(A3) HIV Phenotypes, oral lesions, and management of HIV-related disease

Evaluation of Sociodemographic Factors and Prevalence of Oral Lesions in People Living with HIV from Cacoal, Rondônia, Amazon Region of Brazil

Background: It is necessary to evaluate and understand the prevalence and risk factors of oral lesions (OL) in people living with HIV (PLWH) who were never studied before. The present study aimed to describe the prevalence of OL and its correlation with CD4⁺ T lymphocytes counts and HIV plasma viral load in PLWH treated in Rondônia. Methods: A cross-sectional study was carried out at Cacoal city, Rondônia state, Northern Brazil. Sociodemographic, epidemiological, immunologic and virological information of 113 PLWH were collected from medical records and dental examination was conducted to diagnose and classify OL in PLWH. Statistical analysis was performed using relative frequency distribution, ANOVA, Kruskal–Wallis, T-student and Mann-Whitney tests. Results: The overall prevalence of oral lesions was 28.3% (32/113), with candidiasis (7/32; 21.8%) and aphthous ulcer (7/32; 21.8%) being the most prevalent. There was a predominance of females, most patients being married, with a low level of education, a family income of 1 to 3 minimum wages and a single partner. An association was observed between the presence of oral lesions and a high viral load, as well as a lower occurrence of oral lesions in individuals with a higher count of CD4⁺ T cells. Conclusions: This study reveals a low prevalence of OL among PLWH, as well as the absence of relationship between HIV viral load, CD4⁺ T cells count and OL high prevalence.

Relationship between CD4+ count, serum inflammatory cytokines, and oral melanotic hyperpigmentation in newly diagnosed HIV-seropositive patients: a nested case-control study

OBJECTIVE

Oral melanotic hyperpigmentation (OMH) in patients with human immunodeficiency virus (HIV) infection has been attributed to the use of antifungal or antiretroviral drugs, as well as HIV-induced cytokine dysregulation. This research aimed to determine the relationship between immunosuppression and cytokine dysregulation in newly diagnosed HIV-seropositive subjects with OMH.

STUDY DESIGN

The study was conducted among newly diagnosed HIV-seropositive patients at the Infectious Disease Clinic, Ibadan, Nigeria. The cases were patients with OMH matched for age and sex with control subjects without OMH. CD4⁺ count and cytokine levels (interleukin-6 and tumor necrosis factor-α) were compared between the cases and control subjects. SPSS version 21 software was used for data analysis.

RESULTS

Seventy newly diagnosed HIV-seropositive patients were studied, which comprised of 35 cases and 35 control subjects. The median CD4⁺ counts for cases and control subjects were 174 cells/mm³ (interquartile range [IQR], 57-250) and 324 cells/mm³ (IQR, 107-424), respectively. Severe immunosuppression (CD4⁺ count, ≤200 cells/mm³) was found in over half of the study participants, being more prevalent among the cases than among the control group (P = .019). Serum cytokine levels did not significantly vary between the cases and control subjects.

CONCLUSIONS

There was a significant association between HIV-OMH and severe immunosuppression in the newly diagnosed HIV-seropositive patients.

Reviewing the oral pigmented lesions of human immunodeficiency virus with emphasis on the effect of highly active antiretroviral therapy

Acquired immunodeficiency syndrome a disease with high mortality rates is caused by the well-known human immunodeficiency virus. The disease is characterized by several opportunistic infections owing to the decreased CD4 lymphocyte counts. Oral manifestations of human immunodeficiency virus are vital as they are one of the early manifestations of the disease. Also, they serve as prognostic markers as they correlate with the CD4 lymphocyte counts of the affected individuals. Human immunodeficiency virus is not only common in the adult population but also can affect pediatric patients through vertical transmission. The initial therapeutic strategy for the management of the virus was only the prevention of opportunistic infections. Later in the mid-1990s, antiretroviral therapy was introduced but there was no significant improvement in prognosis. After the advent of combination therapy or the use of three antiretroviral drugs also known as highly active antiretroviral therapy, there has been a marked reduction in human immunodeficiency virus-associated mortality rates. The highly active antiretroviral therapy has several effects on the oral manifestations of the human immunodeficiency virus. The present paper aims to review the oral pigmented lesions associated with human immunodeficiency virus with an emphasis on the effect of highly active antiretroviral therapy.

Medicinal Plants Used in the Treatment of Human Immunodeficiency Virus

Since the beginning of the epidemic, human immunodeficiency virus (HIV) has infected around 70 million people worldwide, most of whom reside is sub-Saharan Africa. There have been very promising developments in the treatment of HIV with anti-retroviral drug cocktails. However, drug resistance to anti-HIV drugs is emerging, and many people infected with HIV have adverse reactions or do not have ready access to currently available HIV chemotherapies. Thus, there is a need to discover new anti-HIV agents to supplement our current arsenal of anti-HIV drugs and to provide therapeutic options for populations with limited resources or access to currently efficacious chemotherapies. Plant-derived natural products continue to serve as a reservoir for the discovery of new medicines, including anti-HIV agents. This review presents a survey of plants that have shown anti-HIV activity, both in vitro and in vivo.

HIV-Associated Oral Mucosal Melanin Hyperpigmentation: A Clinical Study in a South African Population Sample

Objective. The aim of the study was to determine the prevalence of HIV-associated oral mucosal melanin hyperpigmentation (HIV-OMH) in a specific population of HIV-seropositive South Africans and to analyse the associations between HIV-OMH clinical features and the demographic and immunological characteristics of the study cohort. Material and Methods. This cross-sectional study included 200 HIV-seropositive Black subjects. The collected data comprised age, gender, CD4+ T cell count, viral load, systemic disease, medications, oral site affected by HIV-OMH, extent (localized or generalized), intensity of the pigmentation (dark or light), and smoking and snuff use. Results. Overall, 18.5% of the study cohort had HIV-OMH. Twenty-two and a half percent had OMH that could not with confidence be attributed to HIV infection, and 59% did not have any OMH. There was a significant but weak association between smoking and the presence of HIV-OMH. Conclusions. The prevalence of HIV-OMH in the study population was 18.5%, the gingiva being the most commonly affected site. It appears that the CD4+ T cell count does not play any role in the biopathology of HIV-OMH.

Impact of highly active antiretroviral therapy on oral manifestations of patients with human immunodeficiency virus/acquired immuno deficiency syndrome in South India

BACKGROUND

Human immunodeficiency virus (HIV) infection remains a global health problem, although the development of highly active antiretroviral therapy (HAART) has significantly modified the course of HIV disease into a manageable disease with improved quality-of-life mainly in the developed countries. Very few studies are available regarding effect of HAART on oral lesions in developing countries like India.

AIMS AND OBJECTIVES

The aim was to document and compare oral lesions in HIV-seropositive patients before and after HAART.

MATERIALS AND METHODS

Oral manifestations were recorded in 320 HIV seropositive patients attending to the Voluntary Counseling and Confidential Testing Centre at the Government General Hospital, Guntur, before and after treating with HAART and the results were statistically analyzed using Student's t-test and Chi-square test.

RESULTS

Oral Candidiasis was significantly reduced in patients under HAART after 3 months. Furthermore, there was decreased incidence of periodontal diseases, but increased hyperpigmentation in patients undergoing HAART.

CONCLUSION

The oral manifestations of HIV infection have changed due to the advent of HAART. Many opportunistic infections have resolved as a result of an improved immune system. Though the risk of hyperpigmentation in those with HAART has increased the prevalence of oral candidiasis and periodontal diseases were less in patients who had access to HAART.

Melanocyte biology and function with reference to oral melanin hyperpigmentation in HIV-seropositive subjects

The color of normal skin and of oral mucosa is not determined by the number of melanocytes in the epithelium but rather by their melanogenic activity. Pigmented biopolymers or melanins are synthesized in melanosomes. Tyrosinase is the critical enzyme in the biosynthesis of both brown/black eumelanin and yellow/red pheomelanin. The number of the melanosomes within the melanocytes, the type of melanin within the melanosomes, and the efficacy of the transfer of melanosomes from the melanocytes to the neighboring keratinocytes all play an important role in tissue pigmentation. Melanin production is regulated by locally produced factors including proopiomelanocortin and its derivative peptides, particularly alpha-melanocyte-stimulating hormone (α-MSH), melanocortin 1 receptor (MC1R), adrenergic and cholinergic agents, growth factors, cytokines, and nitric oxide. Both eumelanin and pheomelanin can be produced by the same melanocytes, and the proportion of the two melanin types is influenced by the degree of functional activity of the α-MSH/MC1R intracellular pathway. The cause of HIV oral melanosis is not fully understood but may be associated with HIV-induced cytokine dysregulation, with the medications commonly prescribed to HIV-seropositive persons, and with adrenocortical dysfunction, which is not uncommon in HIV-seropositive subjects with AIDS. The purpose of this article is to discuss some aspects of melanocyte biology and HIV-associated oral melanin hyperpigmentation.

Sub-inhibitory concentrations of antifungals suppress hemolysin activity of oral Candida albicans and Candida tropicalis isolates from HIV-infected individuals

Secretion of hydrolytic enzymes such as hemolysin is considered an important virulence attribute of the opportunistic pathogenic fungus Candida. It is known that Candida spp. isolated from HIV-infected patients produce copious hemolysins. As common antifungal agents may perturb the production of extracellular enzymes, we evaluated the effect of three antifungals nystatin, amphotericin B and fluconazole on the hemolytic activity of Candida albicans and Candida tropicalis isolates from HIV-infected individuals. The impact of antimycotics on hemolytic activity was assessed by a previously described in vitro plate assay, after exposing ten isolates each of C. albicans and C. tropicalis recovered from HIV-infected individuals to sub-minimum inhibitory concentrations (sub-MIC) of nystatin, amphotericin B and fluconazole. All Candida isolates showed a significant reduction in hemolytic activity. The reduction was highest for amphotericin B-exposed C. albicans and C. tropicalis followed by nystatin and fluconazole. The effect of antimycotics was more pronounced on the hemolytic activity of C. tropicalis compared to that of C. albicans. Commonly used antifungal agents significantly suppress hemolysin activity of Candida species. This implies that the antifungals, in addition to their lethality, may modulate key virulence attributes of the yeast. The clinical relevance of this phenomenon in HIV disease and other similar pathologies remains to be determined.

Oral lesions, HIV phenotypes, and management of HIV-related disease: Workshop 4A

The workshop considered 5 questions related to oral lesions, HIV phenotypes, and the management of HIV-related disease, with a focus on evidence and challenges in resource-poor settings. First, are oral lesions unique with respect to geographic location or phenotype? Second, how useful would an oral lesion index be to predict HIV in resource-poor countries with no access to CD4 counts or viral load? Third, what are the latest methods and delivery modes for drugs used to treat oral lesions associated with HIV? Fourth, what is the role of the oral health care worker in rapid diagnostic testing for HIV? Fifth, what ethical and legal issues are to be considered when managing the HIV patient? The consensus of the workshop was the need for additional research in 4 key areas in developing countries: (1) additional investigation of comorbidities associated with HIV infection that may affect oral lesion presentation and distribution, especially in pediatric populations; (2) the development of region-specific algorithms involving HIV oral lesions, indicating cumulative risk of immune suppression and the presence of HIV disease; (3) well-designed clinical trials to test new therapies for oral lesions, new treatments for resistant oral fungal and viral diseases, effectiveness of therapies in children, and new drug delivery systems; and (4) the role of the oral health care worker in rapid diagnostic testing for HIV in various regions of the world.

Rhinacanthus nasutus protects cultured neuronal cells against hypoxia induced cell death

Rhinacanthus nasutus (L.) Kurz (Acanthaceae) is an herb native to Thailand and Southeast Asia, known for its antioxidant properties. Hypoxia leads to an increase in reactive oxygen species in cells and is a leading cause of neuronal damage. Cell death caused by hypoxia has been linked with a number of neurodegenerative diseases including some forms of dementia and stroke, as well as the build up of reactive oxygen species which can lead to diseases such as Huntington's disease, Parkinson's disease and Alzeheimer's disease. In this study we used an airtight culture container and the Mitsubishi Gas Company anaeropack along with the MTT assay, LDH assay and the trypan blue exlusion assay to show that 1 and 10 µg mL⁻¹ root extract of R. nasutus is able to significantly prevent the death of HT-22 cells subjected to hypoxic conditions, and 0.1 to 10 µg mL⁻¹ had no toxic effect on HT-22 under normal conditions, whereas 100 µg mL⁻¹ reduced HT-22 cell proliferation. We also used H₂DCFDA staining to show R. nasutus can reduce reactive oxygen species production in HT-22 cells.

In Vitro Activity of 2-methoxy-1,4-naphthoquinone and Stigmasta-7,22-diene-3β-ol from Impatiens balsamina L. against Multiple Antibiotic-Resistant Helicobacter pylori

Infection with Helicobacter pylori is strongly associated with gastric cancer and gastric adenocarcinoma. WHO classified H. pylori as a group 1 carcinogen in 1994. Impatiens balsamina L. has been used as indigenous medicine in Asia for the treatment of rheumatism, fractures and fingernail inflammation. In this study, we isolated anti-H. pylori compounds from this plant and investigated their anti- and bactericidal activity. Compounds of 2-methoxy-1,4-naphthoquinone (MeONQ) and stigmasta-7,22-diene-3β-ol (spinasterol) were isolated from the pods and roots/stems/leaves of I. balsamina L., respectively. The minimum inhibitory concentrations (MICs) and minimum bactericidal concentrations (MBCs) for MeONQ were in the ranges of 0.156–0.625 and 0.313–0.625 μg mL⁻¹, respectively, and in the ranges of 20–80 μg mL⁻¹ both of MICs and MBCs for spinasterol against antibiotic (clarithromycin, metronidazole and levofloxacin) resistant H. pylori. Notably, the activity of MeONQ was equivalent to that of amoxicillin (AMX). The bactericidal H. pylori action of MeONQ was dose-dependent. Furthermore, the activity of MeONQ was not influenced by the environmental pH values (4–8) and demonstrated good thermal (121°C for 15 min) stability. MeONQ abounds in the I. balsamina L. pod at the level of 4.39% (w/w db). In conclusion, MeONQ exhibits strong potential to be developed as a candidate agent for the eradication of H. pylori infection.

Evaluation and treatment of oral candidiasis in HIV/AIDS patients in Enugu, Nigeria

INTRODUCTION

Oral candidiasis is one of the common diseases seen in HIV/AIDS patients. It is rare if CD4+ cell counts are above 500 microl. Outbreaks are more common as the count drops to 100 microl. It may be more difficult to treat when CD4+ cell counts fall below 50 microl.

MATERIALS AND METHODS

A retrospective review of 112 HIV/AIDS patients with lesions in the mouth, head, and neck seen at the oral and maxillofacial surgery units of two public hospitals in eastern Nigeria was carried out between 2000 and 2003. The focus was on oral candidiasis patients. Twenty-nine of these patients, made up of 11 males and 18 females, had oral candidiasis. To compare the action of two drugs, namely, nystatin (a topical antifungal drug) and ketoconazole (a systemic antifungal drug), we treated 15 of the patients with nystatin in the first 2 years and the remaining 14 with ketoconazole in the following 2 years.

RESULTS AND DISCUSSION

Amongst the 15 patients treated with topical drugs, 7 (46.7%) had complete remission, 2 (13.3%) had partial response, 4 (26.7%) remained stationary, and 2 (13.3%) died. Out of the 14 cases treated with systemic drugs, 11 (78.6%) had complete remission, 2 (14.3%) had partial response, and 1 (7.1%) died.

Oral lesions among persons with HIV disease with and without highly active antiretroviral therapy in southern India

BACKGROUND

The advent of highly active antiretroviral therapy (HAART) has changed the scenario of human immunodeficiency virus (HIV) infection. HIV patients in India have now access to generic HAART and this is the first report describing oral lesions in patients on HAART from our country.

METHODS

Oral lesions were studied in HIV seropositive patients (n = 50 on HAART and n = 50 not on HAART) attending a tertiary HIV referral care centre in India and patients on HAART were followed up.

RESULTS

There was a difference in the occurrence of oral candidiasis (OC) between HAART and non-HAART participants (8%, 24%; P < 0.05). Pseudomembranous candidiasis was 4% and 18% in HAART and non-HAART groups respectively (P < 0.05). In patients with CD4 count <or=200, OC was 5.6% in the HAART group and 39.1% in the non-HAART group (P < 0.05). Among patients with CD4 count >200, pigmentation was 43.8% in the HAART group and 14.8% in the non-HAART group (P < 0.05).

CONCLUSION

The prevalence of OC in patients who had access to HAART was less when compared with those who did not have access to HAART.