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

Case History

Source: Photograph from David Spach, MD

Case History

Source: Photograph from David Spach, MD

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

Case History

Source: Photograph from David Spach, MD

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

Oral Candidiasis

•  Types - Pseudomembranous - Erythematous (Atrophic) - Angular Cheilitis

Source: Opportunistic Infections Guidelines. 2013

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)

Case 3

Case History

Source: Photograph from David Spach, MD

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

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

Therapy for Initial or Recurrent Orolabial HSV

Case 4

Aphthous Stomatitis

Source: Photograph from David Spach, MD

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

Source: Jacobson JM et al. N Engl J Med 1997;336:1487-93.

Study Design

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

55

7

0

20

40

60

80

Com

plet

e H

ealin

g (%

)

Thalidomide Placebo

16/29 2/28

Aphthous Stomatitis

•  Cause - Unknown

•  Therapy - Topical anesthetics - Topical coating agents - Topical corticosteroids - Systemic (Prednisone; Thalidomide)

Case 5

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

Source: Photograph from David Spach, MD

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