Hiv disease

In the 20 years since the onset of the HIV pandemic, a number of oral and cutaneous entities have been recognized to be associated with HIV disease. Importantly, note that no unique condition specific to HIV disease has been identified in the oral cavity. These conditions have all been described in patients with other forms of immunocompromise and, indeed, in immunocompetent individuals. However, the clinical presentation is often more severe or atypical in patients with HIV disease. Many patients have both oral and cutaneous conditions simultaneously. Most of these conditions seldom manifest with CD4 counts lower than 400 cells/L, and many have a positive predictive value for immune decline. The most common of these entities are discussed below.

Candidiasis

Oral candidiasis is often the first presenting sign of HIV infection, and it may occur in as many as 90% of patients infected with HIV. HIV infection should be considered in patients presenting with repeated oral candidiasis in the absence of other associated risk factors, such as steroid or antibiotic use.

The 4 common classifications of candidal infections are (1) pseudomembranous candidiasis, (2) erythematous candidiasis, (3) angular cheilitis, and (4) hyperplastic candidiasis. Pseudomembranous candidiasis is the most common presentation in HIV-infected individuals. This is characterized by white or whitish-yellow papules that can be wiped from the oral mucosa to reveal erosions or erythematous mucosa. These often manifest on the buccal mucosa, palate, and vestibule, although any surface may be involved.

Erythematous candidiasis is more difficult to diagnose because it manifests as a nonspecific area of erythema, commonly on the palate or dorsum of the tongue. Hyperplastic candidiasis is uncommon and manifests as adherent white plaques that cannot be easily removed. Angular cheilitis manifests as cracked, red, and sometimes ulcerated fissures in the corners of the mouth with or without intraoral symptoms. Although the history and physical examination findings help establish the diagnosis, confirmation can be made by using a potassium hydroxide (KOH) preparation, which shows hyphae, pseudohyphae, or spores. The KOH preparation is often negative in persons with erythematous candidiasis or angular cheilitis. If confirmation is required, cytology or tissue biopsy can also be used, with the latter test being definitive.

The frequency of candidal infection increases as HIV disease progresses (ie, as viral loads increase and CD4 lymphocyte counts decline). Antifungal treatment is often effective, but the condition can be difficult to eradicate in immunocompromised patients. Often, this is because clinical recovery does not coincide with mycologic recovery; the patient may appear well but still may be harboring fungal organisms. Additionally, fungal resistance to azole drugs (eg, fluconazole) is increased among HIV-infected patients. If patients do not respond, culture and sensitivity studies should be considered. Finally, patients must also remember to treat any removable dental prosthesis, such as dentures, because these can act as fomites and can reinoculate the patient.