Racial differences in dermatologic conditions associated with HIV: A cross-sectional study of 4679 patients in an urban tertiary care center

BACKGROUND

Because of reduced mortality, patients with HIV are living longer and presenting with chronic diseases. Little is known about racial differences in dermatologic conditions associated with HIV infection.

OBJECTIVE

This study examines associated dermatologic conditions in a large population of patients with HIV at a tertiary care center with a diverse patient population.

METHODS

Cross-sectional study of patients with HIV seen between July 14, 2013, and July 14, 2018, in a tertiary health care system. The burden of HIV-related dermatologic conditions was collected by using medical records. Patients with HIV were compared with control individuals of the same race, and significance was assessed using the chi-square test. A Bonferroni correction was performed to control for multiple hypothesis testing.

RESULTS

The study population (N = 4679) was 64.7% male and 69% African American, with 88.7% of patients receiving antiretroviral therapy. African American patients with HIV had a greater risk of oral hairy leukoplakia (odds ratio [OR], 64.49), herpes zoster (OR, 9.27), prurigo nodularis (OR, 8.80), and squamous cell carcinoma (OR, 5.72).

LIMITATIONS

Our data describe patients seen by 1 health care system.

CONCLUSIONS

African American patients with HIV may be at increased risk for pruritic disorders compared with race-matched control individuals and white patients with HIV.

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 lesions as an important marker for HIV progression

BACKGROUND

Oral hairy leukoplakia (OHL) is a benign lesion caused by Epstein-Barr virus (EBV) replication in the oral epithelium affecting the borders of the tongue. It is strongly associated with immunosuppression, especially in HIV+ adults but is uncommon in pediatric population. The aim of the study is to show the importance of the correct diagnosis of OHL and its influence on HIV treatment.We report two cases of HIV+ adolescent patients that presented with leukoplakic lesions on the border of the tongue, suggestive of OHL. OHL diagnosis was confirmed in only one case through EBV in situ hybridization. After confirmation of the diagnosis, the patient with OHL was referred to an infectious disease specialist with the decision to start antiretroviral therapy.

CONCLUSION

OHL definitive diagnosis can help clinical management of pediatric HIV+ patients.

Knowledge, attitudes and practices of oral health care workers in Lesotho regarding the management of patients with oral manifestations of HIV/AIDS

Lesotho has the third highest prevalence of HIV in the world with an estimated 23% of the adult population infected. At least 70% of people living with HIV/AIDS (PLWHA) have presented with oral manifestation of HIV as the first sign of the disease. Oral health workers regularly encounter patients presenting with oral lesions associated with HIV disease and therefore need to have adequate knowledge of these conditions for diagnosis and management. The aim of the present study was to determine the knowledge, attitudes and practices of oral health care workers (OHCW) of Lesotho regarding the management of oral manifestations of HIV/AIDS. A descriptive cross-sectional survey was conducted on all 46 OHCW in 26 public and private care facilities in all ten districts of Lesotho. A self-administered questionnaire was used to gather information. The response rate was 100%. Nearly all (94.7%) agreed that oral lesions are common in people living with HIV and/or AIDS. The majority (91.3%) named oral candidiasis (OC) as the most common lesion found in PLWHA while Kaposi's Sarcoma (KS) (34.7%) and Oral Hairy Leukoplakia (OHL) (32.6%) were mentioned as the least common oral lesions of HIV. Most correctly identified the images of oral candidiasis (97.8%), angular cheilitis (86.9%) and herpes zoster (80.4%). Only 16.7% felt they had comprehensive knowledge of oral HIV lesions, although 84.8% reported having previously received training. Almost three quarters (71%) reported that there was no need to treat HIV positive patients differently from HIV negative patients. OHCW in Lesotho demonstrated high confidence levels in their competence in managing dental patients with oral lesions associated with HIV, however, they lacked an in-depth knowledge in this regard. Amongst this group there is a need for comprehensive training with regards to diagnosis and management of oral lesions of HIV including the training of other cadres of health care workers together with nurses and community health workers.

Oral hairy leukoplakia in healthy, immunocompetent individuals

Oral hairy leukoplakia (OHL), while typically associated with HIV infection and immunosuppression, is rarely seen in HIV negative immunocompetent individuals. We report on two cases of OHL in immunocompetent patients.

Oral hairy leukoplakia in patients without HIV: presentation of 2 new cases

OBJECTIVE

We report 2 cases of oral hairy leukoplakia (OHL) in patients without HIV and present a comprehensive review of OHL in HIV-negative individuals.

STUDY DESIGN

Two cases of non-HIV-associated OHL are described. A PubMed search identified previously reported cases. The attributes of those cases were ascertained.

RESULTS

OHL was confirmed in both of our cases. Both patients used inhaled steroids for pulmonary disorders, and were found to have depressed levels of immunoglobulin M. Additionally, 76 cases were identified in the literature. The condition occurred in association with various medical conditions, with the majority of patients on immunosuppressant medications (67 of 76). Systemic drugs were implicated most frequently. The condition has also been reported in healthy individuals (6 of 76).

CONCLUSIONS

Although thought of as an HIV/AIDS-associated condition, OHL can develop in patients without HIV, including healthy individuals. There is a strong correlation between the use of immunosuppressants and development of OHL in these patients.

Oral lesions associated with human immunodeficiency virus disease

Human immunodeficiency virus (HIV)-associated oral disease among people living with HIV infection includes oral candidiasis, oral hairy leukoplakia, Kaposi sarcoma, oral warts, herpes simplex virus ulcers, major aphthous ulcers or ulcers not otherwise specified, HIV salivary gland disease, and atypical gingival and periodontal diseases. Diagnosis of some oral lesions is based on clinical appearance and behavior, whereas others require biopsy, culture, or imaging for definitive diagnosis. Management strategies including pharmacologic and nonpharmacologic approaches are discussed in this article. Dentists also need to be cognizant of the potential oral side effects of HIV antiretroviral medications.

Common tongue conditions in primary care

Although easily examined, abnormalities of the tongue can present a diagnostic and therapeutic dilemma for physicians. Recognition and diagnosis require a thorough history, including onset and duration, antecedent symptoms, and tobacco and alcohol use. Examination of tongue morphology and a careful assessment for lymphadenopathy are also important. Geographic tongue, fissured tongue, and hairy tongue are the most common tongue problems and do not require treatment. Median rhomboid glossitis is usually associated with a candidal infection and responds to topical antifungals. Atrophic glossitis is often linked to an underlying nutritional deficiency of iron, folic acid, vitamin B12, riboflavin, or niacin and resolves with correction of the underlying condition. Oral hairy leukoplakia, which can be a marker for underlying immunodeficiency, is caused by the Epstein-Barr virus and is treated with oral antivirals. Tongue growths usually require biopsy to differentiate benign lesions (e.g., granular cell tumors, fibromas, lymphoepithelial cysts) from premalignant leukoplakia or squamous cell carcinoma. Burning mouth syndrome often involves the tongue and has responded to treatment with alpha-lipoic acid, clonazepam, and cognitive behavior therapy in controlled trials. Several trials have also confirmed the effectiveness of surgical division of tongue-tie (ankyloglossia), in the context of optimizing the success of breastfeeding compared with education alone. Tongue lesions of unclear etiology may require biopsy or referral to an oral and maxillofacial surgeon, head and neck surgeon, or a dentist experienced in oral pathology.

[Progress on study on oral lesions in patients with AIDS]

A large number of studies showed that hairy leukoplakia, pseudomembranous candidiasis, Kaposi' sarcoma, non-Hodgkin's lymphoma, linear gingival erythema, necrotizing ulcerative periodontitis and necrotizing ulcerative gingivitis were the most common lesions in patients with HIV infection and AIDS, and their higher prevalence and incidence rates correlated with the falling CD4 counts and higher virus load of the patients. The use of highly active antiretroviral therapy (HAART) was associated with decreases in the prevalence of oral diseases. Oral manifestations may represent early signs of AIDS disease and call attention to disease progression. Oral fluid has been shown to possess superior sensitivity for HIV antibody detection as serum.

[Frequent and rare dermatological diseases in HIV patients]

HIV patients develop a variety of infectious and non-infectious diseases of the skin and mucous membranes. Some of these serve as indicator diseases for a weakening immune system. While none of the dermatological complications is pathognomonic, conditions such as oral hairy leukoplakia, herpes zoster, thrush, and eosinophilic folliculitis should make physicians consider the possibility of underlying HIV disease. Moreover, one has to consider HIV if these skin diseases take an atypical or severe course, or if they do not respond properly to appropriate medication. Frequent and rare dermatoses occurring in HIV infection are discussed.

Epstein-Barr virus in oral hairy leukoplakia scrapes: identification by PCR

Oral hairy leukoplakia (OHL) is a lesion associated with a compromised immune system, and its diagnosis is determined by the demonstration of the presence of Epstein-Barr virus (EBV) in lesional tissue. The purpose of this article was to develop a simple technique to help the diagnosis of OHL, using PCR as an alternative technique to evidence EBV in scrapings. DNA samples were obtained by scraping the lateral border of the tongue of 38 adult patients: 29 HIV-positive patients (4 with clinical evidence of OHL; 4 with history of OHL, but without lesion at the moment the samples were collected; and 21 without clinical evidence of OHL), and 9 healthy volunteers for the control group. DNA was extracted from scrapes and amplified by PCR using specific primers for EBV. Of the 29 cases of HIV-positive patients, 22 (75.86%) were positive for EBV: 2 patients with clinical evidence of OHL, 4 patients with history of OHL, but without lesion at the moment the samples were collected, and 16 patients without clinical evidence of OHL. In the control group, samples of 5 (55.56%) healthy volunteers presented amplification for EBV. We concluded that the use of PCR in oral scrapes suggests a high sensitivity but low specificity for the diagnosis of OHL.

Secondary syphilis simulating oral hairy leukoplakia

We describe a case of secondary syphilis of the tongue in which the main clinical presentation of the disease was similar to oral hairy leukoplakia. In a man who was HIV seronegative, the first symptom was a dryness of the throat followed by a feeling of foreign body in the tongue. Lesions were painful without cutaneous manifestations of secondary syphilis. IgM-fluorescent treponemal antibody test and typical serologic parameters promptly led to the diagnosis of secondary syphilis. We initiated an appropriate antibiotic therapy using benzathine penicillin, which induced healing of the tongue lesions. The differential diagnosis of this lesion may include oral squamous carcinoma, leukoplakia, candidosis, lichen planus, and, especially, hairy oral leukoplakia. This case report emphasizes the importance of considering secondary syphilis in the differential diagnosis of hairy oral leukoplakia. Depending on the clinical picture, the possibility of syphilis should not be overlooked in the differential diagnosis of many diseases of the oral mucosa.

Oral manifestations associated with HIV infection: evaluation, assessment, and significance

During the course of HIV disease, oral lesions frequently are the initial manifestation of underlying immune deterioration. Typically, these lesions are readily accessible and lend themselves to being examined. Therefore, it is important to perform oral examinations routinely both in dental and medical settings. The recognition and treatment of these early signs of immune suppression may have a significant impact on the survival and the quality of life of HIV-infected patients. This article briefly discusses the HIV epidemic and common intraoral manifestations associated with HIV disease progression.

Applications of continuous time hidden Markov models to the study of misclassified disease outcomes

Disease progression in prospective clinical and epidemiological studies is often conceptualized in terms of transitions between disease states. Analysis of data from such studies can be complicated by a number of factors, including the presence of individuals in various prevalent disease states and with unknown prior disease history, interval censored observations of state transitions and misclassified measurements of disease states. We present an approach where the disease states are modelled as the hidden states of a continuous time hidden Markov model using the imperfect measurements of the disease state as observations. Covariate effects on transitions between disease states are incorporated using a generalized regression framework. Parameter estimation and inference are based on maximum likelihood methods and rely on an EM algorithm. In addition, techniques for model assessment are proposed. Applications to two binary disease outcomes are presented: the oral lesion hairy leukoplakia in a cohort of HIV infected men and cervical human papillomavirus (HPV) infection in a cohort of young women. Estimated transition rates and misclassification probabilities for the hairy leukoplakia data agree well with clinical observations on the persistence and diagnosis of this lesion, lending credibility to the interpretation of hidden states as representing the actual disease states. By contrast, interpretation of the results for the HPV data are more problematic, illustrating that successful application of the hidden Markov model may be highly dependent on the degree to which the assumptions of the model are satisfied.

Case report on a rare lesion in an HIV-infected child: hairy leukoplakia

This report describes a case of hairy leukoplakia in an HIV-infected child, and the treatment adopted. It was diagnosed by clinical and laboratory examinations, using exfoliative cytology (staining by the Papanicolaou method) and additional information was obtained by optical microscope analysis. In view of the lack of painful symptoms, of the innocuous nature of the lesion and large amount of medicines used by the patient, we decided to preserve and monitor the lesion.

Avoiding malpractice for nondental conditions. The example of human immunodeficiency virus

BACKGROUND

Dentists are legally liable for failing to recognize medical conditions that they identify while providing dental care and for failing to refer patients for follow-up care and testing. This article suggests ways to avoid liability using human immunodeficiency virus, or HIV, infection as an example. TYPES OF LITERATURE REVIEWED: The authors conducted a review of the legal literature to determine circumstances that would cause dentists to have legal liability for failing to recognize a medical problem. The authors also conducted a review of the dental literature to identify the most common signs of HIV infection that dentists might see in practice.

RESULTS

The legal literature indicates that dentists can be held liable for failing to recognize medical problems, including HIV and acquired immunodeficiency syndrome. The dental literature shows that there are multiple signs and symptoms that indicate the potential for HIV infection to be the underlying cause of many oral diseases.

PRACTICE IMPLICATIONS

Dentists should be familiar with the most common oral manifestations of medical conditions that are likely to be identified in the dental office, including those associated with HIV infection. They must recognize medical conditions and arrange for appropriate referral to avoid liability.

Ability of HIV/AIDS patients to self-diagnose oral opportunistic infections

OBJECTIVES

To assess the accuracy of HIV/AIDS patients' self-diagnosis of common HIV-related oral opportunistic infections.

METHODS

245 HIV/AIDS patients were interviewed regarding the current presence of oral candidiasis (OC), oral hairy leukoplakia (OHL), and oral ulcers prior to an oral examination by an oral medicine trained dentist examiner. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) are reported for the patient's oral lesion diagnosis compared to the dentist's diagnosis based on established presumptive clinical criteria as the gold standard.

RESULTS

Self-diagnosis accuracy was greatest for pseudomembraneous OC (PPV 42.9%; NPV 93.5%), followed by oral ulcers (PPV 35.7%; NPV 98.3%) and OHL (PPV 23.5%; NPV 86.4%). Past experience with the lesion improved diagnostic accuracy, and bothersome symptoms accompanying the lesion had significant impact only for pseudomembraneous OC and oral ulcers.

CONCLUSIONS

Moderate accuracy of patient self-assessment of oral lesions, with tendency to under rather than over report lesion presence, supports the use of patient self-assessment of these lesions to augment clinician diagnosis in clinical trials. Additionally, HIV/AIDS patients are unlikely to believe they have active OC that would lead to on-demand antifungal use, unless they have had prior experience with the lesion or it is at least moderately bothersome.

Oral hairy leukoplakia: an Epstein-Barr virus-associated disease of patients with HIV

Oral hairy leukoplakia is a common, benign, opportunistic EBV infection of the oral cavity of patients with HIV. It is important to differentiate hairy leukoplakia from other, more serious, oral lesions that may have a similar clinical appearance. In some cases, this is best accomplished by biopsy and histologic examination of the tissue. Several treatment options are available for symptomatic hairy leukoplakia lesions, but none prevent the recurrence of the lesion after therapy. Research studies into the pathogenesis and treatment of oral hairy leukoplakia and other HIV-associated and EBV-associated oral lesions are currently being conducted at the Bering Dental Clinic in Houston.

Oral lesions and conditions associated with human immunodeficiency virus infection in 300 south Indian patients

BACKGROUND

Human immunodeficiency virus infection/acquired immunodeficiency syndrome (HIV/AIDS) is a major health problem in India. The National AIDS Control Organisation (NACO) of India reports a seropositivity of 25.03 per thousand for the whole country, as of October 1999. In spite of this high prevalence there are very few reports of oral lesions and conditions in Indian HIV/AIDS patients, which are important in early diagnosis and management of these patients.

OBJECTIVE AND SETTING

The present report describes the oral lesions in 300 HIV positive symptomatic patients presenting to us at RAGAS-YRG CARE, a non-governmental organisation in Chennai, South India, over a period of 9 months in 1998.

METHOD

Lesions were diagnosed on clinical appearance using international criteria.

RESULTS

Of the 300 patients 89% had acquired the infection through heterosexual contact. There were 205 males and 95 females, aged from 7 months to 72 years. Forty-seven percent of the patients were in the age group 21-30 years. CD4 counts were ascertained for 105 patients, 64 (62%) had CD4 counts < or = 200. A total of 217 (72%) of the 300 patients had some oral lesion when examined. Gingivitis (47%) and pseudomembranous candidiasis (33%) were the most common oral lesions. The other oral lesions seen were oral mucosal pigmentation (23%), erythematous candidiasis (14%), periodontitis (9%), angular cheilitis (8%), oral ulcers (3%), oral hairy leukoplakia (3%), hyperplastic candidiasis (1%), oral submucous fibrosis (2%) and one case of leukoplakia.

CONCLUSIONS

Oral lesions occur commonly in HIV infection. A comprehensive oral examination may not only suggest HIV disease but may also be useful in monitoring the disease progression. This is a cost-effective procedure, which may be useful in screening large populations in developing countries like India.

A simple and rapid technique for the detection of Epstein-Barr virus DNA in HIV-associated oral hairy leukoplakia biopsies

A method of generating nucleic acid probes by polymerase chain reaction (PCR) for the detection of Epstein-Barr virus (EBV)-DNA by in situ hybridization in oral hairy leukoplakia (OHL) lesions is described. This method has the advantage over older methods of being cheaper, quicker and retaining sensitivity and specificity. Purified PCR products of Epstein-Barr virus DNA of 110 bp and 328 bp were labelled with biotin by nick translation or random primer labelling and were compared in in situ hybridization experiments with probes prepared by incorporation of biotin-labelled nucleotides in the PCR reaction mixture, with EBV viral DNA as a template. These probes were applied to 18 OHL tongue biopsies known to be positive for EBV-DNA, using a commercially available biotin-labelled BamHI "V" fragment EBV-DNA probe. To determine the specificity of the probes, we applied them to 20 normal tongue tissue samples and to 12 biopsies taken from keratotic tongue lesions from patients without risk factors for HIV infection and known to be negative for EBV-DNA. Clear positive signals for EBV-DNA were detected in all 18 cases of OHL biopsies using the amplimer of 328 bp labelled by PCR and random primer labelling. However, nick translation labelling was less efficient and sensitive. All control specimens were negative for EBV-DNA.

HIV infection and oral health care in South Africa

This study determined the knowledge, attitude and practice of oral health care workers in public clinics in South Africa towards HIV/AIDS and investigated the implementation of infection control measures. A total of 727 questionnaires were distributed to dentists, dental therapists, oral hygienists and chairside assistants in the public dental clinics of 9 provinces, of which 276 were returned from 8 provinces, giving a response rate of 38%. The questionnaire covered demographic factors and assessed issues such as knowledge, infection control practices, continuing education, legal, ethical and psychosocial issues and available support for HIV/AIDS. The common oral manifestations seen by respondents were candidiasis, acute necrotising ulcerative gingivitis (ANUG), hairy leukoplakia and Kaposi's sarcoma. Of the 174 who had a previous HIV test, 48% were for insurance purposes and 21% for post-needle-stick injury. Over 10% of the respondents indicated that gloves were not available at all, that there was an inadequate supply of water, and that there was no autoclave in their clinic. Nearly 50% of the clinicians had not had hepatitis B vaccination in the last 3 years. Fifteen respondents (5.4%) were not willing to treat HIV-positive patients. Only 48% had access to a written post-exposure management protocol and post-exposure medication was available to only 36.6%. The vast majority of the respondents clearly expressed a need for additional education on HIV/AIDS. The study demonstrated a need to add knowledge, enhance personal skills and improve the application of universal precautions.

Update on precancerous lesions

Oral cancer continues to be a serious problem in the UK and it is well known that prevention and early recognition of potentially malignant lesions will provide the best prognosis. This article discusses recent changes in the nomenclature of lesions and current concepts in diagnosis and management.

Oral hairy leukoplakia: an ultrastructural study and review of the literature

A 39-year-old, homosexual, Caucasian man with a 9-month history of acquired immunodeficiency syndrome by reduced CD4 lymphocyte count alone was found to have extensive, asymptomatic, nonremovable, corrugated, white patches on the lateral borders and ventral aspects of the tongue typical of oral hairy leukoplakia (OHL). Histologically, irregular hyperparakeratosis, acanthosis, and clusters of ballooned keratinocytes in the stratum spinosum were present in the biopsied lateral tongue. Some of the superficial ballooned keratinocytes had peripherally beaded nuclei, whereas others had ground glass intranuclear inclusions. Ultrastructurally, the ballooned keratinocytes had three important findings of diagnostic significance. First, frequent herpesvirus nucleocapsids were largely confined to superficial ballooned keratinocytes having marginated and condensed chromatin. In searching for herpesvirus nucleocapsids, the marginated and condensed chromatin was an invaluable marker for cells harboring the virions. Second, the marginated and condensed chromatin frequently had a distinctive punched-out or cribriform appearance. Third, the ground glass intranuclear inclusion bodies consisted of central, medium electron-dense, finely granular material containing frequent herpesvirus nucleocapsids and partially surrounded or capped by prominent, clumped chromatin. The patient died with progressive multifocal leukoencephalopathy 24 months after OHL was diagnosed.

Comparison of cytopathic changes in oral hairy leukoplakia with in situ hybridization for EBV DNA

OBJECTIVE

It has been observed that the cytopathic changes in hairy leukoplakia (HL) correlate with ultrastructural evidence of intra-keratinocyte herpes-type viral particles. In situ hybridization is considered to be the definitive confirmation of Epstein-Barr virus (EBV)-induced HL. This study evaluated the consistency of histopathological findings, which many believe to be diagnostic, with in situ hybridization for EBV-DNA in 60 patients with lesions clinically suggestive of HL.

MATERIALS AND METHODS

Hematoxylin and eosin (H&E)-stained sections were reviewed independently by three oral pathologists who did not know the hybridization results. The presence in keratinocytes of nuclear inclusions and/or homogenization, believed to be specific for EBV in these lesions, was used as an indicator for infection. Cytoplasmic changes were evaluated separately.

RESULTS

With in situ hybridization, 48 cases were positive and 12 were negative. When the two methods were compared, pathologist concurrence ranged from 83% to 92%. False negatives ranged from 6% to 19%, and false positives ranged from 8% to 25%. Cytoplasmic ballooning, homogenization, and perinuclear clearing were evident in all cases of hybridization-confirmed HL; however, these changes were also noted in 75% (9/12) of the cases with negative hybridization results. Most confirmed HL cases exhibited both nuclear homogenization and inclusions, although the former was more consistently seen.

CONCLUSION

Cytoplasmic changes did not agree well with EBV-DNA hybridization results, whereas nuclear changes demonstrated good, but not complete, agreement. In appropriate clinical settings, the finding of nuclear inclusions and/or homogenization may be of diagnostic value. However, because the potential for false positives and negatives is high, H&E cytopathology should not be used as a substitute for in situ hybridization in the definitive diagnosis of oral hairy leukoplakia.

Oral hairy leukoplakia: clinicopathologic features, pathogenesis, diagnosis, and clinical significance

Oral hairy leukoplakia (OHL) is a lesion frequently, although not exclusively, observed in patients infected by human immunodeficiency viruses (HIV). OHL is clinically characterized by bilateral, often elevated, white patches of the lateral borders and dorsum of the tongue. Histologically, there is profound acanthosis, sometimes with koilocytic changes, and a lack of a notable inflammatory infiltrate. The koilocytic changes are due to intense replication of Epstein-Barr virus (EBV), while epithelial hyperplasia and acanthosis are likely to result from the combined action of the EBV-encoded proteins, latent membrane protein-1, and antiapoptotic BHRF1. How OHL is initiated and whether it develops after EBV reactivation from latency or superinfection remain unresolved; nevertheless, definitive diagnosis requires the demonstration of EBV replicating vegetatively in histological or cytological specimens. In patients with HIV infection, the development of OHL may herald severe HIV disease and the rapid onset of AIDS, but despite its title, OHL is not regarded as premalignant and is unlikely to give rise to oral squamous cell carcinoma.

Is erythematous candidiasis associated with advanced HIV disease?

OBJECTIVES

A multicentre collaborative study by the London HIV and Dentistry Group failed to associate the presence of erythematous candidiasis (EC) with advanced HIV disease. Data from a study of the periodontal health of homosexual men attending a genito-urinary medicine clinic presented an opportunity to investigate social and medical factors related to the presence of EC and mucosal disease.

SUBJECTS AND METHODS

312 men with HIV were examined by a single examiner blinded to HIV status; 22.8% had an indicator condition for AIDS; 37.8% had CD4 lymphocyte counts less than 200 cells mm-3; and 53.8% met the 1993 case definition for AIDS; 59.6% of the men with HIV had oral manifestations of the infection. The most common were: oral hairy leukoplakia, 44.2%; EC, 26.9%; and pseudomembranous candidiasis (PC), 11.5%.

RESULTS

Advanced HIV disease was a less powerful predictor of EC than PC. Advanced HIV disease also predicted the presence of hairy leukoplakia and mucosal ulceration. EC was strongly associated with tobacco use.

CONCLUSIONS

While methodological differences explain some variation with previous research, these data also suggest that EC and PC may not carry the same prognostic significance and longitudinal studies are required to confirm these findings.

Uremic stomatitis mimicking oral hairy leukoplakia: report of a case

Report on an unusual case of uremic stomatitis mimicking oral hairy leukoplakia. The similarities of the two lesions are discussed, and the differential diagnosis reviewed.

Viral lesions of the mouth in HIV-infected patients

Viral lesions of the mouth in patients with HIV infection are common and these diseases any be a marker for HIV and disease progression. We review the spectrum of oral viral manifestations and discuss treatment modalities. The most common Epstein-Barr virus (EBV)-induced disorder in HIV-infected patients is oral hairy leukoplakia. EBV-related oral B-cell and T-cell lymphoma in AIDS patients has been described repeatedly. Herpes virus type 1 and rarely type 2 may lead to painful and resistant oral ulcers, and systemic treatment with acyclovir, valaciclovir or famciclovir is indicated. In acyclovir-resistant cases foscarnet is the treatment of choice. In recent years it has been documented that Kaposi's sarcoma, which often affects oral mucosa, is probably induced by herpesvirus type 8. Cytomegalovirus was found in 53% of cases with herpesviridae-induced mucosal ulcers as the only ulcerogenic viral agent in AIDS patients. In severe cytomegalovirus infection treatment with ganciclovir is helpful. Viral warts induced by different HPV may occur in the mouth. Several physical treatment modalities are possible in the oral mucosa. In AIDS patients mollusca contagiosa may occur as large and atypical lesions in the face and lips and rarely in the oral cavity. Cryotherapy is a bloodless treatment in such patients.

A rapid microwave-in situ hybridization method for the definitive diagnosis of oral hairy leukoplakia: comparison with immunohistochemistry

As a diagnostic technique, in situ hybridization requires a long processing time, a degree of expertise and may be difficult to handle routinely in some laboratories. To simplify the in situ hybridization method, we have modified a microwave in situ hybridization technique and applied it to oral hairy leukoplakia (OHL) biopsies obtained from 10 HIV-seropositive patients (definitively diagnosed by a conventional in situ hybridization technique) with appropriate controls. It was necessary to design a novel chamber to avoid drying of sections during the hybridization step. This modified microwave in situ hybridization technique was equispecific and equisensitive to the conventional technique and it shortens the hybridization time from overnight incubation to 14 minutes. To determine the sensitivity of our microwave in situ hybridization method we applied it to previously documented tongue tissue obtained from an AIDS autopsy without clinical evidence of OHL, but found to contain Epstein-Barr virus (EBV) by conventional in situ hybridization. This tissue specimen acted as a low EBV copy number, positive control. The sensitivity of immunohistochemistry using three different commercial detection kits was compared to that of in situ hybridization on the same tissues, following optimisation steps. This included the use of 2 cycles of primary and biotinylated secondary antibodies (antibody double cycling). Clearly positive signals for EBV were detected in all OHL biopsies with the Vectastain Elite ABC and the Histostain-SP kits. The sensitivity of the three commercial detection kits was evaluated at immunohistochemistry level by their application to the low-EBV copy number positive control specimen. Signals for EBV antigen in the low copy number positive control specimen were obtained only with the Vectastain Elite ABC kit. This indicates that, in this application, use of the Vectastain Elite ABC kit gives comparable sensitivity for immunohistochemistry to that found by in situ hybridiation.

The accurate diagnosis of oral lesions in human immunodeficiency virus infection. Impact on medical staging

OBJECTIVE

To compare identification of oral candidiasis (OC) and oral hairy leukoplakia (OHL) by medical examiners and oral/dental examiners and to assess the impact of these diagnoses on the medical staging of the human immunodeficiency virus (HIV).

DESIGN

Retrospective analysis of data collected by medical and oral/dental examiners at the baseline examination of a prospective study.

SETTING

Homosexual men and men and women who were parenteral drug users residing in New York City, enrolled in a longitudinal cohort study.

SUBJECTS

A total of 245 individuals participated in this study.

MAIN OUTCOME MEASURES

The diagnoses of OC and OHL as recorded in the medical and oral/dental charts were analyzed retrospectively for the same medical and oral/dental evaluation visits. The medical staging of HIV infection based on that evaluation was analyzed concomitantly.

RESULTS

Among homosexual men, the oral/dental examiners diagnosed OC in 11% of the individuals and the medical examiners in 4%. In the same cohort, OHL was diagnosed by the oral/dental examiners in 14% of the individuals and by the medical examiners in 8%. Among the parenteral drug users the oral/dental examiners diagnosed OC in 29% of the individuals while the medical examiners made this diagnosis in 11%. In the same cohort, OHL was diagnosed by the oral/dental examiners in 9% of the individuals and by the medical examiners in 2%. The OC and OHL diagnoses affected the medical staging of 12% of the HIV-positive homosexual men and of 22% of the HIV-positive parenteral drug users. Forty percent of the HIV-positive homosexual men and 79% of the HIV-positive parenteral drug users with stage-defining oral lesions were not properly identified by the medical examiners.

CONCLUSIONS

Specific training and a comprehensive oral examination have a significant impact on the diagnoses of OC and OHL, and on the medical staging of individuals with HIV infection.

Epstein-Barr virus (EBV) DNA in saliva and EBV serology of HIV-1-infected persons with and without hairy leukoplakia

Secretion of Epstein-Barr virus (EBV) in saliva, as well as serum antibody titres against various EBV antigens, were analyzed in respect of (1) 15 HIV-1-infected patients with oral hairy leukoplakia proven to contain EBV by in situ hybridization, (2) 45 HIV-1 infected patients without hairy leukoplakia, (3) 10 HIV-1 infected patients treated with acyclovir or foscarnet and (4) 21 healthy controls. The numbers of CD4+ cells in the peripheral blood were also recorded. The HIV-1 infected patients were at various stages of HIV-1-associated disease. Excretion of EBV DNA in the saliva was determined by means of the polymerase chain reaction (PCR) while the amount of EBV DNA in positive samples was estimated by repeated titrations. The frequency of shedding of EBV DNA increased from 33% in healthy controls to 78% in asymptomatic HIV-1 infected persons, but did not increase significantly with progression of HIV-1-associated disease. The titres of EBV DNA in saliva correlated inversely and significantly with the number of CD4+ cells in the peripheral blood. All patients with hairy leukoplakia shed by EBV DNA in their saliva but the titres were not significantly higher than those of other HIV-1 infected persons. The serum titres of antibodies against EBV nuclear antigen 1 (EBNA-1) correlated positively and significantly with the CD4+ cell count in the peripheral blood. EBNA-1 IgG antibody in the serum was also significantly lower in symptomatic than in asymptomatic HIV-1 infected persons. There were, however, no significant differences in serum antibodies to various EBV antigens between patients with and without hairy leukoplakia.

Ability of primary care physicians to recognize physical findings associated with HIV infection

OBJECTIVE

To assess the ability of primary care physicians to identify physical findings associated with human immunodeficiency virus (HIV) infection.

DESIGN

Standardized patient examination.

PARTICIPANTS

A total of 134 general internists and family practitioners were randomly selected after stratifying by year of medical school graduation, specialty, and experience caring for patients with HIV infection.

MAIN OUTCOME MEASURES

Recognition of physical findings of Kaposi's sarcoma, oral hairy leukoplakia, and diffuse lymphadenopathy.

RESULTS

Despite being directed by presenting histories to sites of prominent physical abnormalities, only 23 (25.8%) of 89 physicians evaluating a patient with Kaposi's sarcoma and 22 (22.7%) of 97 physicians evaluating a patient with oral hairy leukoplakia detected and correctly diagnosed the abnormalities. Twenty-three (17%) of 133 physicians detected diffuse lymphadenopathy in a patient complaining of fatigue, fever, and arthralgias. Physicians with the most experience treating patients with HIV infection more frequently identified oral hairy leukoplakia, but HIV experience did not influence identification of Kaposi's sarcoma or detection of lymphadenopathy. There were no differences between general internists and family practitioners or among physicians by year of medical school graduation in identifying the three physical findings associated with HIV infection.

CONCLUSIONS

Primary care physicians may frequently miss important physical findings related to HIV infection during patient examinations.