with posterior cheek enlargement were treated with botulinum toxin A. Clinical, photographic, and radiological evaluations allowed the precise calculation of any change in volumes resulting from botulinum toxin A.

RESULTS

All 5 patients had a good response with a mean decrease of 21.4% and 11.2% in the volumes of the masseter muscle and parotid gland, respectively. The effect was long lasting even at 6 months after injection and well tolerated.

CONCLUSION

Botulinum toxin A may be a less invasive treatment of posterior cheek enlargement in HIV+ patients, with advantages of a good result that is long lasting with good tolerability and minimal risk.

HIV-associated salivary gland disease--clinical or imaging diagnosis?

OBJECTIVES

This work aimed at studying the salivary gland disease (SGD) as it relates to associated factors, such as persistent generalised lymphadenopathy (PGL), lymphocytic interstitial pneumonia (LIP), clinical and immunological features of AIDS, and salivary flow rate and pH, as well as at exploring the relationship between the clinical diagnosis and the imaging diagnosis by ultrasound (US) examination of the parotid glands.

METHODS

Information regarding the observation of parotid gland enlargement, PGL, LIP, and clinical and immunological features of AIDS was gathered from medical records, and a saliva sample for unstimulated salivary flow rate and pH measurement was collected from 142 children aged 3 through 10 years treated at the Department of Infectious Diseases of Joana de Gusmão Children's Hospital, Florianópolis, SC, Brazil. High-resolution ultrasonography was performed in 58 children. Pearson's chi-square test and t-test were used to evaluate the association between the variables.

RESULTS

A significant association was found between SGD and LIP. Ultrasound revealed a 50% higher incidence of SGD that was not reported in the patients' records.

CONCLUSION

US examination proved to be essential for the correct diagnosis and monitoring of the progression of HIV/SGD.

Cystic lymphoid hyperplasia of the parotid gland as the initial manifestation of HIV infection

We report the case of a patient who presented with cystic lymphoid hyperplasia of the right parotid gland as the index diagnosis of HIV infection. Histological examination of the excised parotid gland revealed a solid-cystic lymphoepithelial lesion with a non-keratinous squamous epithelium, which grew into the lymphoid component via anastomosing cords and islands. These anastomosing cords and islands contained variably abundant B cells, several subepithelial multinucleated histiocytes, salivary ducts infiltrated by small lymphocytes, and a dense lymphoid infiltrate containing lymphoid follicles with enlarged, irregular germinal centres.

A bibliometric study of scientific research conducted on second-generation antipsychotic drugs in Singapore

INTRODUCTION

A bibliometric study was carried out to ascertain the volume and impact of scientific literature published on second-generation antipsychotic drugs (SGAs) in Singapore from 1997 to 2011.

METHODS

A search of the EMBASE and MEDLINE databases was performed to identify articles originating from Singapore that included the descriptors 'atypic* antipsychotic*', 'second-generation antipsychotic*', 'clozapine', 'risperidone', 'olanzapine', 'ziprasidone', 'quetiapine', 'sertindole', 'aripiprazole', 'paliperidone', 'amisulpride', 'zotepine', 'asenapine', 'iloperidone', 'lurasidone', 'perospirone' and 'blonanserin' in the article titles. Certain bibliometric indicators of production and dispersion (e.g. Price's Law on the increase of scientific literature, and Bradford's Law) were applied, and the participation index of various countries was calculated. The bibliometric data was also correlated with some social and health data from Singapore, such as the total per capita expenditure on health and gross domestic expenditure on research and development.

RESULTS

From 1997 to 2011, a total of 51 articles on SGAs in Singapore were published. Our results suggested non-fulfilment of Price's Law (r = 0.0648 after exponential adjustment vs. r = 0.2140 after linear adjustment). The most widely studied drugs were clozapine (21 articles), risperidone (16 articles) and olanzapine (8 articles). Division into Bradford zones yielded a nucleus occupied by the Journal of Clinical Psychopharmacology (6 articles) and the Singapore Medical Journal(4 articles). The analysed material was published in a total of 30 journals, with the majority from six journals. Four of these six journals have an impact factor greater than 2.

CONCLUSION

Publications on SGAs in Singapore are still too few to confirm an exponential growth of scientific literature.

Replication of oral BK virus in human salivary gland cells

BK polyomavirus (BKPyV) is the most common viral pathogen among allograft patients. Increasing evidence links BKPyV to the human oral compartment and to HIV-associated salivary gland disease (HIVSGD). To date, few studies have analyzed orally derived BKPyV. This study aimed to characterize BKPyV isolated from throat wash (TW) samples from HIVSGD patients. The replication potential of HIVSGD-derived clinical isolates HIVSGD-1 and HIVSGD-2, both containing the noncoding control region (NCCR) architecture OPQPQQS, were assessed and compared to urine-derived virus. The BKPyV isolates displayed significant variation in replication potential. Whole-genome alignment of the two isolates revealed three nucleotide differences that were analyzed for a potential effect on the viral life cycle. Analysis revealed a negligible difference in NCCR promoter activity despite sequence variation and emphasized the importance of functional T antigen (Tag) for efficient replication. HIVSGD-1 encoded full-length Tag, underwent productive infection in both human salivary gland cells and kidney cells, and expressed viral DNA and Tag protein. Additionally, HIVSGD-1 generated DNase-resistant particles and by far surpassed the replication potential of the kidney-derived isolate in HSG cells. HIVSGD-2 encoded a truncated form of Tag and replicated much less efficiently. Quantitation of infectious virus, via the fluorescent forming unit assay, suggested that HIVSGD BKPyV had preferential tropism for salivary gland cells over kidney cells. Similarly, the results suggested that kidney-derived virus had preferential tropism for kidney cells over salivary gland cells. Evidence of HIVSGD-derived BKPyV oral tropism and adept viral replication in human salivary gland cells corroborated the potential link between HIVSGD pathogenesis and BKPyV.

An Algorithm Approach to Diagnosing Bilateral Parotid Enlargement

Objective

This contemporary review aims to categorize the disease entities that cause bilateral parotid enlargement and to develop a question-based algorithm to improve diagnosis of bilateral parotid masses.

Data Sources

A PubMed search for bilateral and parotid showed 818 results. Of these, 68 relevant studies were reviewed to compile a list of disease processes that can cause bilateral parotid enlargement.

Review Methods

A total of 22 diseases entities were reviewed. The disease processes were initially grouped into 6 categories based on etiology: sialadenosis, infection, neoplasm, autoimmune, iatrogenic, and miscellaneous. For each lesion, the incidence, history, and physical examination were compiled in a matrix.

Conclusion

After reviewing the matrix, it was clear that grouping diseases based on specific history and physical findings limits the differential diagnosis. The most important factors included disease incidence, timing of onset, nodular or diffuse, pain, and overlying skin changes. With this algorithm, the differential diagnosis can be limited from 28 to 7 or fewer likely diagnoses for a given presentation.

Implications for Practice

Bilateral parotid disease has a wide differential diagnosis with an expanding number of available tests. An algorithm, based solely on data obtained from the history and physical examination in the first patient encounter, may reduce the differential and aid the clinician in deciding on further workup and treatment. Following the algorithm presented here should allow the clinician to arrive at a diagnosis rapidly without ordering unnecessary tests and wasting resources.

Viruses and salivary gland disease (SGD): lessons from HIV SGD

Viral infections are often associated with salivary gland pathology. Here we review the pathogenesis of HIV-associated salivary gland disease (HIV-SGD), a hallmark of diffuse infiltrative lymphocytosis syndrome. We investigate the presence and contributions of viral diseases to the pathogenesis of salivary gland diseases, particularly HIV-SGD. We have detected BK viral shedding in the saliva of HIV-SGD patients consistent with viral infection and replication, suggesting a role for oral transmission. For further investigation of BKV pathogenesis in salivary glands, an in vitro model of BKV infection is described. Submandibular (HSG) and parotid (HSY) gland salivary cell lines were capable of permissive BKV infection, as determined by BKV gene expression and replication. Analysis of these data collectively suggests the potential for a BKV oral route of transmission and salivary gland pathogenesis within HIV-SGD.

Salivary dysfunction associated with systemic diseases: systematic review and clinical management recommendations

OBJECTIVES

The objective of this study was to identify systemic diseases associated with hyposalivation and xerostomia and develop evidence-based management recommendations for hyposalivation/xerostomia.

STUDY DESIGN

Literature searches covered the English language medical literature from 1966 to 2005. An evidence-based review process was applied to management studies published from 2002 to 2005.

RESULTS

Several systemic diseases were identified. From studies published 2002 to 2005, 15 were identified as high-quality studies and were used to support management recommendations: pilocarpine and cevimeline are recommended for treating hyposalivation and xerostomia in primary and secondary Sjögren's syndrome (SS). IFN-alpha lozenges may enhance saliva flow in primary SS patients. Anti-TNF-alpha agents, such as infliximab or etanercept, are not recommended to treat hyposalivation in SS. Dehydroepiandrosterone is not recommended to relieve hyposalivation or xerostomia in primary SS. There was not enough evidence to support any recommendations for the use of local stimulants, lubricants, and protectants for hyposalivation/xerostomia. However, professional judgment and patient preferences may support the use of a specific product for an individual patient.

CONCLUSIONS

These evidence-based management recommendations should guide the clinician's management decisions for patients with salivary dysfunction related to systemic disease. Future treatment strategies may include new formulations of existing drugs, e.g., local application of pilocarpine. Recent discoveries on gene expression and a better understanding of the etiopathogenesis of SS may open new treatment options in the future.

Assessment of adrenal function by measurement of salivary steroids in response to corticotrophin in patients infected with human immunodeficiency virus

OBJECTIVE

Adrenal insufficiency has been reported among critically ill HIV-infected patients. This is the first study that attempts to detect subclinical hypoadrenal states in non-critical HIV patients through salivary steroids in response to intramuscular low-dose ACTH injection.

PATIENTS AND METHODS

We studied 21 ambulatory adult HIV-infected patients without specific clinical signs or symptoms of adrenal insufficiency. Normal salivary flow-rate and salivary alpha-amylase activity confirmed adequate salivary gland function. Salivary cortisol (SAF) and salivary aldosterone (SAL) were obtained at baseline and 30 min after the injection of 25 microg of ACTH in the deltoid muscle (LDT(s)). Assessment of salivary steroids after stimulation with 250 microg of intramuscular ACTH (HDT(s)) was performed on those who hyporesponded to LDT(s). Basal blood samples were drawn for steroids, renin and ACTH measurements.

RESULTS

At baseline SAF and SAL correlated significantly (p=0.0001) with basal serum cortisol and aldosterone (r=0.70 and 0.91, respectively). Plasma ACTH and renin concentrations were within the normal range in all patients. Eight of the twenty-one HIV(+) patients were LDT(s) hyporesponders in either SAF (n:1) or SAL (n:7). LDT(s) repeated in six cases after a year reconfirmed the impairment of aldosterone secretion. LDT(s) hyporesponders had normal steroid responses to HDT(s).

CONCLUSIONS

LDT(s) is a simple, safe, well-accepted and non-invasive approach to assess adrenal function in HIV-infected ambulatory patients. It revealed subnormal cortisol (5%) and aldosterone responses (33%) when HDT(s) results were normal.

Idiopathic hyperplasia of the sublingual glands in totally or partially edentulous individuals

OBJECTIVE

To determine the possible etiologic factors associated with the development of idiopathic hyperplasia of the sublingual gland (IHSG).

STUDY DESIGN

Fifty partially or totally edentulous patients were divided into 2 groups, each with 25 subjects, matched by sex. Group 1 was made up of patients with IHSG, whereas group 2 consisted of patients without IHSG. Patients of both groups were investigated with respect to the use of prostheses, systemic medication, systemic diseases, smoking habits, alcohol consumption, and xerostomia. In addition, patients of group 1 were examined by occlusal radiography, and in 6 of them, a biopsy of the sublingual gland swelling was taken for histopathologic investigation. The Fisher exact test was used, with significance set for P < or = .05.

RESULTS

The comparative analysis revealed no statistical difference between the 2 groups concerning all factors investigated (P > .05). Radiographic examination did not detect any presence of salivary calculi; the histopathologic findings revealed either chronic sialadenitis (4 cases) or normal glandular tissue (2 cases).

CONCLUSION

Our clinical and histopathologic analyses confirm that IHSG is a harmless condition for which no surgical treatment is required. The etiologic investigation did not find any local or systemic factors significantly associated with the development of IHSG. The absence of posterior teeth remains as the only known predisposing factor to be strongly linked to this condition.

Infection and musculoskeletal conditions: Rheumatologic complications of HIV infection

The pandemic caused by the human immunodeficiency virus (HIV) has entered its second quarter-century, with 40 million people now affected worldwide - particularly in Africa, where the impact has been most devastating. A complex array of rheumatic disease manifestations has been described, including diseases specific to HIV infection such as HIV-associated arthritis and the diffuse infiltrative lymphocytosis syndrome; other conditions which occur prominently in HIV-positive individuals include vasculitis, reactive and psoriatic arthritis and HIV-associated polymyositis, opportunistic musculoskeletal infections, and finally disorders that were originally ameliorated by HIV infection, such as rheumatoid arthritis and lupus. Effective antiretroviral treatment ameliorates many of these disorders; however, the introduction of highly active antiretroviral treatment (HAART) has introduced a new spectrum of disorders and new challenges confronting the clinician, including osteonecrosis, rhabdomyolysis, and, with immune reconstitution, the appearance de novo of a variety of autoimmune disorders and phenomena.

Ranula: another HIV/AIDS associated oral lesion in Zimbabwe?

AIM

To show that sublingual ranula is associated with HIV/AIDS and as such should be considered an HIV/AIDS associated oral lesion in Zimbabwe.

OBJECTIVES

To retrospectively study the prevalence, age and gender distribution, the HIV serostatus of ranula patients and the trend in prevalence of ranula and Kaposi's sarcoma (KS) in patients at the two largest referral Oral and Maxillofacial Surgery specialist centres in Harare, Zimbabwe. To use this information to infer an association between ranula and HIV/AIDS in Zimbabwe.

DESIGN

Descriptive study with a retrospective and prospective component.

SETTING

Oral and Maxillofacial Surgical clinics at specialist referral hospitals, Harare Central Hospital and Parirenyatwa Government Hospital, Harare, Zimbabwe.

SUBJECTS

Eighty-three cases of ranula were studied: 45 cases retrospectively and 38 consecutively. A total of 231 cases of KS were studied retrospectively.

METHODS

Histopathologic records of patients who presented with ranula and KS during the period January 1981 to September 2003 were studied. Gender and age were recorded for each case. Thirty-eight ranula patients studied consecutively during the period June 1999 to September 2003 were consented for HIV testing.

RESULTS

There were 83 cases of ranula; 43.4% male and 56.6% female. There were 231 cases of KS, 61.2% male and 38.8% female. Male to female ratio was 1:1.3 for ranula and for KS was 1:0.6. Ranula was predominant in the 0-10 year age group (73.5%) while KS was most common in the 21-40 year age group (76.4%). Ranula and KS both had a marked rise in prevalence from 1992 to 2003. A total of 88.5% of the ranula cases tested HIV positive with 95% in the 0-10 year age group.

CONCLUSION

There was a rising prevalence of ranula which mirrors that of KS (an HIV/AIDS associated oral lesion) and that 88.5% of ranula patients were HIV positive with 95% of them in the 0-10 year age group. Sublingual ranula should thus be considered another HIV/AIDS associated lesion in Zimbabwe, especially in children.

Bioadhesive, rheological, lubricant and other aspects of an oral gel formulation intended for the treatment of xerostomia

Xerostomia is commonly known as 'dry mouth' and is characterised by a reduction or loss in salivary production. A bioadhesive gel for its localised treatment was formulated to help enhance the residence time of the product, based on the polymer Carbopol 974P. The bioadhesion of various formulations was evaluated on different mucosal substrates, as simulations of the oral mucosa of xerostomic patients. Depending on the type of model substrate used, the mechanism of bioadhesion could alter. When the rheology of various formulations was examined, changes in bioadhesion were more easily interpreted, as the presence of other excipients caused an alteration in the rheological profile, with a change from a fully expanded and partially cross-linked system to an entangled system. Improving the lubricity of the product was considered important, with optimum incorporation of vegetable oil causing a desirable lowering of the observed friction of the product. The final complex formulation developed also contained salivary levels of electrolytes to help remineralisation of teeth, fluoride to prevent caries, zinc to enhance taste sensation, triclosan as the main anti-microbial/anti-inflammatory agent and non-cariogenic sweeteners with lemon flavour to increase the palatability of the product while stimulating any residual salivary function.

Infection of the facial area, oral cavity, oropharynx, and retropharynx

Radiologists play an important role in the evaluation of upper neck infections. Although most oral cavity infections arise from diseased teeth, several other sources of infection need to be considered. The distinction between abscess and phlegmon is of particular importance. Cross-sectional imaging is frequently used to identify complications of the initial infection.

Salivary gland disease in HIV/AIDS and primary Sjögren's syndrome: analysis of collagen I distribution and histopathology in American and African patients

BACKGROUND

Salivary gland disease (SGD) in HIV/AIDS is clinically and histopathologically very similar to Sjögren's Syndrome (SS), although the mechanism of tissue damage is unknown. The aim of this study is to determine the prevalence of SGD in primary SS and in HIV/AIDS in USA and in West African patients, and to seek distinguishing histopathologic features that may help to elucidate underlying mechanisms.

METHODS

Histologic sections of minor salivary glands from 164 HIV-positive and -negative patients from Cameroon and the US, and from 17 US patients with primary SS, were evaluated following salivary gland biopsy for inflammatory changes. To confirm the presence of fibrosis, collagen I, which is the most abundant collagen type, was assessed immunohistochemically in H&E-stained sections.

RESULTS

Forty-eight per cent of patients with HIV from Cameroon had severe SGD, while it was only in 6% of patients from the US. Patients with HIV in the US had less fibrosis and collagen I deposits than Cameroonians. Seventy-six per cent of US HIV-positive patients had received anti-retroviral therapy, while none of the African patients had. SS and AIDS patients had a tendency for lymphocytes to locate in a perivascular rather than in a periductal distribution.

CONCLUSIONS

The prevalence of SGD and the presence of fibrosis and collagen I in Cameroonians with HIV is significantly higher than in HIV-positive American patients, and is similar to US patients with primary SS. The impact of patient selection, anti-retroviral therapy, and pathogenic mechanisms on salivary gland pathology is discussed.

Regression of HIV parotid swellings after antiviral therapy: case reports with computed tomographic scan evidence

Parotid swellings have been noted in approximately 5% to 10% of patients with HIV-1. These swellings are a result of lymphoproliferative activity or lymphoepithelial cyst formation in response to a viral parotid presence. Two patients with cosmetic concerns regarding parotid swellings are presented before and after antiviral therapy. Regression of the swellings after treatment is substantiated with clinical photographs and computerized tomographic scans. The successful outcome was a reflection of a diminution in viral load and some degree of immune restoration.

Self-reported oral dryness and HIV disease in a national sample of patients receiving medical care

OBJECTIVES

We sought to analyze the relationship between self-reported oral dryness and the demographic, enabling, behavioral, clinical, and treatment characteristics among human immunodeficiency virus (HIV)-positive patients in medical care.

STUDY DESIGN

The study group consisted of the HIV Cost and Services Utilization Study cohort, a nationally representative probability sample of HIV-infected adults receiving medical care in the contiguous United States.

RESULTS

It was estimated that 29% of adults (64,947 individuals) with HIV infection receiving medical care in the United States have a complaint of dry mouth. A multivariate logistic analysis was carried out to explore the association between several covariates and dry mouth. It was shown that compared with whites, individuals of Hispanic ethnic origin were 61% more likely to report dry mouth (OR, 1.61; 95% CI, 1.04-2.50; P =.04). Those who were unemployed were 55% more likely to report the symptom of dry mouth than were subjects who were employed (OR, 1.55; 95% CI, 1.22-1.98; P =.001). In comparison with nonsmokers, current smokers were 36% more likely to report dry mouth (OR, 1.36; 95% CI, 1.04-1.79;P =.03). The use of antidepressant drugs and antituberculosis/anti-Mycobacterium avium (anti-TB/anti-MAC) medications had the strongest association with dry mouth complaint. Those taking antidepressants were 55% more likely to report dry mouth (OR, 1.55; 95% CI, 1.23-1.97; P =.0001); compared with nonusers, patients receiving anti-TB/MAC drugs were 46% more likely to report dry mouth (OR, 1.46; 95% CI, 1.03-2.06; P =.04]. In comparison with those with undetectable viral load, individuals with a viral load of more than 100,000/mm(3) were 151% more likely to report dry mouth (OR, 2.51; 95% CI,1.58-3.96; P =.0001).

CONCLUSIONS

Our findings suggest that optimizing viral suppression, smoking cessation, and tailoring antidepressant and anti-TB/MAC medications may be promising interventions to decrease dry-mouth symptoms among HIV-infected individuals.

Pseudo-Primary Infection Syndrome following Discontinuation of Antiretroviral Therapy

We report the case of a retroviral rebound syndrome associated with parotid gland enlargement in a chronically HIV-infected man.

Classifications of oral lesions in HIV infection

BACKGROUND

Manifestations of immunosuppression may take the form of opportunistic infection, and neoplasia. While this paper has focused on gingival and periodontal manifestations. these tissues cannot be evaluated in isolation. The presence of involvement of other oral tissues such as the cheek or tongue with manifestations associated with HIV such as hairy leukoplakia, Kaposi's sarcoma at these sites, and candidiasis in addition to periodontal manifestations may further increase the clincal suspicion of underlying immunosuppression and/or progression of the immunosuppressive state.

DISCUSSION

The periodontist plays an essential r le in identifying the periodontal status of an individual and has an important r le to play in early recognition of signs and symptoms of HIV disease or progression of the medical condition.

CONCLUSION

Only through such recognition can appropriate definitive diagnostic testing be conducted, and appropriate therapeutic intervention for the oral condition and the systemic condition be considered.

The changing spectrum of rheumatic disease in human immunodeficiency virus infection

CONTEXT

Although it has been known for over 15 years that a number of rheumatic diseases occur in patients with human immunodeficiency virus (HIV) infection, increasing knowledge about these disorders and advances in HIV treatment need to be considered in approaching patients with HIV-associated rheumatic disease.

OBJECTIVE

To examine the clinical, pathologic, and therapeutic features of HIV-associated rheumatic diseases in the context of what is known about the immunology of HIV infection.

DATA SOURCES

The author's own extensive collection of references, supplemented by PubMed Medline searches for articles in English-language journals published between 1985 and 2000. The indexing term HIV and the following coindexing terms were used for searching: arthritis, Reiter's syndrome, psoriatic arthritis, rheumatoid arthritis, osteonecrosis, vasculitis, pulmonary hypertension, myositis, myopathy, fibromyalgia, septic arthritis, parotid enlargement, diffuse infiltrative lymphocytosis syndrome, systemic lupus erythematosus, septic arthritis, mycobacterial arthritis, fungal arthritis, autoantibodies, anti-cardiolipin antibodies, and anti-neutrophilic cytoplasmic antibodies.

STUDY SELECTION

All papers identified in the literature search were reviewed. Studies presenting data that merely confirmed previous studies were not included in the analysis.

DATA EXTRACTION

All identified papers were abstracted by the author. Letters to the editor were included only if a new observation had been made.

DATA SYNTHESIS

This was a qualitative review of papers published, with new knowledge about these disorders summarized and presented.

RESULTS

Despite new treatments for HIV, reports of rheumatic diseases presenting in AIDS patients persist, especially in HIV-associated arthritis, diffuse infiltrative lymphocytosis syndrome, HIV-associated vasculitis, and polymyositis. However, new HIV treatments may ameliorate these diseases.

CONCLUSIONS

The spectrum of HIV-associated rheumatic disease remains a diagnostic and therapeutic challenge for the clinician. The impact of changes in HIV treatment on these disorders requires further assessment.

CT and MR imaging evaluation of neck infections with clinical correlations

Infection of the neck is a common clinical problem in all age groups, especially children and young adults. The clinical symptoms and signs are often suggestive of the diagnosis. Imaging studies including CT and MR imaging are frequently required to confirm the diagnosis but more importantly to localize the infectious process and search for and delineate an abscess cavity. Ultrasound has also been used in the evaluation of superficial neck infections, especially to determine fluid accumulation. Conventional films consisting of an anteroposterior and lateral view were the examination before the introduction of CT in 1972. Conventional films can still be used for a preliminary survey, especially of the retropharyngeal space when there is a question of a retropharyngeal phlegmon or abscess.

Kaposi sarcoma of major salivary gland origin: A clinicopathologic series of six cases

BACKGROUND

Kaposi sarcoma (KS), one of the defining tumors of acquired immune deficiency syndrome (AIDS), is rarely identified in the major salivary glands. To the authors' knowledge, no previous published series has evaluated the clinicopathologic aspects of this tumor in major salivary glands.

METHODS

Six cases of salivary gland KS, diagnosed between 1970 and 1998, were retrieved from the files of the Oral and Maxillofacial Pathology Registry of the Armed Forces Institute of Pathology. Histologic features were reviewed and special stains, immunohistochemical studies, and in situ hybridization were performed (n = 4). Patient follow-up data were obtained.

RESULTS

The patients included 6 men ages 20-73 years (average, 53.0 years). Patients presented clinically with a mass in the submandibular (n = 4) or parotid (n = 2) gland region. Symptoms were present for a mean of 13.7 months. The tumors measured 1-4 cm (average, 2.5 cm) in greatest dimension. Histologically, the tumors exhibited the usual features of KS: a spindle cell vascular proliferation arranged in fasciculated bundles, variable nuclear pleomorphism, mitotic figures, extravasated erythrocytes, and hyaline globules. Five patients were serologically positive for human immunodeficiency virus (HIV) (three homosexual males, one infected by a contaminated blood transfusion, and one with an unknown risk factor). Human herpesvirus-8 (HHV-8) was present in all cases tested (n = 4). Patients were treated with surgical excision (n = 6), followed by chemotherapy (n = 1) for the single patient with other foci of KS (rectal). Three patients died of AIDS-related infectious complications and one of congestive heart failure, whereas the remaining patients are alive with AIDS but free of salivary gland KS.

CONCLUSIONS

Salivary gland enlargement is frequently identified in HIV positive or AIDS patients. Although rare, it is important to consider KS in the differential diagnosis of other AIDS-related salivary gland manifestations (infections and tumors).

Primary sialoangiectasia--a diagnostic pitfall in Sjögren's syndrome: case report

A case of primary sialoangiectasia, which in this case was initially misdiagnosed as Sjögren's syndrome, is described. Other diseases, including HIV infection, psoriatic arthritis, and acute parotitis, may cause glandular changes similar to the changes found in the syndrome. Therefore, sialography must be combined with other methods of assessment of the oral cavity when suspicion is high for Sjögren's syndrome. Properly applied, sialography provides essential information regarding the severity of glandular damage and the progression of the disease.

Otolaryngologic manifestations of human immunodeficiency virus infection

Patients infected with HIV have become a steadily increasing part of most medical practices. Because most patients with HIV-related problems have manifestations in the head and neck, it is important that these be understood and recognized. This article briefly reviews the various otolaryngologic manifestations of HIV infection, including otologic, nasal, and paranasal sinus; oral cavity, pharynx, and larynx; and the neck.

Parotid gland swelling in HIV diffuse infiltrative CD8 lymphocytosis syndrome

HIV can affect salivary gland tissue. Parotid swellings have been observed in a subset of patients who are HIV-positive; the swellings are the result of a condition that has been termed diffuse infiltrative CD8 lymphocytosis syndrome. Initially the glandular enlargement results from a massive CD8 cell lymphoproliferation, but with time lymphoepithelial cysts become manifest. Two case reports are presented to illustrate this progression of diffuse infiltrative CD8 lymphocytosis.

Lymphoepithelial cysts of salivary glands: an immunohistochemical study of HIV-related and HIV-unrelated lesions

An indolent lesion of the salivary glands that mimics Sjøgren syndrome has been repeatedly reported in HIV-infected (HIV+) patients. It is characterized by the occurrence, usually in the parotid gland, of variably sized lymphoepithelial cysts (LECs), whose origin is still unclear. We have compared the morphological and immunohistochemical features of six cases of LEC in HIV+ patients with those of five cases of LEC in HIV-negative (HIV-) patients. The results of the study show that LECs have similar histological and immunohistochemical features in both HIV+ and HIV- patients, and that they may simultaneously affect the salivary gland parenchyma and the intrasalivary lymph nodes. Furthermore, a diffuse lymphoid infiltrate is invariably observed in the glandular tissue around LECs and it is consistently associated with ectatic changes of the striated ducts. These data and the finding of an equivalent proliferation fraction of the epithelial compartment in both LEC and salivary retention cysts, used as controls for this study, are consistent with the hypothesis that cyst formation is secondary to the obstruction of salivary ducts by exuberant lymphoid infiltration.

Oral manifestations of HIV disease: an update

More than 40 different oral diseases and conditions have been described in patients infected with human immunodeficiency virus (HIV). The recognition of the oral manifestations of HIV disease is of great significance because they may represent the first signs of the disease and have been shown to be highly predictive markers of severe immune deterioration and disease progression. Although some oral diseases and conditions have a weak association with HIV disease, others are strongly linked with the disorder, and a few are acquired immune deficiency syndrome (AIDS)-defining in nature. The spectrum of oral manifestations of HIV disease is reviewed with emphasis on clinical recognition, diagnosis, and treatment.

Association between carriage of oral yeasts, malnutrition and HIV-1 infection among Tanzanian children aged 18 months to 5 years

The objective was to determine whether there is an association between carriage of oral yeasts, malnutrition and HIV-1 infection among Tanzanian children. A case-control study design within a cross-sectional study was used, and the outcome was carriage of oral yeasts. The exposure variables were malnutrition and HIV-1 antibody, and confounders to be adjusted for were age, sex, and breastfeeding. The study was carried out in Dar-es-Salaam, Tanzania, in two maternal and child health (MCH) clinics that offer routine medical checkups to all expectant mothers and children aged between 0 and 5 years in the catchment area. A total of 882 children aged between 18 months and 5 years participated. Smears from the tongue and buccal mucosa were examined for oral yeasts. Malnutrition was categorized according to standards on the MCH chart and World Health Organization/Centers for Disease Control (WHO/CDC) standards as weight-for-height (wasted), weight-for-age (underweight), and height-for-age (stunted). HIV-1 infection was determined by an enzyme-linked immunosorbent assay. Reactive sera were confirmed by Western Blot. About 27% of the children were slightly or severely malnourished according to standards on the MCH chart. According to WHO/CDC standards, 2.6% were wasted, 16.3% were underweight, and 29.6% were stunted. Fourteen (1.6%) were seropositive for HIV-1 antibody. Hyphal forms and blastospores were much more frequent among children infected with HIV-1 with odds ratios ranging from 3.8 (95% CI: 1.3;11.2) to 6.2 (95% CI: 2.1;18.4) depending on categorization of malnutrition. Malnutrition was a risk factor, too, albeit to a much lesser and insignificant degree. The study supports our previous findings that malnutrition may predispose to carriage of oral yeasts and subsequent infection. However, in this study population HIV infection was clearly the predominant risk factor.

[HIV-associated salivary gland diseases. Review of the literature and 3 case reports]

HIV-associated salivary gland disease (HIV-SGD) includes lymphoepithelial lesions and cysts involving the salivary gland tissue and/or intraglandular lymph nodes, and Sjögren-like conditions. Three cases of salivary gland disease occurring in HIV-infected patients are reported. Histopathological examination showed squamous epithelium-lined cysts. In the walls of the cysts lymphoid tissue, epitheloid granulomas and giant cells were found. The clinical and histopathological criteria as well as magnetic resonance imaging and therapy are discussed.