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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