Lesions of the oral mucosa in HIV. AIDS. manifestation of HIV infection in the oral cavity. Group III: lesions occurring in HIV infection, but not directly related

Oral manifestations of AIDS

Belarusian Medical Academy of Postgraduate Education

Department of Therapeutic Dentistry

I.K. Lutskaya

GENERAL CHARACTERISTICS OF HIV INFECTION

The infectious process in the human body (from the moment of infection with the human immunodeficiency virus to the death of the patient) is characterized by a long incubation period (from several months to 5 years or more), a slow course, selective damage to T-lymphocytes and neuroglia cells.

EPIDEMIOLOGY

The only source of infection is a person infected with this virus. The most dangerous are persons who do not have any clinical manifestations: virus carriers are the main source of HIV infection among the population.

At the dentist's office, infection can occur in the following cases:

When using medical instruments contaminated with blood or other biological fluid that have not been disinfected (various devices, discs, burs, probes, needles, syringes, cutting and stabbing instruments, etc.);

In the presence of wound surfaces and ulcerations in the oral cavity;

With extensive contamination of the skin of health workers with blood, blood in the eyes;

Known examples of infection with acupuncture treatment.

(There is no airborne transmission of infection.)

The highest concentration of the immunodeficiency virus is found in the blood. Further, in decreasing gradation, semen, vaginal and cervical secretions of the glands, breast milk, saliva follow. Blood and other specified biological fluids are factors in the transmission of HIV from an infected person to others.

The virus is moderately resistant outside the human body. In the external environment (biosubstrates), its infecting effect lasts up to 2 weeks, in a dried state (discharge on linen, objects, etc.) up to 1 week. Radiation exposure and ultraviolet rays do not affect it. When boiled, the virus dies within 5 minutes, when heated to 56 °, inactivation occurs after 30 minutes. Disinfectants used in the practice of medical institutions (chloramine, calcium hypochloride, hydrogen peroxide, alcohol, etc.) in the concentrations provided for the disinfection of hepatitis viruses are guaranteed to destroy HIV when the disinfectant comes into direct contact with contaminated blood or other human biological fluid on the surface of an object, including a hollow ( inner surfaces of a syringe, needles, capillaries, probes, etc.).

CLINIC

The incubation period for HIV infection is 1-3 months, but it can be longer. After this, the initial stage of the disease, called acute HIV infection, develops.

Only 20% of those infected have clinical signs in the form of a general infectious syndrome of an undifferentiated nature (mononucleosis-like manifestations, serous meningitis, encephalopathy, myelopathy or neuropathy).

A clinically successful outcome of the acute stage of the disease does not mean either the acquisition of immunity or recovery, despite seroconversion. The disease passes into a chronic stage, which proceeds either subclinically, or in the form of persistent generalized lymphadenopathy with a constant, barely noticeable transition to the AIDS-associated syndrome.

Patients remain active, work capacity and well-being. There are no signs of immunosuppression yet.

Prognostically unfavorable is a decrease in the size of the lymph nodes, which means the involution of the follicles - a morphological sign of immunosuppression.

The clinical symptoms of the AIDS-associated stage of the disease consist of signs of initial immune deficiency. They are manifested by local infections of the skin and mucous membranes caused by low-pathogenic representatives of opportunistic microflora (viral and bacterial stomatitis, pharyngitis, sinusitis, oral, genital, perianal herpes, recurrent herpes zoster, candidal stomatitis, genital and perianal candidiasis, dermatomycosis of the feet, , acne folliculitis, hairy leukoplakia of the tongue, etc.).

Lesions of the skin and mucous membranes are initially easily amenable to conventional therapy, but quickly recur and gradually become chronically recurrent. The most important feature of the clinical picture of the AIDS-associated complex is a steady increase in symptoms with the aggravation of existing ones and the appearance of new lesions.

The chronic stage of the disease gradually passes into its last stage - AIDS. By this time, the functions of the immune system are inhibited and upset as much as possible (CD-4-lymphocytes are reduced to 100 in 1 mm 3).

According to available observations, in 5 years after infection, from 25 to 50% of people fall ill with AIDS, after 7 years - up to 75%, after 10 years (observations since 1981) - slightly more than 90% of those infected. Can the remaining 10% not get sick? They can, if the latent period of the disease is longer than the remaining years of their life.

Infections - the most common and dangerous manifestation of AIDS - develop in the form of localized, generalized and septic forms. The skin, mucous membranes, internal organs are affected.

The clinical features of infectious processes in AIDS are their growing nature, prevalence, severity, atypical symptoms and a multiplicity of localizations.

The main diseases manifested in AIDS on the mucous membrane oral cavity , depending on the etiotropic factor, are grouped as follows.

1. Fungal infections:

Candidiasis (pseudomembranous; erythematous; hyperplastic - in the form of plaques or nodes; angular cheilitis);

Histoplasmosis.

2. Bacterial infections:

Fusospirochetosis (necrotizing ulcerative gingivitis);

Non-specific infections (chronic periodontitis);

Mycobacteria, enterobacteria.

3. Viral infections:

Herpetic stomatitis;

Hairy leukoplakia;

Herpes zoster (shingles);

Xerostomia caused by cytomegalovirus.

4. Neoplasms:

Kaposi's sarcoma in the mouth;

Squamous cell carcinoma;

Non-Hodgkins lymphoma.

5. Lesions of unexplained etiology:

Recurrent ulcerative aphthae;

Idiopathic thrombocytopetic purpura (ecchymosis);

Lesions of the salivary glands.

Fungal lesions

Candidal stomatitis diagnosed in the vast majority of AIDS patients (up to 75%) and manifests itself in several clinical forms.

Pseudomembranous candidiasis more often it begins as an acute one, however, with AIDS it can continue or recur, therefore it is considered already as a chronic process. Fungal lesions are characterized by the presence of a yellowish coating on the oral mucosa, which may be hyperemic or unchanged in color. Plaque adheres tightly to the surface of the epithelium and is difficult to remove. In this case, the bleeding areas of the mucous membrane are exposed. The favorite localization of plaque is the cheeks, lips, tongue, hard and soft palate (Fig. 1).

Figure: 1. Pseudomembranous candidiasis. Plaque on the palate.

Erythematous, or atrophic, candidiasis develops in the form of bright red spots or diffuse hyperemia, with AIDS has a chronic course. The palate is more often affected, which acquires an uneven bright red color. The epithelium becomes thinner, erosion may appear. Localization of lesions on the back of the tongue leads to atrophy of the filiform papillae along the midline (in contrast to this picture, age-related changes in the tongue are characterized by diffuse atrophy; in syphilis, atrophy of the filiform papilla takes the form of foci of a mown meadow) (Fig. 2).

Figure: 2. Erymatous candidal glossitis.

Chronic hyperplastic candidiasis characterized by the arrangement of elements symmetrically on the mucous membrane of the cheeks in the form of polygonal raised foci of hyperplasia, covered with a yellow-white, cream, yellowish-brown bloom. The hyperplastic form of candidiasis is much less common. Researchers associate this manifestation with the effects of nicotine when smoking (Fig. 3).

Figure: 3. Hyperplastic candidiasis.

Fungal lesions of the oral mucosa can be combined with candidiasis of the corners of the mouth - angular cheilitis, which is a sign of generalization of the process.

The diagnosis, which is made on the basis of clinical manifestations, must be confirmed by laboratory tests. The active growth of a large number of colonies (hundreds) on a nutrient medium, the detection of mycelium by microscopy of the samples indicates the pathogenicity of the Candida fungus. In some cases, a biopsy is necessary.

Treatment of candidiasis can be systemic or local, depending on the extent of the spread of the process. The etiotropic effect is necessary, the symptomatic one depends on the clinical manifestations.

Bacterial infections

Necrotizing ulcerative gingivitis develops in HIV-infected individuals, both at different periods of clinical manifestations of AIDS, and without them in the presence of antibodies against the virus. Patients complain of pain and bleeding of the gums while brushing their teeth, eating; bad breath. On examination, a gray-yellow plaque (necrotic film) is found that covers the gingival margin and interdental papillae. The mucous membrane in the gum area is hyperemic, edematous, tense.

After treatment, the symptoms disappear, but there is a tendency to relapse. A protracted course can lead to deep ulcers with damage to bone structures, necrotization of the interdental septum (Fig. 4).

Figure: 4. Necrosis of the interdental papilla.

The consequence of gingivitis is periodontitis (periodontitis) with irregular generalized destruction of bone tissue and the supporting-retaining apparatus of the tooth. Treatment of patients does not provide a lasting result.

Viral infections

In HIV-infected people, the most common manifestations of stomatitiscaused by a virus herpes simplex... Primary infection with the herpes virus occurs in children, adolescents, and less often in young people. Since the infection is latent, there is a tendency to recurrence, and the manifestations are both general (fever, pain when swallowing, swallowing, swollen lymph nodes) and local. Acute herpetic eruptions can be localized in any part of the maxillofacial region. Favorite places - lips, gums, hard palate. Small bubbles formed at the beginning then merge into larger ones. After the destruction of the tire, the underlying tissues tend to ulcerate. In the oral cavity, vesicles burst very quickly, and erosion is usually detected immediately. On the red border of the lips, the covers of the bubbles shrink, forming dry or weeping crusts.

The herpes virus can cause generalized lesions up to herpes encephalitis.

Recurrent herpetic stomatitis most often localized on the red border of the lips with the involvement of the surrounding skin. The bubbles rapidly increase, merge, and a secondary infection joins. The contents of the blisters suppurate, resulting in the formation of crusts of a dirty yellow color, after their separation, an eroded or ulcerated surface is exposed (Fig. 5).

Figure: 5. Herpes simplex on the lip.

The elements of the lesion on the hard palate and gums are represented by small bubbles that quickly burst, leading to ulcerative lesions of the mucous membrane. Clinical manifestations can be triggered by a cold, stress, respiratory infection (fig. 6).

Figure: 6. Herpetic stomatitis.

Shingles (herpes zoster) in the oral cavity and on the face is characterized by asymmetry of the lesion, respectively, the area of \u200b\u200binnervation of one of the branches trigeminal nerve... It is also possible to involve two or three branches of trigeminus, when elements appear on the mucous membrane in the form of small bubbles, and then an ulcerating surface. The rash is preceded by burning pains simulating pulpitis of intact teeth, radiating along the maxillary or mandibular branch of the V pair of nerves. These pains can persist even after involution of lesions (up to 1-2 months).

Viral growth are in the form of a wart, papilloma, genital warts and frontal epithelial hyperplasia (papules or nodular lesions with filamentous growths).

Warty formations are localized in the corners of the mouth. They can look like papilloma, crest, projections (Fig. 7).

Figure: 7. Viral wart.

Genital warts... Depending on the localization, the elements of the lesion can have a different appearance: multiple pointed projections or rounded slightly raised areas with a flat surface. When localized on the gum or hard palate, the foci are multiple pointed projections. When located on the cheeks and lips, the elements have a picture similar to focal epithelial hyperplasia: rounded, slightly elevated areas with a diameter of about 5 mm with a flattened surface.

Hairy leukoplakia... The lesion is localized, as a rule, on the tongue, having various sizes and appearance. It is found in limited areas of the lateral, dorsal, ventral surface or covers the entire tongue. The mucous membrane takes on a whitish appearance, but hyperkeratosis does not develop. On palpation, the seals are not determined, which served as the basis for the designation of this form of lesion - soft leukoplakia (Fig. 8).

Figure: 8. Hairy leukoplakia on the lateral surface of the tongue.

On the lateral surface of the tongue, elements can be located bilaterally or unilaterally (Fig. 9).

Figure: 9. Hairy leukoplakia of the ventral and dorsal surface of the tongue.

The mucous membrane in a limited or widespread area becomes irregular and rises in the form of folds ("corrugated") or protrusions above the surrounding surface, which appearance may resemble hair. Hence the name - hairy leukoplakia.

On the lower surface of the tongue, the focus of opacity of the epithelial cover can be smooth or slightly folded. Much less often mild leukoplakia occurs on the cheeks, the floor of the mouth, and the palate.

There are no subjective sensations other than discomfort.

Hairy leukoplakia can be combined with candidal glossitis, confirmed by laboratory methods. In this case, the treatment of candidiasis does not affect the appearance of the lesion.

Histological, virological, including serological studies suggest that the cause of soft hairy leukoplakia is the Epstein-Barr virus.

Mild leukoplakia must be differentiated from leukoplakia, lichen planus, chemical or electrical burns, chronic hyperplastic candidiasis.

Manifestations in the oral cavity of neoplasms

Kaposi's sarcoma - vascular tumor (lymph and hemovascular), which, in the absence of HIV infection, is characterized by a low-quality course, occurring in residents of African countries. With AIDS, Kaposi's sarcoma can appear in young people in the form of red, rapidly turning brown spots, which are initially found on the legs, but tend to spread. They differ from the classical version by increased malignancy and dissemination on the skin, mucous membranes, and internal organs.

The characteristic brown spots of Kaposi's sarcoma on the face are the “calling card” of AIDS patients, occurring in 30% of HIV-infected people, regardless of the country of residence. The elements of the lesion are initially represented by single, and more often multiple, spotty, papular (nodular) formations of pink, red, purple color on the skin (Fig. 10).

In the context of a potential AIDS pandemic, each patient should be considered as a possible carrier of the infection. The instruments, apparatus, laboratory glassware and others used for its examination and treatment must be processed in accordance with the requirements of the instructional and methodological documents on disinfection and sterilization. The basis should be taken the requirements for the prevention of viral hepatitis.

Any damage to the skin, mucous membranes, splashing them with blood or other biological fluid when provided to patients medical care should qualify as possible contact with material containing HIV or other infectious disease agent.

If contact with blood or other fluids occurs with a violation of the integrity of the skin (injection, cut), medical worker must:

Quickly remove the glove with the working surface inside;

Nasal cavities - drip a 30% solution of albucide from a dropper tube;

Eyes - rinse with water (with clean hands), drip a few drops of 30% albucide solution from a dropper tube.

The current epidemiological situation with regard to HIV infection in the territory of the Republic of Belarus is characterized by an increase in the number of newly diagnosed HIV infected with changing leading routes of transmission of the pathogen. In this regard, HIV infection has become the most important medical and social problem, since in addition to its immediate social significance - the illness and death of millions of people, AIDS also causes economic and political damage. The epidemiological situation with regard to HIV infection is further complicated by the fact that there is a parallel development of epidemics of drug addiction and viral hepatitis. The common pathways and factors of transmission of pathogens leads to the rapid spread of HIV infection in groups with a risk factor for HIV infection.

Epidemiology. The only source of infection is a person infected with this virus. The most dangerous are persons who do not have any clinical manifestations: virus carriers are the main source of HIV infection among the population.

There is no airborne transmission of infection. The highest concentration of the immunodeficiency virus is found in the blood. Further, in decreasing gradation, sperm, vaginal and cervical secretions of glands, saliva follow. Blood and other specified biological fluids are factors in the transmission of HIV from an infected person to others.

The main diseases manifested in AIDS on the oral mucosa.

The manifestation of a certain pathology in the oral cavity can not only indicate the presence of HIV infection; a number of lesions are also early clinical markers of infection, and some may predict the transition from HIV to immunodeficiency syndrome (AIDS). HIV-related oral pathology is present in 30-80% of HIV-infected individuals. In untreated HIV-positive patients, the presence of certain manifestations of this kind in the oral cavity may indicate the progression of the disease. It should also be noted that in patients with HIV infection who are taking antiretroviral drugs, the presence of certain manifestations of this kind in the oral cavity may mean an increase in the level of human immunodeficiency virus in the blood.

The main diseases manifested in AIDS on the oral mucosa, depending on the etiotropic factor, are grouped as follows:

1. Fungal infections:
   • candidiasis (pseudomembranous; hyperplastic - in the form of plaques or nodes; angular cheilitis).
   • histoplasmosis.
2. Bacterial infections:
   • fusospirochitis (necrotizing ulcerative gingivitis);
   • nonspecific infections (chronic periodontitis);
   • mycobacteria, enterobacteria.
3. Viral infections:
   • herpetic stomatitis;
   • hairy leukoplakia;
   • herpes zoster (shingles);
4. Neoplasms:
   • kaposi's sarcoma in the mouth;
   • squamous cell carcinoma;
   • lymphoma;
5. Lesions of unexplained etiology:
   • recurrent ulcerative aphthae;
   • idiopathic thrombocytopenic purpura (ecchymosis);
   • lesions of the salivary glands.

Fungal lesions.

Candidal stomatitis is diagnosed in suppressed AIDS patients (up to 75%) and manifests itself in several clinical forms.

Pseudomembranous candidiasis more often it begins as acute, however, with AIDS, it can continue or recur, therefore it is considered a chronic process. Fungal lesions are characterized by the presence of a yellowish coating on the oral mucosa, which may be hyperemic or unchanged in color. Plaque adheres tightly to the surface of the epithelium and is difficult to remove. In this case, the bleeding areas of the mucous membrane are exposed. The favorite localization of plaque is the cheeks, lips, tongue, hard and soft palate.

Erythematous, or atrophic, candidiasis develops in the form of bright red spots or diffuse hyperemia, with AIDS has a chronic course. The sky is more often affected, which acquires an uneven bright red color. The epithelium becomes thinner, erosion may appear. Localization of lesions on the dorsum of the tongue leads to atrophy of the filiform papillae along the midline.

Chronic hyperplastic candidiasis with the arrangement of the elements symmetrically on the mucous membrane of the cheeks in the form of polygonal raised foci of hyperplasia, covered with a yellow-white, cream, yellowish-brown bloom. This form of candidiasis is much less common. Researchers have associated this manifestation with the effects of nicotine when smoking.

The diagnosis, which is made on the basis of clinical manifestations, must be confirmed by laboratory tests.

Histoplasmosis - sapronous deep systemic mycosis with an aspiration mechanism for the transmission of the pathogen. It is caused by a biphasic, or dimorphic, fungus of the genus Histoplasma capsulatum. Non-contagious; there are micellar and yeast variants. Depending on the clinical course, primary histoplasmosis of the lungs and secondary, disseminated, which develops more often in endemic areas (in 5% of patients) are distinguished. In disseminated forms, damage to the skin, joints, bone marrow, heart, adrenal glands, and central nervous system occurs. Mortality can reach 20-30%.

Bacterial infections.

Necrotizing ulcerative gingivitis develops in HIV-infected individuals, both at different periods of clinical manifestations of AIDS: and without them in the presence of antibodies against the virus. Patients complain of pain and bleeding of the gums while brushing their teeth, eating; bad breath. On examination, a gray-yellow plaque (necrotic film) is found that covers the gingival margin and interdental papillae. The mucous membrane in the gum area is hyperemic, edematous, tense.

After treatment, the symptoms disappear: however, there is a tendency to relapse. A protracted course can lead to deep ulcers with damage to bone structures, necrotization of the interdental septum.

Viral infections. In HIV-infected people, the most common manifestations of stomatitis caused by herpes simplex virus. Primary infection with the herpes virus occurs in children, adolescents, and less often in young people. Since the infection is latent, there is a tendency to recurrence, and the manifestations are both general (fever, pain when swallowing, swallowing, swallowing, lymph nodes), and local. Acute herpetic eruptions can be localized in any part of the maxillofacial region. Favorite places - lips, gums, hard palate. The initially small bubbles then coalesce into larger ones. After the destruction of the tire, the underlying tissues tend to ulcerate. In the oral cavity, vesicles burst very quickly, and erosion is usually detected immediately. On the red border of the lips, the caps of the bubbles shrink, forming dry or weeping crusts.

Recurrent herpetic stomatitis is most often localized on the red border of the lips with the involvement of the surrounding skin. The bubbles rapidly increase, merge, and a secondary infection joins. The contents of the blisters suppurate, resulting in the formation of dirty yellow crusts, after their separation an eroded or ulcerated surface is exposed.

The elements of the lesion on the hard palate and gums are represented by small bubbles that quickly burst, leading to ulcerative lesions of the mucous membrane. Clinical manifestations can be triggered by a cold, stress, respiratory infection.

Shingles (herpes zoster) in the oral cavity and on the face is characterized by the asymmetry of the lesion, respectively, the area of \u200b\u200binnervation of one of the branches of the trigeminal nerve. It is also possible to involve two or three branches of trigeminus, when elements appear on the mucous membrane in the form of small bubbles, and then an ulcerating surface. The rash is preceded by burning pains simulating pulpitis of intact teeth, radiating along the upper - or mandibular branch of the 5th pair of nerves. These pains can persist even after involution of lesions (up to 1-2 months).

Viral growths are in the form of a wart, papilloma, genital warts and frontal epithelial hyperplasia (papules or nodular lesions with filamentous growths).

Genital warts.Depending on the localization, the elements of the lesion can have a different appearance: multiple peaked protrusions or rounded slightly raised areas with a flat surface. When localized on the gum or hard palate, the lesions are multiple pointed projections. When located on the cheeks, lips, the elements have a picture similar to focal epithelial hyperplasia: rounded, slightly elevated areas with a diameter of about 5 mm with a flattened surface.

Hairy leukoplakia... The lesion is localized, as a rule, on the tongue, having various sizes and appearance. It is found in limited areas of the lateral, dorsal, ventral surface or covers the entire tongue. The mucous membrane acquires a whitish appearance, however, hyperkeratosis does not develop. On palpation, the seals are not determined, which served as the basis for the designation of this form of lesion - soft leukoplakia.

On the lateral surface of the tongue, elements can be located bilaterally or unilaterally. The mucous membrane, in a limited or widespread area, becomes irregular and rises in the form of folds or protrusions above the surrounding surface, which in appearance may resemble hair. Hence the name - hairy leukoplakia.

There are no subjective sensations other than discomfort.

Histological, virological, including serological, studies suggest that the cause of soft hairy leukoplakia is the Epstein-Barr virus.

Manifestations in the oral cavity of neoplasms

Kaposi's sarcoma - vascular tumor, which, in the absence of HIV infection, is characterized by a low-grade course, occurring in residents of African countries. With AIDS, Kaposi's sarcoma can appear in young people in the form of red, rapidly turning brown spots, which are initially found on the legs, but tend to spread. They differ from the classical version by increased malignancy and dissemination on the skin, mucous membranes, and internal organs.

The characteristic brown spots of Kaposi's sarcoma on the face are the “calling card” of AIDS patients, occurring in 30% of HIV-infected people, regardless of the country of residence. The elements of the lesion are initially represented by single, and more often multiple, spotty, papular formations of pink, red, purple on the skin.

In the oral cavity, Kaposi's sarcoma is most often localized in the palate, in the early stages of development it looks like a blue, red, black flat spot. In subsequent stages, the lesions darken, begin to rise above the surface, become lobular, and finally ulcerate, which is especially characteristic when located in the oral cavity. The entire surface of the hard and soft palate can change, deforming due to the formation of both tuberosity and ulcerative defects. The mucous membrane of the gums can also be involved in the process. Moreover, in some cases, the element of defeat looks like an epulis.

The etiological factor of Kaposi's sarcoma has not yet been clarified.

Squamous cell carcinoma can develop in AIDS patients, usually localized in the tongue and occurring in young people. Treatment with immunosuppressive drugs reduces the incidence of malignant tumors, including intraoral carcinoma.