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

Ulcerations

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.

[FIGURE 1 OMITTED]

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.

[FIGURE 2 OMITTED]

Candida albicans

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

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.

[FIGURE 4 OMITTED]

Lymphoma

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.

Molluscum contagiosum

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

Lymphadenopathy

HIV-related lymphadenopathy is discussed by WJ Jacobs. (5)

Parotid enlargement

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.

[FIGURE 6 OMITTED]

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

Conclusion

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

References

(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 ([e-mail])