Oral recrudescent herpes simplex virus infection

Orofacial Cryptococcosis: A Challenging Clinical Report and a Systematic Analysis of the Literature

Cryptococcosis is a neglected fungal disease. The scarcity of studies on oral cryptococcosis is certainly due to rarity and/or underreporting of the disease, especially in Brazil. We describe an example of orofacial cryptococcosis affecting a 57-year-old man after heart transplantation, who presented with multiple erythematous ulcers and erosions distributed in the chin, nasal cavity, labial mucosa, hard palate, and buccal vestibule. Computed tomography revealed opacities and micronodules in the lungs. Histopathological features of the oral and pulmonary lesions were compatible with Cryptococcus spp. Amphotericin B and fluconazole were used for treatment during hospitalization and itraconazole for prolonged therapy after hospital discharge. The patient has been under follow up for 6 months without signs of disease. According to a review conducted in PubMed, Web of Science, Scopus, Embase, and LILACS for data analysis of oral cryptococcosis, 26 reports were described in the literature. Predilection for men was observed (85%), with a male:female ratio of 5.5:1. The mean age of the individuals was 49 ± 15.3 years. Oral cryptococcosis mostly presented as an ulcer (n = 17). The palate and tongue were the most affected sites (n = 9 for each). Amphotericin B was the primary therapy utilized in most patients. Seventeen (65%) individuals survived. Knowledge of the clinicodemographic aspects of oral cryptococcosis is important for clinicians in decision making and surveillance.

Herpesvirus-Related Lesions of the Oral Mucosa

The human herpesvirus (HHV) family is a group of enveloped DNA viruses containing 8 members known to produce oral mucosal lesions. Following initial exposure, which may result in symptomatic primary infection, the viruses establish latency within specific cells/tissues. After reactivation, herpesviruses can cause localized symptomatic or asymptomatic recurrent (secondary) infections or diseases. HHV may have a significant role in the cause of oral mucosal infectious diseases in immunocompromised patients. This article discusses the role of those herpesviruses that can induce oral mucosal lesions, with focus on the clinical features and treatment/management.

Acute periodontal lesions

This review provides updates on acute conditions affecting the periodontal tissues, including abscesses in the periodontium, necrotizing periodontal diseases and other acute conditions that cause gingival lesions with acute presentation, such as infectious processes not associated with oral bacterial biofilms, mucocutaneous disorders and traumatic and allergic lesions. A periodontal abscess is clinically important because it is a relatively frequent dental emergency, it can compromise the periodontal prognosis of the affected tooth and bacteria within the abscess can spread and cause infections in other body sites. Different types of abscesses have been identified, mainly classified by their etiology, and there are clear differences between those affecting a pre-existing periodontal pocket and those affecting healthy sites. Therapy for this acute condition consists of drainage and tissue debridement, while an evaluation of the need for systemic antimicrobial therapy will be made for each case, based on local and systemic factors. The definitive treatment of the pre-existing condition should be accomplished after the acute phase is controlled. Necrotizing periodontal diseases present three typical clinical features: papilla necrosis, gingival bleeding and pain. Although the prevalence of these diseases is not high, their importance is clear because they represent the most severe conditions associated with the dental biofilm, with very rapid tissue destruction. In addition to bacteria, the etiology of necrotizing periodontal disease includes numerous factors that alter the host response and predispose to these diseases, namely HIV infection, malnutrition, stress or tobacco smoking. The treatment consists of superficial debridement, careful mechanical oral hygiene, rinsing with chlorhexidine and daily re-evaluation. Systemic antimicrobials may be used adjunctively in severe cases or in nonresponding conditions, being the first option metronidazole. Once the acute disease is under control, definitive treatment should be provided, including appropriate therapy for the pre-existing gingivitis or periodontitis. Among other acute conditions affecting the periodontal tissues, but not caused by the microorganisms present in oral biofilms, infectious diseases, mucocutaneous diseases and traumatic or allergic lesions can be listed. In most cases, the gingival involvement is not severe; however, these conditions are common and may prompt an emergency dental visit. These conditions may have the appearance of an erythematous lesion, which is sometimes erosive. Erosive lesions may be the direct result of trauma or a consequence of the breaking of vesicles and bullae. A proper differential diagnosis is important for adequate management of the case.

Oral ulceration associated with concurrent herpes simplex virus, cytomegalovirus, and Epstein-Barr virus infection in an immunocompromised patient

In immunocompromised patients, oral ulcerations are common and have a wide spectrum of causes, including herpesvirus infection. We report on a case in which an oral ulcer was simultaneously infected by herpes simplex (HSV), cytomegalovirus (CMV), and Epstein-Barr virus (EBV) in a kidney-pancreas transplant recipient. A 46-year-old woman presented with a clinically nonspecific dorsal tongue ulcer of 3 months duration. Histopathologic evaluation indicated keratinocytes exhibiting herpetic viral cytopathic effect. Nuclear and cytologic alterations suggestive of CMV infection were found in endothelial cells subjacent to the ulcer. Immunohistochemistry testing for HSV and CMV was positive in these cells. Large atypical mononuclear cells were also evident in the ulcer bed's inflammatory infiltrate, which had intense nuclear positivity for Epstein-Barr encoding region in situ hybridization. We believe this is the first well-documented report of the definitive concomitant presence of HSV, CMV, and EBV in an immunocompromised patient. Although the pathogenesis of coinfected ulcers remains unknown, a synergistic effect is possible.

Stomatitis-related pain in women with breast cancer undergoing autologous hematopoietic stem cell transplant

The purpose of this cross-sectional, correlational study was to describe stomatitis-related pain in women with breast cancer undergoing autologous hematopoietic stem cell transplant. The hypotheses that significant, positive relationships would exist between oral pain and stomatitis, state anxiety, depression, and alteration in swallowing were tested. Stomatitis, sensory dimension of oral pain, and state anxiety were hypothesized to most accurately predict oral pain overall intensity. Thirty-two women were recruited at 2 East Coast comprehensive cancer centers. Data were collected on bone marrow transplantation day +7 +/- 24 hours using Painometer, Oral Mucositis Index-20, Oral Assessment Guide, State-Trait Anxiety Inventory, and Beck Depression Inventory. Data analysis included descriptive statistics, correlations, and stepwise multiple regression. All participants had stomatitis; 47% had oral pain, with a subset reporting continuous moderate to severe oral pain despite pain management algorithms. Significant, positive associations were seen between oral pain, stomatitis, and alteration in swallowing and between oral pain with swallowing and alteration in swallowing. Oral pain was not significantly correlated with state anxiety and depression. Oral sensory and affective pain intensity most accurately predicted oral pain overall intensity. Future research needs to explore factors that affect perception and response to stomatitis-related oropharyngeal pain and individual patient response to opioid treatment.

Management of recurrent oral herpes simplex infections

The literature has been reviewed for evidence of the efficacy of antiviral agents in both the prophylaxis and treatment of recurrent oral herpes simplex virus (HSV) infections and discussed by a panel of experts. Emphasis was given to randomized controlled trials. Management of herpes-associated erythema multiforme and Bell palsy were also considered. The evidence suggests that 5% acyclovir (ACV) in the cream base may reduce the duration of lesions if applied early. Recurrent herpes labialis (RHL) and recurrent intraoral HSV infections can be effectively treated with systemic ACV 400 mg 3 times a day or systemic valacyclovir 500 to 1000 mg twice a day for 3 to 5 days (longer in the immunocompromised). RHL in the immunocompetent can be effectively prevented with (1) sunscreen alone (SPF 15 or above), (2) systemic ACV 400 mg 2 to 3 times a day, or (3) systemic valacyclovir 500 to 2000 mg twice a day. Valacyclovir 500 mg twice a day is also effective in suppressing erythema multiforme triggered by HSV. Further studies are needed to compare treatment efficacy between topical penciclovir, docosanol, and ACV cream for RHL.

Úlceras orales

Ulcers commonly occur in the oral cavity, their main symptom being pain. There are different ways to classify oral ulcers. The most widely accepted form divides them into acute ulcers--sudden onset and short lasting--and chronic ulcers--insidious onset and long lasting. Commonest acute oral ulcers include traumatic ulcer, recurrent aphthous stomatitis, viral and bacterial infections and necrotizing sialometaplasia. On the other hand, oral lichen planus, oral cancer, benign mucous membrane pemphigoid, pemphigus and drug-induced ulcers belong to the group of chronic oral ulcers. It is very important to make a proper differential diagnosis in order to establish the appropriate treatment for each pathology.

Study of the viral infections and cytokines associated with recurrent aphthous ulceration

Mouth ulcers are one of the most common oral complaints. However, the association between oral ulceration and viruses and cytokines is uncertain. We detected the presence of human papilloma virus (HPV), cytomegalovirus (CMV), Epstein-Barr virus (EBV), herpes simplex virus (HSV)-1, HSV-2 and human herpesvirus (HHV)-8 DNA in oral tissues by polymerase chain reaction (PCR) and Southern hybridization techniques, and quantified the serum levels of cytokines including interleukin (IL)-2, IL-4, granulocyte-macrophage colony-stimulating factor (GM-CSF), soluble Fas (sFas) and the Fas ligand (FasL) by enzyme-linked immunosorbent assay (ELISA) for 67 recurrent aphthous ulcer (RAU) patients and 72 normal individuals. Seven patient specimens were excluded from the study due to the negative PCR results for the beta-globin used as the internal control. Among the 32 (53.3%) virus-positive results from 60 patients' samples, 8 (13.3%) HPV, 4 (6.7%) HSV-1, 11 (18.3%) CMV, 9 (15.0%) EBV, and 16 (26.7%) HHV-8 samples proved to be positive. No HSV-2-positive samples were found. The percentage of single-virus infection (56.3%) was significantly greater than that of double-virus co-infection (31.3%) and the percentage of double-virus co-infection was significantly greater than the percentage of triple-virus co-infection (12.5%) (P < 0.05). In the 72 normal oral-tissue specimens, no viral DNA was detected. The mean serum cytokine level for patients was significantly (P < 0.05) greater than for controls for most of the separate age groups. The mean serum cytokine concentrations for the patient group demonstrated a diffuse pattern covering a wide range of serum concentrations, a very different result from the compact serum concentration pattern and lower mean serum cytokine concentrations revealed by the normal group. Overall association between viruses and recurrent aphthous ulceration is HHV-8 > CMV > EBV > HPV > HSV-1, regarding the frequency of prevalence (P < 0.05).

Resolution of oral ulcerations after decreasing the dosage of tacrolimus in a liver transplantation recipient

Oral ulcers have may possible causes, including immunosuppression and drug therapy. Severe cases of oral ulceration merit special consideration because the ulcers may become large enough to alter the quality of life of the patient. The present case involves a male patient who in 1994 received an orthotopic liver transplantation because of alcoholic cirrhosis. The initial immunosuppressive regimen was induced with tacrolimus (4 mg/d) and prednisone (20 mg/d). Ten months after orthotopic liver transplantation, the patient complained of multiple recurrent oral ulcers, dysphagia, and severe oral pain, which did not respond to any of the treatments over a 3-year period. Approximately 3(1/4) years after these unresponsive ulcers appeared, the reduction of the oral dosage of tacrolimus resulted in the total remission of the ulcers. A retrospective analysis demonstrated that appearance of the ulcers coincided with a dose of 9 mg/d of tacrolimus (whole blood levels of 12 ng/mL); the ulcers did not disappear until the dose was reduced to 4 mg/d (whole blood level of 6.6 ng/mL).

Oral recurrent human herpes virus infection and bone marrow transplantation survival

OBJECTIVE

This study was conducted to compare the survival rates of bone marrow transplantation (BMT) patients who were affected with the survival rates of those who were not affected by oral recrudescent human herpes virus-1 infection (HHV-1) after transplantation.

STUDY DESIGN

Fifty-two consecutive patients who underwent BMT were included in the study. The time of death after BMT was displayed, by means of the Kaplan-Meier method, for the following parameters: age and gender of the patient, donor gender, primary disease, stem cells, conditioning regimen, platelet number after day 100, acute and chronic graft-versus-host disease, oral recurrent HHV-1 infection post-BMT, oral lichenoid lesions of graft-versus-host disease, graft-versus-host disease at the salivary glands, parenteral nutrition, and oral mucositis. The data were initially analyzed by means of the log-rank test and then included in the Cox proportional hazards model.

RESULTS

The multivariate analysis demonstrated a significance of 5% for only the platelet numbers and oral recurrent HHV-1 infection.

CONCLUSION

The present study provides evidence that platelet numbers below 100,000 cells/mm(3) after day 100 and oral recurrent HHV-1 infection are independent negative prognostic variables in BMT patients' 24-month survival rates.

Frequency of oral conditions in a dermatology clinic

BACKGROUND

Oral mucosal manifestations may be the initial feature, the most florid clinical feature, or the only sign of mucocutaneous diseases.

METHODS

Sixty adult patients (48 women, 12 men) with oral mucous complaints were referred to and evaluated at a dermatology clinic in a tertiary care hospital in Mexico City between November 1996 and September 1998.

RESULTS

The most frequent oral conditions observed were pemphigus vulgaris (18.3%), lichen planus (8.3%), candidiasis (8.3%), recurrent aphthous ulcers (6.7%), herpetic lesions (6.7%), xerostomia (6.7%), and traumatic lesions (6.7%). Oral affection in mucocutaneous conditions was observed in 21 (35%) patients; the diagnosis was based on oral signs in 10 (48%) of these patients. A large number of oral conditions had previously been misdiagnosed.

CONCLUSIONS

The importance of the diagnosis of oral conditions in dermatology has been underlined in this study due to the frequency and diversity of oral lesions. The benefits of an interdisciplinary approach in the management of patients has been highlighted.

The clinical characteristics of intraoral herpes simplex virus infection in 52 immunocompetent patients

OBJECTIVE

Intraoral herpes simplex virus infection is commonly mistaken for recurrent aphthous stomatitis. The purpose of this study was to describe the clinical features of intraoral herpes simplex virus infection.

STUDY DESIGN

Fifty-two immunocompetent patients with culture-positive intraoral herpes simplex virus infection were studied.

RESULTS

The median age of the patients was 42 years. One third of the patients exhibited single ulcers; the remaining patients displayed multiple lesions. In 47 of 52 cases, the ulcers occurred on keratinized surfaces of the oral cavity; however, 5 patients had persistent ulcerations on nonkeratinized mucosa, a typical feature of herpetic ulcers in immunosuppressed patients. Of 27 patients with histories of recurrences, 22 were previously incorrectly diagnosed with recurrent aphthous stomatitis.

CONCLUSIONS

Herpes simplex virus infection of the oral cavity can usually be differentiated from other causes of recurrent oral ulcerations on the basis of its clinical appearance and distribution. The recognition of atypical features may prevent unnecessary and costly treatments for unrelated though clinically similar-appearing disorders.