Oral hairy leukoplakia: observations in 95 cases and review of the literature

The global changing pattern of the oral manifestations of HIV

The significance of the oral manifestations of HIV has been widely recognised since the start of the epidemic. It is estimated that more than 38 million people are living with HIV currently, with more than a third presenting with oral manifestations. Access to optimum clinical management and effective treatment in resource-rich countries has led to a remarkable decrease in some of the oral manifestations in the HIV population but this is not mirrored in developing countries, where most HIV-positive patients reside. In this paper, a review of the literature since the start of the HIV infection in different parts of the world is presented to highlight the current significance of the oral conditions in this population. Oral candidiasis was repeatedly reported as the most encountered oral manifestation of HIV in different countries, including in studies on groups on anti-retroviral therapy. Over time salivary gland disease was reported less in developed countries but was encountered more in developing countries. There is evidence to show that the prevalence of oral warts increased with the establishment of anti-retroviral therapy. A review of the worldwide prevalence of HIV-related oral conditions indicates that except for oral hairy leucoplakia, the prevalence of all other nine commonly reported oral conditions remained the same or increased over time. Oral opportunistic infections in HIV-infected patients are an ongoing clinical burden mainly in developing countries. Maintaining research in the subject and improving access to HIV treatment will help address the oral health inequalities around the world.

Oral hairy leukoplakia in healthy immunocompetent patients: a small case series

BACKGROUND

Oral hairy leukoplakia (OHL) is caused by the Epstein-Barr virus (EBV) and usually presents in patients with human immunodeficiency virus (HIV) infection and systemic immunosuppression. It is rarely seen in patients who are immunocompetent. It is clinically characterised as an asymptomatic, soft, white and corrugated lesion that cannot be scraped from the surface it adheres to.

METHODS

Immunocompetent patients with OHL attending Bristol Dental Hospital within the last 6 months were identified. EBV infection was demonstrated using EBV in situ hybridization. Clinical features and medical history were determined by reviewing medical records.

CASE REPORT

Four cases of OHL in immunocompetent individuals were identified. All lesions were located on the lateral borders of the tongue.

DISCUSSION

OHL should be considered as a differential diagnosis for white patches on the lateral borders of the tongue in apparently healthy immunocompetent patients, even when they do not have a typical corrugated appearance. OHL should no longer be regarded as pathognomonic for HIV infection or systemic immunosuppression.

Considerations in the diagnosis of oral hairy leukoplakia-an institutional experience

OBJECTIVE

We report here the 10-year experience with oral hairy leukoplakia (OHL) at the Division of Oral and Maxillofacial Pathology at the University of North Carolina at Chapel Hill, NC, USA.

STUDY DESIGN

All the associated hematoxylin and eosin and Epstein-Barr virus encoding region in situ hybridization slides of OHL cases between January 1, 2008, and February 1, 2017, were retrieved and reviewed. Collected demographic characteristics, clinical presentation, medical and social histories were reviewed and reported.

RESULTS

Six OHL cases with confirmed in situ hybridization showed predilection for the lateral tongue. The study included 3 females and 3 males (mean age 50.5 years; age range 29-70 years). One patient had known HIV-positive status before biopsy was performed. Three patients had reported a history of heavy smoking. Other medical conditions reported were history of breast cancer, a long history of corticosteroid inhaler use for asthma treatment, high cholesterol, diabetes, and hypertension.

CONCLUSIONS

The findings of this study indicate the need to include OHL as a potential entity in the differential diagnosis of leukoplakic tongue lesions, regardless of the patient's HIV status. In addition, the presence of OHL in the patient requires investigation of various explanations for EBV infection, including immunosuppression caused by HIV infection or chronic steroid use.

Oral hairy leukoplakia arising in a patient with hairy cell leukaemia: the first reported case

Oral hairy leukoplakia (OHL) is an oral mucosal lesion that is associated with Epstein-Barr virus infection. It commonly presents as an asymptomatic, non-removable white patch on the lateral borders of the tongue in individuals who are immunocompromised. Historically, OHL was thought to be pathognomonic of HIV infection; however, it is now an established phenomenon in a range of conditions affecting immune competence. Hairy cell leukaemia (HCL) is a rare chronic B cell lymphoproliferative disease named after the distinctive cytology of the atypical cells. We report the first case of OHL arising in an individual with HCL that resolved following remission of the haematological malignancy.

Twenty-first-century oral hairy leukoplakia--a non-HIV-associated entity

OBJECTIVE

This study presents the clinicopathologic features of a series (N = 35) of patients with non-human immunodeficiency virus (HIV)-associated oral hairy leukoplakia (OHL).

METHODS

Patients with non-HIV-associated OHL were identified from three centers. Epstein-Barr virus infection was demonstrated by using EBV early ribonucleic acid in situ hybridization. The presence of Candida co-infection was evaluated by diastase periodic acid-Schiff staining. The clinical features were determined by review of the medical records.

RESULTS

Twenty-eight patients had intercurrent respiratory problems requiring long-term steroid inhaler use, four suffered from autoimmune diseases requiring immunosuppressant therapy, and four had diabetes. The majority of lesions were located on the tongue, and 24 showed evidence of Candida co-infection.

CONCLUSIONS

In the twenty-first century, the presence of OHL should not be regarded as pathognomic for HIV infection or significant systemic immunosuppression. Local and systemic immunosuppression, in the form of steroid inhaler use, is a risk factor for the development of OHL.

Oral hairy leukoplakia in an HIV-negative patient

We report the case of a 31-year-old woman with systemic lupus erythematosus who was found to have oral hairy leukoplakia (OHL). She was on immunosuppressive therapy but was human immunodeficiency virus (HIV)-negative. OHL has been previously reported in HIV-negative patients who were immunosuppressed for other reasons, such as solid organ or hematopoietic stem cell transplantation, hematologic malignancies, or systemic diseases. To the best of our knowledge, this is the first case of OHL in an HIV-negative patient reported in the otolaryngology literature. It adds to the growing list of cases of OHL in HIV-negative patients and serves as a reminder to physicians to include OHL in the differential diagnosis for oral cavity lesions in all immunosuppressed patients. The article also summarizes the current state of knowledge about the pathogenesis of OHL, its relation to the Epstein-Barr virus, and the treatment options.

Prevalence of Oral Manifestations and Their Association with CD4/CD8 Ratio and HIV Viral Load in South India

The objective of the present research was to determine the prevalence of oral manifestations in an HIV infected population from south India and evaluate their association with HIV viral load and CD4/CD8 ratio. Intraoral examination of 103 patients, whose CD4/CD8 ratio was available, were conducted. HIV viral loads were available for thirty patients only. The prevalence of oral manifestations was 80.6% (83/103). The most common oromucosal lesion was erythematous candidiasis (EC) (38.8%) followed by melanotic hyperpigmentation (35.9%). Patients having any oral manifestation had a mean CD4/CD8 ratio of 0.24. EC had positive predictive value of 85.0% for CD4/CD8 ratio <0.30. The prevalence of oral manifestations in patients taking ART was lesser (78.6%) as compared to patients not taking ART (82%). Patients having any oral manifestation had a higher HIV viral load as compared to patients not having any oral manifestations (P < 0.05). Pseudomembranous candidiasis (PC) was significantly associated with higher HIV viral loads (>20,000 copies/mL) (P < 0.05). Patients having EC had 4 times greater chance of having CD4/CD8 ratio <0.30. PC can be considered as a marker of immune suppression (HIV viral load >20,000 copies/mL).

White lesions

Increased thickness of the epithelium imparts a white appearance to the oral mucosa by increasing the distance to the underlying blood vessels. Usually this thickening is a result of the increased formation of keratin. Some other less common causes of white lesions are acanthosis or a thickening of the spinous cell layer, edema of the epithelium, or increased fibrosis of the connective tissue thereby reducing blood vessels. Occasionally the surface of an ulcer may appear white, due to collection of fibrin on the surface. In this article the authors discuss white lesions based on putative etiology, that is, hereditary, reactive, inflammation related, immunologic, traumatic, infection related, and idiopathic.

Oral Hairy Leukoplakia in HIV-Negative Patients: Report of 10 Cases

Ten cases of oral hairy leukoplakia (OHL) in HIV- negative patients are presented. Eight of the 10 patients were on steroid treatment for chronic obstructive pulmonary disease, 1 patient was on prednisone as part of a therapeutic regimen for gastrointestinal stromal tumor, and 1 patient did not have any history of immunosuppression. There were 5 men and 5 women, ages 32-79, with mean age being 61.8 years. Nine out of 10 lesions were located unilaterally on the tongue, whereas 1 lesion was located at the junction of the hard and soft palate. All lesions were described as painless, corrugated, nonremovable white plaques (leukoplakias). Histologic features were consistent with Epstein—Barr virus—associated hyperkeratosis suggestive of OHL, and confirmatory in situ hybridization was performed in all cases. Candida hyphae and spores were present in 8 cases. Pathologists should be aware of OHL presenting not only in HIV-positive and HIV-negative organ transplant recipients but also in patients receiving steroid treatment, and more important, certain histologic features should raise suspicion for such diagnosis without prior knowledge of immunosuppression.

Detection of the Epstein-Barr virus (EBV) by in situ hybridization as definitive diagnosis of hairy leukoplakia

Histopathological findings in cases of hairy leukoplakia (HL) are not exclusive to this lesion. A total of 36 tissue samples from patients previously diagnosed with HL based solely on morphological aspects were used in this study. Our purpose was to confirm the presence of Epstein-Barr virus (EBV) in these tissue samples by in situ hybridization (ISH), and to compare the detection of EBV with specific histopathological findings observed in each case. Among the 36 specimens, 80.55% were EBV positive, confirming the previous clinical and histhophatological diagnosis. None of the histopathological findings analyzed correlated with the presence or absence of EBV. This shows that a definitive diagnosis of HL cannot be established based on histopathological findings alone. Because there are many important implications on the establishment of definitive diagnosis of HL, the detection of EBV by ISH is obligatory.

Epstein-Barr virus in oral diseases

Epstein-Barr virus (EBV), a B-lymphotropic gamma-herpesvirus, causes infectious mononucleosis and oral hairy leukoplakia, and is associated with various types of lymphoid and epithelial malignancies. Saliva is the main vehicle for EBV transmission from individual to individual. Recent studies have also implicated EBV in the pathogenesis of advanced types of periodontal disease. EBV DNA is detected in 60-80% of aggressive periodontitis lesions and in 15-20% of gingivitis lesions or normal periodontal sites. The periodontal presence of EBV is associated with an elevated occurrence of periodontopathic anaerobic bacteria. Moreover, EBV active infection occurs in approximately 70% of symptomatic and large-size periapical lesions. EBV and cytomegalovirus often co-exist in marginal and apical periodontitis. Periodontal therapy can markedly suppress the EBV load in periodontal pockets as well as in saliva, which has the potential to reduce the risk of viral transmission between close individuals. EBV proteins up-regulate cytokines and growth factors, which seem to play a central role in the proliferative response of tongue epithelial cells in oral hairy leukoplakia and in the cell-transformation process of EBV-associated malignancies. Further research is needed to identify the full range of EBV-related diseases in the human oral cavity.

Detection of Epstein-Barr virus (EBV) in the oral mucosa of renal transplant patients

The purpose of this study was to determine the prevalence of Epstein-Barr virus (EBV)-DNA in the oral mucosa of renal transplant patients and observe the efficacy of mouth rinses with phosphate-buffered saline (PBS) to eliminate EBV present in the saliva. Lingual, gingival, and buccal cytobrushings were obtained from normal oral mucosa of 10 renal transplant patients and 10 normal subjects, and were examined through polymerase chain reaction (PCR), before and after rinses with PBS. EBV-DNA was detected in 86.6% of renal transplant recipients and in 46.6% of healthy subjects. No significant difference was observed between oral scrapes obtained before and after rinses with PBS with regard to detection of EBV-DNA. Our results suggest that the use of PCR to detect the presence of EBV-DNA in oral mucosa in the absence of specific lesions gives rise to the problem of identifying the viral replication sites. In addition, PBS was not effective at minimizing contamination by saliva.

Virologic Diagnosis, Viral Monitoring, and Treatment of Epstein-Barr Virus Infectious Mononucleosis

Epstein-Barr virus (EBV) is the cause of infectious mononucleosis and is associated with severe infections in immunocompromised patients. EBV is also causally linked with several human malignancies. The heterophile antibody test and EBV-specific antibody tests remain the principal means of diagnosis of initial infection in otherwise healthy patients. Enzyme-linked immunosorbent assays have replaced the traditional immunofluorescence assays for EBV-specific antibodies. Several newer molecular diagnostic tests have become available that facilitate accurate monitoring of infection. The role of these tests for patients with uncomplicated infectious mononucleosis is limited, although these tests are being increasingly used to monitor the state and level of EBV replication for severe infections and among immunocompromised patients. Antiviral therapy has a limited, short-term effect on oropharyngeal shedding but has proven ineffective for the clinical manifestations of infectious mononucleosis. Patients with selected complications frequently benefit from short-term corticosteroid therapy.

A non-invasive technique for studying oral epithelial Epstein-Barr virus infection and disease

Oral Epstein-Barr virus (EBV) infection is associated with hairy leukoplakia and possibly other oral diseases. Many studies of oral EBV infection utilize surgical specimens. This study tested a non-invasive brush biopsy technique as an alternative to surgical biopsy to study oral EBV infection and disease. Paired, same-site, samples of tongue epithelium were obtained from research subjects, first by brush and then by surgical biopsy. Brush cells and surgical specimens were fixed and prepared for histologic sectioning and/or processed for nucleic acid extraction. Brush cell pellet sections proved equivalent to surgical specimen tissue sections for hairy leukoplakia diagnosis by routine histologic staining and EBV immunohistochemistry or in situ hybridization. Amplification of EBV sequences demonstrated superiority of the brush cells over surgical specimens for both sensitivity (90% vs. 73%) and negative predictive value (93% vs. 82%). This non-invasive brush biopsy technique should facilitate larger, prospective studies of oral EBV infection and pathogenesis.

A retrospective analysis of oral hairy leukoplakia in South Australia

BACKGROUND

The features of oral hairy leukoplakia (OHL) have been widely reported in the literature. However, no studies have described this lesion in the Australian setting. This study retrospectively examines, with respect to specific clinical factors, the prevalence of OHL in a South Australian HIV-infected population.

METHODS

Clinical data were collected from the records of 197 HIV-infected patients who had attended the Adelaide Dental Hospital between January 1986 and February 1995. Data were analysed using the chi-square test.

RESULTS

The prevalence of OHL in South Australian HIV-infected patients was 45.2 per cent. The study found the presence of OHL was not related to CD4+ T-lymphocyte count or AIDS-defining illness nor did the length of time a patient had been infected with HIV relate to the presence of OHL. An association was observed between a reduced prevalence of OHL in patients who were taking antiviral medication.

CONCLUSION

The prevalence of OHL in South Australia is comparable with results of other studies. This study supports the notion that OHL is not an indicator of immunosuppression in South Australian HIV-infected patients. Further longitudinal studies are required to ascertain the relationship of OHL to HIV disease progression.

Natural history of HIV-1 infection

Infection with the human immunodeficiency virus type 1 (HIV-1) results in progressive loss of immune function marked by depletion of the CD4+ T-lymphocytes, leading to opportunistic infections and malignancies characteristic of AIDS. Although both host and viral determinants influence the rate of disease progression, the median time from initial infection to the development of AIDS among untreated patients ranges from 8 to 10 years. The clinical staging of HIV disease and the relative risk of developing opportunistic infections historically relied on the CD4+ T-lymphocyte counts. Although more recent studies have shown the importance of viral load quantitation in determining the rate of disease progression, it is still useful to categorize HIV disease stage on the basis of the degree of immunodeficiency: early disease (CD4+ > 500 cells/mL), mid-stage disease (CD4+ between 200 and 500 cells/mL), and end-stage disease (CD4+ < 50 cell/mL). This article reviews the natural history of HIV disease at each stage of HIV-1 infection with emphasis on acute infection and the major virologic and immunologic determinants of disease progression.

Clinical management of selected oral fungal and viral infections during HIV-disease

The purpose of this review is to describe current possibilities of management of selected fungal and viral oral opportunistic infections including oral candidiasis, herpes simplex type 1 and 2-related lesions (HSV1,2), oral hairy leukoplakia (OHL) and oral lesions associated with human papilloma viruses (HPV). Less common diseases such as cytomegalovirus infection or human herpes virus type 8 associated with Kaposi's sarcoma and others are not considered. In a number of instances lifelong therapy or prophylaxis has to be instituted. Antiretroviral combination therapy, also called highly active antiretroviral therapy (HAART), has considerably changed the frequency of oral lesions caused by opportunistic agents. A short description of the antiretroviral agents available including respective side-effects is presented.

Oral lesions in organ transplant patients

Patients who have undergone organ transplantation can present with a variety of oral lesions that appear to be related either directly to their medication or arise as a consequence of drug-induced immunosuppression. Such lesions include hairy leukoplakia, an increased propensity to both fungal and viral infections and a high incidence of malignant change, especially lip cancer. Cyclosporin remains the immunosuppressant of choice in most transplant patients. Gingival overgrowth is the main unwanted oral effect associated with cyclosporin. Some 30% of dentate transplant experience this problem, which is further compounded by concomitant medication with a calcium channel blocker. This review appraises the various oral problems that can arise in this group of patients and emphasises the importance of regular oral screening and the establishment of links with the various transplant teams.

Epidemiology of HIV-related oral manifestations in women: a review

OBJECTIVE

(1) To assess the extent of knowledge acquired since 1981 on the epidemiology of HIV-related oral manifestations in women; (2) to determine if these findings differ by gender; and (3) to assess the needs and direction for future epidemiologic research on oral disease and HIV infection in women in relation to men.

DATA IDENTIFICATION

A computer-assisted search was conducted to identify epidemiologic studies reporting the frequency of various oral conditions in HIV-infected women. Studies on periodontal disease as manifestation of HIV infection were not included.

DATA EXTRACTION

Methods used in the retrieved articles were reviewed with respect to target population, study design, sampling scheme, outcomes, measurements and statistical issues. Results were summarized in relation to oral findings in HIV-infected men.

RESULTS OF DATA SYNTHESIS

Most studies were prospective, and sample selection was non-random. Studies differed with respect to geographic location, risk category for HIV transmission, and stage of HIV disease. Despite these differences, oral lesions were found in at least 15% of HIV-infected women, and the most common oral lesion in all studies was candidiasis. Women differed from men with respect to the prevalence of hairy leukoplakia and Kaposi's sarcoma (KS) both of which were significantly less common in women.

CONCLUSION

Future epidemiologic studies should be directed at identifying cofactors involved in addition to Epstein-Barr virus (EBV) in the development of hairy leukoplakia, and in addition to KS herpes virus (KSHV) in the occurrence of KS.

HIV-associated oral lesions: prevalence in Zambia

OBJECTIVES

To describe the prevalence of HIV-associated oral lesions in known HIV+ subjects in Zambia and assess the predictive value of these lesions to identify individuals with CD4 cell counts less than 200 x 10(6) L-1.

SETTING

St Francis Hospital, situated in the rural Katete District, Eastern Province, Zambia.

SUBJECTS

107 newly diagnosed heterosexual HIV positive individuals included 42% males and 58% females (mean age 34.5, range 16-62).

METHODS

Following a medical history and detailed oral examination, blood and whole saliva were collected in each subject.

RESULTS

A total of 47.7% from this sample had an AIDS diagnosis. The mean CD4 count was 252.2 cells mm-3 (s.d. +/- 160.5, range 44-810); 40.2% of the study group demonstrated oral lesions associated with HIV seropositivity. Candidiasis was most commonly seen (25% prevalence). In this population erythematous candidiasis was the only oral lesion significantly associated with CD4 counts of less than 200 x 10(6) L-1 (P < 0.05, Two-tailed Fisher's Exact Test).

CONCLUSION

In resource poor countries a thorough oral examination may suggest HIV infection and predict disease progression. Health care professional education regarding the orofacial manifestations of HIV infection needs urgent reinforcement in these areas.

Oral hairy leukoplakia in 71 HIV-seropositive patients: clinical symptoms, relation to immunologic status, and prognostic significance

BACKGROUND

Oral hairy leukoplakia (OHL) is a benign hyperplasia of the oral mucosa that is induced by Epstein-Barr virus. It occurs nearly exclusively in men infected with HIV. OHL is a marker of moderate to advanced immunodeficiency and disease progression in patients with HIV infection.

OBJECTIVE

We attempted to determine the clinical characteristics of OHL in a large group of patients infected with HIV and to analyze its relation to immune status and prognosis.

METHODS

A total of 456 patients with HIV-associated skin disorders were evaluated during the years 1982 through 1992. All patients had an oral examination. CD4+ cell counts were obtained within 3 months of the examination.

RESULTS

OHL was diagnosed in 15.6% of 456 patients. The median age of the patients was 35 years. OHL was found most often on the lateral aspect of the tongue; in one patient the lesion covered the entire dorsal surface of the tongue. Significant immunosuppression was present in the majority of patients at the time of OHL diagnosis (median CD4+ T-lymphocyte count, 235/microliter; median CD4+/CD8+ ratio, 0.3). The median survival time was 20 months in patients with OHL. In patients with a higher CD4 cell count (CD4+ T lymphocyte count, > or = 300/microliter) the diagnosis of OHL was associated with shorter survival times (median survival time, 25 months) compared with other patients with HIV (median survival time, 52 months).

CONCLUSION

OHL is a frequent finding in patients with HIV and indicates advanced immunosuppression. Even in patients with more than 300/microliter CD4+ T lymphocytes, OHL is associated with a poor prognosis.

Pseudomembranous oral candidiasis in HIV infection: ultrastructural findings

A light and electron microscopic investigation of pseudomembranous candidiasis in HIV infection was undertaken as there is little data available on the ultrastructural features of the invasive phase of Candida in this disease. On examination of biopsy specimens of four patients, histopathology revealed the classic features of superficial candidiasis, including hyphal penetration down to the spinous cell layer, parakeratosis, acanthosis and spongiosis of the infected, superficial epithelium. However, in one case, hyphae traversed the entire epithelium and crossed the basal membrane, invading the adjacent connective tissue. Ultrastructural investigations revealed initial hyphal penetration through the intercellular spaces, possibly demonstrating thigmotropism. However, hyphal penetration was not solely confined to intercellular spaces, as some specimens demonstrated hyphal elements traversing both the cytoplasm and the nuclei of the spinous cells. In these areas of the epithelium appressoria-like appendages were often found at the hyphal tip. These phenomena, commonly described in plant fungi, have rarely been described in human material. Pools of desmosomes were seen in the vicinity of the hyphal pathways, implying that the penetration procedure is associated with detachment and congregation of desmosomes, possibly by enzymatic means. Interestingly, the host immune response to fungal invasion appeared to be minimal, as no immune-effector cells were seen closely associated with either the blastospores or the hyphae in any of the tissues examined. Whether the foregoing events are exaggerated by the abortive immune response seen in HIV-infected patients, or common in immunocompetent individuals during candidal invasion of epithelia, needs to be ascertained by further studies.

Median rhomboid glossitis. An oral manifestation in patients infected with HIV

A follow-up study included the oral examination of 39 persons known to be infected with the human immunodeficiency virus. In addition to the other human immunodeficiency virus-associated oral lesions, lesions clinically similar to the smooth form of median rhomboid glossitis, which is now believed to be erythematous candidiasis located in the dorsum of the tongue, were found in seven patients (18%). Patients with median rhomboid glossitis were classified in different stages of the Centers for Disease Control 1986 classification system and showed an average of CD+4 cell counts 397.5/mm3. Also the presence or the absence of anti-p24 antibodies in the serum and stimulated whole saliva of the patients with median rhomboid glossitis did not correlate with the stage of the disease or with low levels of CD+4 cell counts as in other forms of oral candidiasis. Therefore our results suggest that median rhomboid glossitis should be included as a distinct form of oral candidiasis in the classification of the oral manifestations of infection with the human immunodeficiency virus.

Oral manifestations associated with HIV-related disease as markers for immune suppression and AIDS

BACKGROUND

Oral lesions are common findings in HIV-related disease, but little is known about their significance in predicting immune suppression among a representative group of HIV-infected persons.

METHODS

Oral examinations were performed on 454 patients who came to an outpatient dental clinic for dental care. CD4+ cell counts were obtained within 2 months of the examination.

RESULTS

In persons with a specific lesion and a CD4+ cell count below 200 cells/mm3 the corresponding mean CD4+ cell counts and predictive values were 149.5 cells/mm3 and 69.9% for candidiasis, 143.3 cells/mm3 and 70.1% for oral hairy leukoplakia, 126.0 cells/mm3 and 69.4% for xerostomia, 51.8 cells/mm3 and 95.1% for necrotizing ulcerative periodontitis, 98.7 cells/mm3 and 87.0% for long-standing herpes simplex virus infections, 66.6 cells/mm3 and 93.6% for Kaposi's sarcoma, and 33.7 cells/mm3 and 100% for major aphthous ulcers. The mean CD4+ cell count declined with increased numbers of different concurrent lesions.

CONCLUSION

The presence of specific oral manifestations and the number of different concurrent intraoral lesions among HIV-infected persons are associated with severe immune suppression and AIDS. Oral examinations are an essential component for early recognition of disease progression and comprehensive evaluation of HIV-infected patients.

Epstein-Barr virus in lingual epithelium of liver transplant patients

Thirty-three liver transplant patients and 20 controls were examined for the presence of EBV in epithelium of the lateral border of the tongue by negative staining electron microscopy. Five of the specimens (15%) showed particles typical of the herpes virus family, while all controls were negative for EBV. In 3 of the 5 patients moderate oral hairy leukoplakia was observed clinically. Our results indicate that EBV may be expressed at the lateral border of the tongue of liver transplant patients, who in some cases show oral hairy leukoplakia clinically.

Hairy leukoplakia after bone marrow transplantation

Hairy leukoplakia in 10 patients after bone marrow transplantation was identified clinically and assessed histologically. In situ hybridization for Epstein-Barr virus and human papilloma virus confirmed Epstein-Barr virus in hairy leukoplakia in two cases, and human papillomavirus in three cases. All cases with clinical follow-up resolved without treatment. These findings suggest that severe immunosuppression after a bone marrow transplantation may result in the development of hairy leukoplakia, and that as the immunosuppression resolves after the transplant the lesions also resolve.

Epstein-Barr virus latent and replicative gene expression in oral hairy leukoplakia

Oral hairy leukoplakia is an epithelial lesion of the tongue associated with productive infection by Epstein-Barr virus (EBV). However, no data concerning the pattern of EBV latent gene expression have been reported, and it remains unresolved whether true latent infection occurs in basal cell layers of oral hairy leukoplakia. We have studied six cases of oral hairy leukoplakia using monoclonal antibody immunohistology for EBV latent--EB nuclear antigen (EBNA) 1, EBNA 2 and latent membrane protein 1 (LMP 1); immediate-early (BZLF1); and replicative (EA, VCA, MA) proteins, and for the EBV-receptor (CD21 antigen). EBV DNA was demonstrated by nucleic acid in situ hybridization. Mid- to upper-zone keratinocytes contained EBV DNA and co-expressed EBNA 1, EBNA 2 (5 of 6 cases), LMP 1, BZLF1 protein, EA, VCA and MA. No EBV genome or gene expression could be demonstrated in basal or parabasal cells. Spinous keratinocytes were labelled by anti-CD21 antibodies HB5 and B2, but did not express the EBV-receptor as defined by reactivity with OKB7. The co-expression of latent and replicative infection-associated antigens is striking, indicating possible functional roles for latent proteins during the productive cycle. Our results suggest that oral hairy leukoplakia is caused by repeated direct infection of upper epithelial cells with virus from saliva or adjacent replicatively infected cells, rather than by a latent EBV infection of basal epithelial cells with a differentiation-dependent switch to productive infection as previously proposed.

Oral signs and symptoms in 160 Greek HIV-infected patients

One hundred and sixty HIV-infected Greek patients were prospectively examined and the oral signs and symptoms were recorded. At the time of oral examination, 76 patients were asymptomatic seropositive, 47 were in ARC stage and 37 had AIDS. One or more oral findings were recorded in 90.6% of the patients while a total of 33 different lesions were observed. The more common oral lesions (highly suspicious) were candidiasis (61%), hairy leukoplakia (24%), periodontitis (19%), necrotizing gingivitis (11%) and Kaposi's sarcoma (12%). In addition some unclassified lesions or symptoms (xerostomia 26%, burning mouth syndrome 19%, patchy depapillated tongue 16%, hairy tongue 10%, exfoliative cheilitis 4%), were common while submandibular and cervical lymph node enlargement were found in 49% of the patients. Interestingly in 16 patients (10%) the suspicion of HIV infection was exclusively based on oral lesions. Our findings show that oral signs and symptoms are common and some times early manifestations of HIV infection and it is in association to those reported in previous studies.

Immunocytochemical detection of herpes viruses in oral smears of HIV-infected patients

Cytologic smears (CS) were taken from the lateral border of the tongue of HIV-seropositive patients (HIV+) (n = 39) and of seronegative controls (HIV-) (n = 19) and examined by immunocytochemistry (APAAP) and in situ hybridization (ISH) (biotinylated DNA probes) for the presence of viral antigens/DNA of EBV and CMV. While none of the HIV controls showed positive results for EBV antigen, 61% (APAAP) resp. 79% (ISH) of oral epithelial cells in the group of HIV+ patients were EBV-positive. While all CS taken from areas with the clinical diagnosis of hairy leukoplakia (HL) were EBV positive (APAAP and/or ISH), the detection of EBV in CS from uninvolved oral mucosa seemed to be associated with the later development of HL. In the group of HIV+ patients the detection rate for CMV was about five times (APAAP) resp. three times (ISH) higher than in HIV- persons. This non-invasive technique seems to be a valuable tool to screen for viral antigens/genomes.

The oral mucosa as a mirror of general health or disease

There is a close relationship between general health/disease and oral mucosal reactions. Many diseases show unspecific or specific changes which may evolve throughout the course of the disease but the mucosal reaction may also constitute the initial clinical sign of the disease. Among the broad spectrum of conditions/diseases, three have been selected for this review--HIV/AIDS, Sjögren's syndrome and lichen planus. They illustrate how general disease may be mirrored in the oral mucosa. An attempt has been made to describe the scientific frontiers and to select pertinent key or review articles or books from among the huge amount of literature published in recent years.

Significance of oral hairy leukoplakia

Since the original description of oral hairy leukoplakia among homosexual men in San Francisco in 1984, this white lesion of the tongue has been seen in the mouths of persons infected with the human immunodeficiency virus (HIV) worldwide. Its presence in HIV-positive persons usually but not always indicates fairly rapid progression to acquired immunodeficiency syndrome in the absence of antiretroviral therapy. Although the lesion appears to be common in HIV-positive persons, it is also, albeit rarely, seen in other conditions associated with immunosuppression. Epstein-Barr virus is associated with and presumably causes hairy leukoplakia, and the lesion offers insights into the biology of this ubiquitous DNA-oncogenic virus.

Oral hairy leukoplakia: clinical aspects, histologic morphology and differential diagnosis

Clinical and histologic morphology of oral hairy leukoplakia in 85 HIV-positive patients were studied. Differential diagnosis of oral hairy leukoplakia in comparison with the normal lingual and buccal epithelium from both HIV-positive and HIV-negative patients, and with other tongue conditions was also examined. Oral hairy leukoplakia lesions were located on the lateral borders of the tongue and showed a corrugated/hairy aspect in the majority of cases. Hyperparakeratosis, hyperplasia/acanthosis, and a papillated epithelial surface were common findings. A parakeratin band and ballooning cells were present in 60% and 99% of the cases, respectively. Some of the histologic features of oral hairy leukoplakia were present in the normal lingual epithelium of both HIV-negative and HIV-positive patients as well as in other tongue conditions. Thus, many histologic features of oral hairy leukoplakia appear not to be specific.

Expression of proteins encoded by Epstein-Barr virus trans-activator genes depends on the differentiation of epithelial cells in oral hairy leukoplakia

The Epstein-Barr virus (EBV) immediate early gene product BZLF1 was localized by indirect immunofluorescence to the cytoplasm of the basal epithelial layer at the lateral border and dorsum of tongue in human immunodeficiency virus-infected and -seronegative patients. Two biopsies of oral hairy leukoplakia revealed a sporadic cytoplasmic staining of the BHRF1 and BRLF1 gene products in the basal epithelial layer. The widespread presence of BZLF1 in the basal epithelial layer indicated that this cell layer contained EBV DNA and was probably directly infected by EBV. Nuclear localization of the immediate early and early gene products BZLF1, BHRF1, BRLF1, and BMLF1 was limited to oral hairy leukoplakia in human immunodeficiency virus-seropositive patients and revealed a codistribution with the virus capsid antigen. Our results indicate that the epithelium of the tongue is a potential reservoir for EBV and that in heavily immunocompromised patients EBV may move from the cytoplasm to the nucleus with increasing differentiation and be coactivated there during the terminal differentiation of epithelial cells at the lateral border and dorsum of tongue.

Hairy leukoplakia--a histological study

Hairy leukoplakia is a recently described oral mucosal condition seen in immunosuppressed individuals, usually in association with HIV infection, when it is thought to be a sign of decreasing immunocompetence. It probably results from reactivation of infection by Epstein-Barr virus (EBV) and usually presents as bilateral white patches on the lateral borders of the tongue. From a histological study of 20 cases we have found that the typical appearance of hairy leukoplakia is of acanthotic, hyperparakeratinized epithelium with Candida hyphae sometimes present in the parakeratin. A band of EBV infected, koilocyte-like cells is present in the upper part of the prickle cell layers, these cells being swollen and pale staining, with prominent cell borders and perinuclear vacuoles. There is a paucity of inflammation in both the epithelium and lamina propria. An atypical appearance shows the koilocyte-like cells lying isolated or in small groups, irregularly arranged in the prickle cell layer and without a hyperparakeratinized surface. Diagnosis of hairy leukoplakia should normally be confirmed by demonstrating EBV in the koilocyte-like cells by immunocytochemistry or DNA in situ hybridization.

Demonstration of Epstein-Barr virus in scrape material of lateral border of tongue in heart transplant patients by negative staining electron microscopy

Scrape material from the lateral border of the tongue of 50 heart transplant patients and 20 controls was studied for the presence of EBV by negative staining electron microscopy. Mild oral hairy leukoplakia was observed in two cases. Particles of the herpes virus were found in 20% of the specimens. Controls were negative for EBV. The study has shown that EBV may be expressed at the lateral border of the tongue during immunosuppression, occasionally resulting in the clinical appearance of hairy leukoplakia.

Oral manifestations of HIV infection and their management. I. More common lesions

Oral lesions are common at all stages of HIV infection. This first of two articles reviews the clinical features and pathogenesis of common oral manifestations of HIV disease (candidiasis, hairy leukoplakia, Kaposi's sarcoma, and HIV-related periodontal disease) and considers current treatment measures.

Diagnosis of Epstein-Barr virus infection in hairy leukoplakia by using nucleic acid hybridization and noninvasive techniques

The presence of Epstein-Barr virus (EBV) DNA in the epithelial cells of oral hairy leukoplakia is the confirming criterion in the diagnosis of this lesion, which occurs mainly in persons infected by the human immunodeficiency virus. Because hairy leukoplakia often presages the development of the acquired immune deficiency syndrome, it is important that suspicious lesions be accurately diagnosed. Commonly, biopsy tissue is removed for detection of EBV DNA by in situ hybridization, but biopsy is contraindicated in some patients. This study evaluated filter and cytospin in situ hybridization, two noninvasive techniques that examine epithelial cells swabbed from the surfaces of the lesions, for their sensitivity in detecting EBV DNA. As compared with tissue in situ hybridization, the filter and cytospin techniques had sensitivities of 100 and 92%, respectively. We conclude that these two noninvasive techniques can provide the clinician with an accurate alternative to biopsy whenever this human immunodeficiency virus-associated lesion is suspected.

Oral lesions in Mexican HIV-infected patients

One hundred and twenty-five HIV-infected patients, of whom 49 (39%) were at early stages of the infection (CDC-II & III) and 76 (61%) in CDC IV, were prospectively examined. In 100 (80%) one or more oral mucosal lesions were observed; candidiasis (51%) and hairy leukoplakia (43%) were the commonest. Erythematous candidiasis was more often seen (35%) than the pseudomembranous type (16%), and appeared with the higher values at early than later stages. The prevalence of hairy leukoplakia, oral hyperpigmentation and xerostomia were incremented in groups CDC-IV. Pseudomembranous candidiasis and exfoliative cheilitis increased significantly with severity of disease. Our study demonstrates that oral alterations associated to HIV are a frequent finding, both at early (76%) and late (83%) stages of the infection in Mexican patients.

Negative staining EM for the detection of Epstein-Barr virus in oral hairy leukoplakia

The performance of two different EM techniques applied for the detection of Epstein-Barr Virus (EBV) in oral hairy leukoplakia (HL) was assessed, i.e. the conventional two-step method of negative staining (CNS) and negative staining after Airfuge enrichment (ANS). Scrape specimens from the lateral borders of tongue of 66 HIV-positive patients with or without HL, of 3 patients with infectious mononucleosis and of 10 HIV-negative patients were evaluated. While CNS resulted in virus detection only in 25% of clinically diagnosed HL cases, EBV was detected by ANS in 85% of clinically suspected cases of HL. Scrape specimens of individuals negative for HIV were negative in EM while 2 of 3 mononucleosis patients were positive without clinical evidence for HL. Due to this high sensitivity the method of negative staining after Airfuge enrichment appears to be useful in the diagnosis of HL. The finding of EBV in clinically normal oral mucosa in HIV-seropositive individuals is interesting and indicates that EBV expression may precede the clinical appearance of HL.

Oral hairy leukoplakia in an HIV-seronegative heart transplant patient

While oral hairy leukoplakia has been observed predominantly in patients with HIV-infection at various stages, recent reports have shown that HL may also occur in patients immunosuppressed for other reasons. This report describes oral hairy leukoplakia in a heart transplant recipient with negative HIV serology. The histopathologic diagnosis of HL was confirmed by immunohistochemical detection of EBV-VCA in the surface epithelium of the lesion and by negative staining electron microscopy.

Macro- and microanatomy of the lateral border of the tongue with special reference to oral hairy leukoplakia

The macro- and microanatomy of the marginal tongue mucosa were studied. Tissues were harvested from 12 individuals at autopsy. Random sections from six different locations along the margin and serial sections representing three defined section planes to the margin of the tongue were evaluated. Vertical, parallel mucosal folds alternating with shallow grooves were a characteristic macroscopical findings on the lateral border of the tongue. The mucosa presented a non-keratinized epithelium with PAS-positive, lightly stained spinous cells and no or slight inflammatory reaction in the connective tissue. Changes in the epithelium mimicking hyperplasia, acanthosis, keratin projections, and focal parakeratosis could be produced by changing the direction of tissue sectioning. The macro- and microscopical parameters recorded in normal marginal tongue mucosa are among other included in criteria for diagnosing oral hairy leukoplakia. The results emphasize the importance of a thorough knowledge of the normal anatomy of a mucosal site to arrive at reliable diagnostic criteria.