23.2 HIV and the oropharynx

Question 1

How is HIV acquired?

Answer 1

Through bodily fluids e.g. sexual contact, IV drug use

Question 2

Describe the events that occur following acute HIV infection.

Answer 2

• When HIV enters the body, it reduces CD4 cell count (T-helper cells) and people have primary HIV symptoms e.g. fever, pharyngitis, rash
• After a few weeks the body produces some antibodies and symptoms will improve slightly
• As the CD4 cell count drops to below 200 opportunistic infections occur and there are serious consequences

Question 3

Is HIV always detectable in blood?

Answer 3

No, some people with HIV can have undetectable levels, meaning they are uninfectious.

Question 4

What is PrEP?

Answer 4

Pre-exposure prophylaxis
- Antiviral tablet taken prior to sex
- Reduces risk of HIV by 80-90%

Question 5

Will CD4 count always increase significantly with treatment?

Answer 5

No, if treatment begins too late after infection, the CD4 count will not increase signigicantly.

Question 6

People with untreated HIV are more likely to suffer from viral, fungal and parasitic infections, what oral manifestations and pathologies may you see in these patients?

Answer 6

• Oral candida
• Erythematous candidiasis
• Pseudomembranous candidiasis
• Angular cheilitis
• Oral hairy leukoplakia
• Linear gingival erythema
• NUG/NUP
• Warts
• Herpes
• Herpes zoster
• Kaposi’s satcoma
• Ulceration

Question 7

Describe candida infection in untreated HIV+ patients.

Answer 7

• Oral candida
• Erythematous candidiasis: untreated thrush, more severe (see image)
• Pseudomembranous candidiasis: more severe than standard oral thrush, thick white coating in the mouth

Candida infection can also spread to the oesophagus and stomach in immunosuppressed pts, ask if they have any issues with swallowing, indigestion, abdominal pain.

Question 8

Why may HIV+ pts experience oral hairy leukoplakia?

Answer 8

• Oral hairy leukoplakia is most common in people with HIV
• It is due to low CD4 counts, immunosuppression
• Presents due to EBV infection, body cannot fight the virus
• White plaques present most commonly on lateral borders of the tongue, cannot be wiped off

Question 9

What is linear gingival erythema?

Answer 9

A form of periodontal disease seen in HIV infected individuals.

Question 10

Describe NUG/NUP in HIV patients.

Answer 10

• Bacterial aetiology
• Can be seen in non-HIV patients but common in those who are immunocompromised

Question 11

Describe oral warts in HIV patients.

Answer 11

Oral warts in HIV patients are likely to be more severe.
A manifestation of HPV infection, immunosuppression means difficulty fighting off the virus.

Question 12

Describe herpes and herpes zoster in HIV patients.

Answer 12

• Herpes: in an untreated HIV patient, lesions are more florid and extreme, difficult to treat, can affect the palate
• Herpes zoster: more severe, requires strong antivirals for treatment (see image)

Question 13

Describe Kaposi’s sarcoma in HIV patients.

Answer 13

• A cancer which causes purple plaques or nodules on the skin or mucosa
• Prone to bleeding
• 10% visceral involvement
• More commonly seen in HIV+ pts

Question 14

Describe oral ulceration in HIV patients.

Answer 14

• Severe ulceration in HIV positive patient can be related to a virus called CMV or syphilis
• Unusual or severe presentation

Key message: in HIV, conditions and pathologies present more severely and more florid due to immunosuppression.

Question 15

What signs and symptoms of HIV may you observe on general examination?

Answer 15

• Wasting
• Lipodystrophy (abnormal fat distribution, loss of facial fat)
• Seborrhoea detmatitis (patches of red flaky skin on face and scalp)