NORTHWEST AIDS EDUCATION AND TRAINING CENTER Oral Manifestations of HIV: Case Studies David Spach, MD Principal Investigator and Clinical Director, Northwest AETC Professor of Medicine, Division of Infectious Diseases University of Washington School of Medicine Last Updated: July 8, 2014
Case 1
Source: Photograph from David Spach, MD Case History
Source: Photograph from David Spach, MD Case History
Question 1: Which virus is associated with this disorder? A. Herpes simplex virus type 2 B. Epstein-Barr Virus C. Human herpes virus type 8 D. Human papillomavirus
Oral Hairy Leukoplakia Cause - Epstein-Barr virus Significance - Indicates significant level of immunosuppression - Rare other than HIV infection Therapy - None generally required
Case 2
Source: Photograph from David Spach, MD Case History
Question 2: What would recommend for treatment? A. Oral Valacyclovir B. Oral Doxycycline C. Oral Fluconazole D. IM Penicillin G
Oral Candidiasis: Erythematous Source: Photograph from David Spach, MD
Oral Candidiasis: Pseudomembranous Source: Photograph from David Spach, MD
Oral Candidiasis: Pseudomembranous Source: Photograph from David Spach, MD
Oral Candidiasis: Angular Chelitis Source: Photograph from David Spach, MD
Types - Pseudomembranous - Erythematous (Atrophic) - Angular Cheilitis Oral Candidiasis
Oral Candidiasis Treatment of Oropharyngeal Candidiasis; Initial Therapy (For 7-14 Days) Preferred Therapy Alternative Therapy Oral Therapy Fluconazole 100 mg PO daily (AI) Itraconazole oral solution 200 mg PO daily (BI) or Posaconazole oral solution 400 mg PO BID for 1 day, then 400 mg daily (BI) Topical Therapy Clotrimazole troches, 10 mg PO 5 times daily (BI) or Miconazole mucoadhesive buccal 50-mg tablet once daily (do not swallow, chew, or crush) (BI) Nystatin suspension 4 6 ml QID or 1 2 flavored pastilles 4 5 times daily (BII) Source: Opportunistic Infections Guidelines. 2013
Case 3
Source: Photograph from David Spach, MD Case History
Question 3 What is in your differential diagnosis? 1. 2. 3. 4.
Orolabial Herpes Simplex Virus Source: Photograph from David Spach, MD
Orolabial Herpes Simplex Virus Source: Photograph from David Spach, MD
Orolabial Herpes Simplex Virus Source: Photograph from David Spach, MD
Orolabial Herpes Simplex Virus Source: Photograph from David Spach, MD
Therapy for Initial or Recurrent Orolabial HSV Recommendations for Treating Orolabial HSV in HIV-Infected Persons Therapy for Orolabial Lesions Valacyclovir: 1000 mg PO twice daily x 5-10 days Famciclovir: 500 mg PO twice daily x 5-10 days Acyclovir: 400 mg PO three times daily x 5-10 days Chronic Suppressive Therapy Valacyclovir: 500 mg PO twice daily Famciclovir: 500 mg PO twice daily Acyclovir: 400 mg PO twice daily Source: Opportunistic Infections Guidelines. 2013
Case 4
Source: Photograph from David Spach, MD Aphthous Stomatitis
Question 4 This 32-year-old man has severe extremely painful aphthous stomatitis that has not responded to topical anesthetics, or topical corticosteroids. He has required repeat courses of oral prednisone.
What other systemic therapy is effective in treating severe aphthous stomatitis? A. Thalidomide B. Methotrexate C. Hydroxychloroquine D. Naproxen
Thalidomide for Aphthous Lesions Study Design Study Design 80 Thalidomide Placebo Protocol - Double blind, placebo controlled - N = 57 - HIV-infected - Aphthous lesions > 5 mm - 4 week oral treatment course - Thalidomide 200 mg daily versus placebo - Excluded if pregnant or breastfeeding Complete Healing (%) 60 40 20 0 55 7 16/29 2/28 Source: Jacobson JM et al. N Engl J Med 1997;336:1487-93.
Aphthous Stomatitis Cause - Unknown Therapy - Topical anesthetics - Topical coating agents - Topical corticosteroids - Systemic (Prednisone; Thalidomide)
Case 5
Source: Photograph from David Spach, MD Case History
Source: Photograph from David Spach, MD Case History
Source: Photograph from David Spach, MD Oral Kaposi s Sarcoma
Source: Photograph from David Spach, MD Oral Kaposi s Sarcoma
Question 5: What is the most likely diagnosis these HIV-infected persons share in common? A. Oral squamous cell cancer B. Bacillary angiomatosis C. Kaposi s sarcoma D. Pigmented viral warts
Oral Kaposi s Sarcoma Cause - Human herpes virus type 8 (HHV-8) Significance - Indicates immune suppression - AIDS-defining condition - May be associated with systemic Kaposi s sarcoma Therapy - Antiretroviral therapy - Local therapy - Systemic cytotoxic chemotherapy in severe cases
Questions