ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS)

• More than 39.5 million cases worldwide.• Considered almost 100% fatal and no known

vaccine developed so far.ROUTES OF TRANSMISSION: -1.Sexual contact2.Infected blood / blood products3.Intravenous drug abuse4.Transplacental transfer

Dr. Adel Jumaan Binsaad 1

ميكرو 1س

L1

المناعة نقص فيروس بنيةالبشرية

Dr. Adel Jumaan Binsaad 2

PATHOGENESIS: -• When virus enters the body, its DNA

incorporated into primary target cell i.e. CD4+ helper T lymphocyte.

• Similar to other viral infections, antibodies to virus are formed but are not protective.

• Virus can remain silent or cause cell death, as a result, decrease in helper T- cells occurs, leading to loss in immune function.

• There is an asymptomatic stage lasting for about 8 – 10 years after which the final symptomatic stage develops.

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CLINICAL FEATURES: -• After infection, patient may be asymptomatic or

develop acute response similar to infectious mononucleosis.

• Acute response – fever, generalized lymphadenopathy, sore throat, myalgia, diarrhea, maculopapular rash etc.

• Acute response (Acute syndrome) clears within a few weeks and a variable asymptomatic phase follows which may last for 8 – 10 years.

• Symptomatic phase – opportunistic infections (pneumonia, CMV, HSV, TB etc) and neoplastic processes (Kaposi sarcoma, Non-Hodgkin’s lymphoma etc).

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ORAL MANIFESTATIONS

Group 1 (lesions strongly associated with HIV):

1. Oral candidal infections - Erythematous - Hyperplastic - Pseudomembranous2. Hairy leukoplakia3.HIV associated periodontitis - HIV gingivitis - HIV periodontitis - Necrotizing ulcerative gingivitis - Necrotizing ulcerative stomatitis 4. Kaposi sarcoma (READ)5. Non-Hodgkin’s lymphoma (READ)

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ORAL CANDIDIASIS

HAIRY LEUKOPLAKIA 7

HIV ASSOCIATED PERIODONTITIS

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HIV ASSOCIATED GINGIVITIS

NECROTIZING ULCERATIVE GINGIVITIS

NECROTIZING ULCERATIVE STOMATITIS

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CANCRUM ORIS• Acute, rapidly progressing, localized, bacterial

infection of the orofacial tissues and jaws• Causative organisms – Fusobacterium

necrophorum, Fusobacterium nucleatum and Prevotella intermedia.

• Predisposing factors: include poverty, malnutrition, poor oral hygiene & sanitation, recent illness, malignancy and immunodeficiency states like AIDS.

CLINICAL FEATURES: -Age incidence: Predominantly children

between 1 – 10 years.Sex incidence: MaleSite predilection:Usually begins on gingivae as

ANUG, then spreads facially / lingually to adjacent soft tissues. 10

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Patch stage

Plaque stage

Nodular stage

KAPOSI SARCOMA

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Kaposi's Sarcoma

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Group 2 (lesions less commonly associated with HIV):

1. Aphthous ulcers (oropharyngeal region) (READ)2. Idiopathic thrombocytopenia (READ)3. Salivary gland disorders - Dry mouth and decreased salivary flow - Uni or bilateral swelling of major glands4. Viral infections (apart from EBV) - Cytomegalovirus - Herpes simplex virus - Human papilloma virus - Varicella - zoster virus Dr. Adel Jumaan Binsaad 14

HIV ASSOCIATED APHTHOUS ULCERS

HIV ASSOCIATED HPV INFECTION

HIV ASSOCIATED HERPETIC ULCERS

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HAIRY LEUKOPLAKIA• It is a chronic, localized infection. • Caused by: Epstein-Barr virus (EBV).

CLINICAL FEATURES :-

Asymptomatic, slowly spreading, non scrapable, papillary, greyish white lesion.

Usually in young age males and located bilaterally at the lateral borders of the tongue.

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HISTOLOGICAL FEATURES• Lesion is characterized

by hyperparakeratosis and acanthosis.

• Epithelial cells are infected by EBV which appear as swollen cells with ballooning degeneration.

• Characteristic pattern of peripheral margination of nuclear chromatin is seen, called nuclear beading.Dr. Adel Jumaan Binsaad 18

DIAGNOSIS1. Screening test: ELISA is most commonly used

test. But it can show false positive results.

2. Western Blot test: It is a test to detect viral antibodies. More accurate than ELISA.

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Candidiasis• Candidiasis is the most

common type of yeast infection.

• Candida ssp is an opportunistic fungus (yeast).

• It can infect the mouth, vagina, skin, and urinary tract.

• About 75% of women will get vaginal yeast infection during their life.

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Candidal virulent factors:Candidal virulent factors:

1. Ability to adhere to host tissues and prostheses (e.g. dentures) and form biofilm.

2. Ability to form hyphae that helps in tissue invasion.

3. Ability to modify the surface antigen.

4. Ability to produce extracellular phospholipase, proteinase, and haemolysin which break down physical defence barriers.

Candida species rarely cause disease in absence of predisposing factors (opportunistic organisms) .

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Predisposing factors1.1.Heavy smoking.Heavy smoking.2.2.Age (e.g. very young or very old).Age (e.g. very young or very old).3.3.Malignant and chronic disease.Malignant and chronic disease.4.4.Inadequate care of appliances.Inadequate care of appliances.5.5.Immunological and endocrine disorders Immunological and endocrine disorders

(e.g. diabetes mellitus).(e.g. diabetes mellitus).6.6.Radiation to the head and neck.Radiation to the head and neck.7.7.Disturbed oral ecology by antibiotics, Disturbed oral ecology by antibiotics,

Corticosteroides.Corticosteroides.8.HIV infection9.Cancer10.Dry mouth11. Pregnancy.

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Signs and symptomsMost candidial infections are treatable and result in

minimal complications such as redness, itching and discomfort, though complication may be severe or fatal if left untreated in certain populations.

Thrush is commonly seen in infants, elderly people, and those with a weakened immune system.

Children, mostly between the ages of three and nine years of age, can be affected by chronic mouth yeast infections, normally seen around the mouth as white patches.

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Thrush (pseudomembrane):Acute infection but may persist intermittently for many months or even years in HIV-infected persons (Oropharyngeal thrush may spread into esophagus), patients using corticosteroids, neonates and in patients with leukaemia.white patches on oral mucosa, tongue and elsewhere. Lesions resembling milk curds.

Microbiology patches consists of necrotic material and desquamated parakeratotic epithelia, penetrated by yeast and hyphae.

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Thrush usually develops suddenly, but it may become chronic, persisting over a long period of time.

A common sign of thrush is the presence of creamy white, slightly raised lesions in the mouth -usually on the tongue.

The lesions, can be painful and may bleed slightly when we scrape them or brush your teeth.

In severe cases, the lesions may spread into esophagus, causing pain or difficulty swallowing.

Thrush can spread to other parts of the body, including the lungs, liver, and skin.

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Oral Candidiasis (Thrush)

Thrush (pseudomembrane) is a yeast infection of the mucus membrane lining the mouth and tongue. Other oral manifestations include erythematous and hyperplastic variants.

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Thrush

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Oral thrush

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Vulvovaginitis in women using contraceptive and associated with yeasty-smelling discharge, and vaginal itching.

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Cutaneous candidiasis• Cutaneous

candidiasis include:• Paronychia and

onychomycosis.• Diaper candidiasis.• Intertrigo candidiasis.

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Paronychia:-•Paronychia of the finger nails may develop in persons whose hands are subject to continuous wetting. •In chronic cases the infection may progress to cause onycho-mycosis with total detachment of the cuticle from the nail plate.

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Paronychia

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Diaper (Nappy rash):-

•Diaper candidiasis is common in infants under unhygienic conditions of chronic moisture and local skin maceration due to irregular change of unclean diapers.

• Caused by C.albicans derived from the lower gastrointestinal tract.

• Scaly macules or vesicles,

associated with pruritus.

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Candidal intertrigo consists of vesicular pustules that enlarge, rupture and cause fissures.

• Seen especially in warm and moist surfaces and in the obese.

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Mucocutaneous candidiasisMucocutaneous candidiasis

• Involve both the skin and the oral and /or vaginal mucosae.

• Chronic mucocutaneous candidiasis is rare and associated with T-cells deficiency.

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Systemic or deep Systemic or deep candidiasiscandidiasis•Involve the lower respiratory tract and urinary tract, then lead to candidaemia; localization in meninges, bone, kidney and eye is common.

• Susceptible settings include prosthetic implantation, heart surgery, organ transplantation and long-term treatment with steroid or immunosuppressive drugs.

• Superficial infection rarely cause dissemination.

• Untreated disseminated disease is fatal.Dr. Adel Jumaan Binsaad 39

Diagnosis:Diagnosis:1.Demonstration of yeasts in Gram – stained

smear, skin scraping (KOH), followed by culture.

2.Serology or PCR or blood culture ( candidaemia) are helpful in diagnosis of disseminated candidiasis.

3.Histopathological examination; helps to know the causative agent (demonstration of hyphae) and in chronic candidal leukoplakial lesions.

4.C.albicans C.dubliniensis differentiated from other Candida species by their ability to produce germ tubes.

5. Definitive identification based on fermentation test and other biochemical tests.

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Treatment:Treatment:

1. Superficial mycoses1. Superficial mycoses::

• Correction of Correction of predisposing Factors.

• Topically with nystatin or amphotericin or Topically with nystatin or amphotericin or miconazole.miconazole.

2. Systemic and disseminated candidiasis2. Systemic and disseminated candidiasis::

• Intravenous amphotericin, either alone or Intravenous amphotericin, either alone or in combination with flucytosine.in combination with flucytosine.

• Fluconazole effective for both Superficial Fluconazole effective for both Superficial and Systemic mycoses and itand Systemic mycoses and it`s the drug of `s the drug of choice in treating Candida infection in HIV choice in treating Candida infection in HIV disease ( C. krusei is resistant). disease ( C. krusei is resistant). Dr. Adel Jumaan Binsaad 41

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Prevention: Prevention: as infection is endogenous, therefore as infection is endogenous, therefore

prevention include:prevention include:1.1. Correction of Correction of predisposing factors.

2. Compromised patients require long term prophylactic treatment continuously or intermittently with antifungal treatment.

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Candidal oral manifestations include three variants. Caused mainly by Candida albicans. Other Candida spp. may also involved. Considered as opportunistic infections.Variants of oral candidiasis:1.Pseudomembranous 2.Erythematous (atrophic) 3. Hyperplastic.Erythematous (atrophic) candidiasisCondition associated with corticosteroids, topical or systemic broad-spectrum antibiotics or HIV disease. May arise when pseudomembranes shed. Erythematous candidasis of palate is commonly seen in elderly people wearing full-denture (candida associated denture stomatitis).

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Clinical featuresErythematous area (s) is asymptomatic.Lesions on the dorsum of the tongue present as depapillated areas.Red areas seen on the palate in HIV disease.

Erythematous candidiasis, dorsum of tongue44

Erythematous candidiasis, hard palateDr. Adel Jumaan Binsaad 45

Hyperplastic candidiasis (candidal leukoplakia) Lesions: chronic, discrete raised areas, asymptomatic and usually occur on the inside surface of one or both cheeks.Microbiology and histopathologyIncludes parakeratosis and epithelial hyperplasia with candida invasion restricted to the upper layers of epithelium.Associated with iron and folate deficiencies and with defective cell-mediated immunity.It is premalignant.Treatment Topical antifungals such as nystatin and amphotericin B.Fluconazole tablets _ useful in chronic infection.

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Candida associated lesions1. Candida-associated denture stomatitis ( Denture sore mouth) •Chronic erythema and oedema of mucosa that contacts the fitting surface of the upper denture. •The mucosa below lower denture is rarely involved. •Due to accumulation of plaque with bacteria and yeast on the fitting surface of denture and the underlying mucosa.•Mechanical irritation or allergic reaction to the denture material.

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Denture stomatitis

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Treatment:I.Removal of dentures at night. II. Regular disinfection by steeping dentures in e.g. chlorhexidine.III. Review of denture fitness to relieve trauma.IV. Diet with low content of fermentable carbohydrates.V.Nystatin or amphotericin.

2. Angular stomatitis (angular cheilitis) Clinical feature:Soreness, erythema and fissuring seen in one or both angles of the mouth.Commonly associated with inadequate denture.

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Condition seen in HIV disease.Condition is occasionally a sign of anaemia or vitamin B12 deficiency. Microbiology Yeast and Staph. aureus (yellow crusting).

TreatmentI.Topical antifungal therapy with nystatin, amphotericin B or miconazole.II.Neomycin and chlorhexidine. III.Adjustment dimension of dentures to prevent saliva retention, and moisture (encourage growth of candida) at the angles of the mouth.IV.Investigate for iron or vitamin B12 deficiency or HIV.Dr. Adel Jumaan Binsaad 50

Angular stomatitis (angular cheilitis)

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