Common head and neck problems in HIV-positive patients.Approximately 41 - 68% of all HIV-infected patients will present with pathological conditions of the head and neck at some point in the disease. (1)
Common head and neck problems in HIV-positive patients are briefly discussed under the following headings:
* ulcers, plaques and gum disease
* neoplastic growths in and around the mouth
* lumps and bumps.
Ulcers, plaques and gum disease
Recurrent oral ulcerations classify the patient as having stage II disease according to the WHO staging of HIV/AIDS. (2) Causes for these ulcers include viruses (herpes simplex virus (HSV), varicella zoster (VZ) and cytomegalovirus (CMV)), immunological causes (aphthous ulcers) and fungal infections (candida, histoplasmosis).
HSV and VZ (shingles) most often involve the perioral skin, but can also involve the oral mucosa. The typical prodrome precedes the vesicular eruption. It is very important to remember that if the tip of the nose is involved in shingles, the patient must be evaluated and monitored for possible involvement of the eye (corneal/conjunctival ulcerations) as this can lead to serious problems if left undiagnosed.
CMV and aphthous ulcers can look very similar to VZ, but lack the typical prodrome.
Leukoplakia and erythroplakia
Oral hairy leukoplakia (Fig. 1) presents as a painless, white, slightly elevated plaque that is not easily removable (as is the case with candida). It has a hairy appearance and is most commonly located on the lateral border of the tongue. It can also involve the ventral tongue and in rare cases the buccal mucosa. Patients are usually asymptomatic and lesions can only be observed. If a lesion should show change, however, a biopsy should be done.
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Erythroplakia (Fig. 2) describes any red mucosal lesion and is more likely to indicate a malignant lesion. These lesions should therefore always be biopsied and followed up closely to rule out malignancy.
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Candida can present in 4 different forms:
* pseudomembranous candidiasis/thrush (most common form)
* erythromatous candidiasis (red lesions on palate/dorsum of tongue)
* angular chelitis (red, flaking lesions at corners of mouth)
* hyperplastic candidiasis (thick white plaques on mucosa) (Fig. 3).
[FIGURE 3 OMITTED]
These oral lesions can also be an indicator that candida is involving the oesophagus if accompanied by odynophagia and retrosternal pain. Oesophageal candida can be confirmed with gastroscopy. Treatment is with oral nystatin drops (only oral candida) or miconazole gel (Daktarin). Fluconazole 400 mg daily PO for 14 days is used if oesophageal candida is diagnosed.
Acute necrotising ulcerative gingivitis/periodontitis
This is an acute opportunistic infection of the gingiva that can spread to the underlying alveolar bone. Causative organisms include Treponema spp, Selenomonas spp, Prevotella intermedia, Borrelia spp, Gram-positive cocci, beta-haemolytic group B streptococci and Candida albicans. (3) Patients present with painful, bleeding gums with varying amounts of necrotic tissue. Treatment consists of meticulous oral hygiene, debridement of necrotic tissue and local and systemic antibiotics. Oral antiseptics such as Glycothymol mouth wash can be used as adjunct therapy.
Neoplastic growths in the mouth
Human papillomavirus infection
These lesions present as condylomata acuminata, warts or focal epithelial hyperplasia. Treatment consists of simple surgical excision; biopsies can be done first if there is doubt about the diagnosis.
Kaposi's sarcoma usually presents on the skin, but the hard palate, gingiva, buccal mucosa and the dorsum of the tongue can also be involved (Fig. 4). Lesions present as red to purple raised plaques which can also ulcerate and cause pain and bleeding. Most of the time, mucosal lesions will accompany cutaneous lesions. Treatment consists of triple antiretroviral therapy and external beam radiation in collaboration with an oncologist.
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Lymphoma can present in the oral cavity as a swelling or mass, but is extremely rare and usually associated with a poor prognosis.
Squamous cell carcinoma
Squamous cell carcinoma will present as in HIV-negative patients and the treatment approach will be the same.
These lesions are characterised by flesh-coloured, dome-shaped, smooth or umbilicated papules and are caused by a DNA poxvirus. They are found commonly on the lips, buccal mucosa and palate (Fig. 5). Treatment of these lesions consists of cryotherapy or excision. (4)
[FIGURE 5 OMITTED]
Lumps and bumps
HIV-related lymphadenopathy is discussed by WJ Jacobs. (5)
Unexplained persistent parotid enlargement is also a stage II-defining disease according to WHO staging of HIV/AIDS. (2) Patients complain of mildly tender, soft parotid swelling that can be unilateral or bilateral (Fig. 6). The pathophysiology behind this phenomenon is a diffuse lymphoid infiltrate, hence the name diffuse infiltrative lymphocytosis syndrome or DILS. Fig. 4. Kaposi's sarcoma.
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The diagnosis of DILS can be made by ultrasound/CT, which will show multiple cystic lesions throughout the superficial and deep lobes of the parotid gland. It has been described as having a Swiss cheese appearance on imaging. FNA of this lesion will reveal a benign lymphoepithelial cyst. Please do not do true-cut biopsies! You don't want the pathology report to come back reporting 'pieces of normal facial nerve'! Management of these lesions is not surgical and consists of antiretroviral therapy and/or external beam radiation.
The diagnosis and treatment of HIV-associated head and neck diseases are summarised in Table I.
Table I. Diagnosis and treatment of HIV-associated head and neck lesions Disease Clinical appearance Diagnosis Management Candida See text for Clinical picture * Topical different clinical +/-culture/biopsy antifungal types treatment * Systemic anti-fungal treatment for oesophageal candida Periodontal Halitosis, bleeding Clinical picture * Aggressive disease gums, severe pain in plaque removal gums and debridement by dentist * Topical or systemic antibiotics * Good oral hygiene Oral hairy White lesion lateral Clinical picture * Observation! leukoplakia aspect of tongue, +/-tissue biopsy non-removable * Biopsy indicated if there is change in lesion's appearance * In severe cases consider oral aciclovir Herpes virus Painful Clinical picture * Oral ulcers solitary/multiple +/- smears aciclovir vesicular lesions, +/-viral culture may erode/coalesce +/- biopsy * Can consider ganciclovir for CMV ulcers Recurrent Painful, Clinical picture * Topical aphthous well-circumscribed, +/-biopsy analgesics ulcers shallow ulcers (Teegel) Topical or systemic steroids in severe cases Kaposi's Painless red, Clinical picture * Antiretroviral sarcoma bluish/purple +/- biopsy therapy maculae, papules/nodules * Radiation, co-ordinate with oncologist Non-Hodgkins Firm, painless focal Biopsy * Oncology lymphoma swelling or poorly referral defned alveolar mass * Surgical debulking in case of airway obstruction DILS Painless Sonar, FNA * Antiretroviral uni/bilateral therapy +/- parotid swelling external beam radiation Molluscum Flesh-coloured, Clinical picture * Cryotherapy contagiosum dome-shaped, smooth or excision or umbilicated papules
There are numerous head and neck conditions that are commonly seen in HIV-positive patients, not all requiring surgical referral. It is very important that primary care physicians recognise these conditions and know when to refer them and when they can be managed at primary care level.
References available at www.cmej.org.za
(1.) Gurney TA, Murr AH. Otolaryngologic manifestations of human immunodeficiency virus infection. Otolaryngol Clin North Am 2003;36:607-624.
(2.) World Health Organization. WHO Case Definitions of HIV Surveillance and Revised Clinical Staging and Immunological Classification of HIV-related Disease in Adults and Children. Geneva: WHO, 2006.
(3.) Rajandram RK, Ramli R, Karim F, et al. Necrotizing gingivitis: a possible oral manifestation of ticlopidine-induced agranulocytosis. N Z Med J 2007;120:1256.
(4.) Saxe, N, Jessop, S, Todd, G. Handbook of Dermatology for Primary Care. Oxford: Oxford University Press, 1999.
(5.) The problem of HIV-related lymphadenopathy, WJ Jacobs
(6.) Weinert M, et al. Oral manifestations in HIV infection. Ann Intern Med 1996:125:486-496.
JOHLENE DU PLESSIS, MB ChB, MMed (Chir)
Surgeon, De Aar Hospital, Northern Cape, and Private Practitioner, De Aar
Correspondence to: Johlene du Plessis (email@example.com)