CHAPTER 10: Head and Neck Manifestations in the Immunocompromised Host Flashcards
1
Q
Protection of the host occurs by two mechanisms
A
- Innate
2. Adaptive
2
Q
First line of defense
A
Innate immune system
3
Q
Primary cells involved in innate immune system
A
- Neutrophils
- Eosinophils
- Basophils
- Macrophages/monocytes
- Dendritic cells
- NK cells
4
Q
Responsible for protecting the host against pathogens that escape innate immunes responses
A
Adaptive immune system
5
Q
Cellular components of adaptive immunity
A
T and B lymphocytes
6
Q
Less common than secondary immunodeficiencies, rarely affect the innate immune system
A
Primary immunodeficiencies
7
Q
Affects both the T and B cells of the adaptive immune system
A
Severe combine immunodeficiency
8
Q
Characteristics of T-cell dysfunction include
A
Onset of symptoms in early infancy with recurrent fungal, viral, mycobacterial, and opportunistic infections (Pneumocystis jirovecii)
9
Q
Marked by pyogenic bacterial infections with encapsulated organisms
A
B-cell antibody deficiencies
10
Q
Key role in DM
A
Neutrophil dysfunction—>functional neutrophil deficiency
11
Q
True or False
Patients with DM demonstrate impaired neutrophil chemotaxis and phagocytic function that improves with insulin treatment and reversal of hyperglycemia
A
True
12
Q
Defect: Lack of bacterial opsonization
Hallmark infection/signs: encapsulated organisms
A
C3
13
Q
Defect: terminal complement deficiency
Hallmark infection/signs: Neisseria meningitidis
A
C5-C9
14
Q
Defect: decrease in at least 2 Ig and defective antibody production
Hallmark infection/signs: encapsulated organisms, poor vaccination responses, increased risk of bronchiectasis at diagnosis
A
Common variable immunodeficiency
15
Q
Defect: thymic hypoplasia/T-cell deficiency
Hallmark infection/signs: variable
A
22q11.2 deletion (DiGeorge/Velocardiofacial) syndrome
16
Q
Defect: one or more deficient Ig class Hallmark infections/signs: variable
A
Selective Ig deficiencies
17
Q
Defect: severe B and T cell deficiency, lymphopenia
Hallmark infection/signs: severe, early-onset bacteria, viral, and fungal infections
A
Severe combined immunodeficiency
18
Q
Defect: WASP gene defect—>neutropenia, T cell lymphopenia
Hallmark infection/signs: thrombocytopenia, recurrent infection, and eczema
A
Wiskott-Aldrich syndrome
19
Q
Defect: BTK gene defect—>Failure of B-lymphocyte maturation and decreased Ig and specific antibody production
Hallmark infection/signs: encapsulated organism, Giardia lambia, and enterovirus infections
A
X-linked agammaglobulinemia
20
Q
Is diagnosed when CD4 count drops below 200 cells/mm or patients develop OI not normally seen in immunocompetent patients
A
AIDS
21
Q
Is a retrovirus of the Lentivirus subfamily, named for the slow progression of disease in affected individuals
A
HIV
22
Q
Affected cells in HIV resulting in both humoral and cell-mediated immunity
A
CD4 T cells and macrophages
23
Q
Virus life cycle begins when…
A
Binds to the CD4 receptor
24
Q
An enzyme carried by the virus, allows transcription of RNA into DNA
A
Reverse transcriptase
25
A viral protein that facilitates incorporation of the viral DNA into the host genome
Integrase
26
Required for viral infectivity
Protease
27
Major goals of ART
1. Prevention of virus entry into CD4 cells
2. Inhibition of viral replication
3. Reduction in HIV-associated morbidity
4. Prevention of vertical transmission
28
Five classes of ART
1. Nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs)
2. Nonnucleoside reverse transcriptase inhibitors (NNRTIs)
3. Protease inhibitors
4. Fusion inhibitors
5. CCR5 antagionists
6. Integrase strand transfer inhibitors (INSTIs)
29
Some patients who receive therapy demonstrate unexpected clinical deterioration despite improved CD4 count and decreased viral load
Immune reconstitution inflammatory syndrome (IRIS)
30
Two subtypes of IRIS
1. Paradoxic
| 2. Unmasking
31
Patient exhibit worsening symptoms or a new manifestation of a known infection
Paradoxic IRIS
32
Diseases that were not previously suspected become apparent shortly after initiation of HAART
Unmasking IRIS
33
Most common pathogens associated with IRIS
1. Mycobacterium (tuberculous and nontuberculous)
2. Cryptococcus
3. Herpesviruses
4. Hepatitis B and C viruses
5. Human papillomavirus
34
True or False
IRIS has also been described in patients with non-HIV immune deficiency (solid-organ and stem cell transplant recipients)
True
35
AIDS-defining malignancies
1. Kaposi sarcoma (HHV 8)
2. Non-Hodgkin lymphoma (EBV)
3. Invasive cervical cancer (HPV)
36
An angioproliferative disorder that causes lesions marked by spindle cell proliferation, neoangiogenesis, inflammation, and edema
Kaposi sarcoma
37
Four clinical variants of KS
1. Classic KS
2. Endemic KS
3. Transplant- or immunosuppression-related KS
4. AIDS-associated KS
38
First described in elderly men of Eastern Europe or Mediterranean descent
Classic KS
39
Lesions typically occurring on the upper and lower extremities
Classic KS
40
Recognized in black adults and children in Africa
Endemic KS
41
Most frequently affected sites in oral KS
1. Hard palate
2. Gingiva
3. Tongue
42
Treatment for KS
Palliative
43
Specific indications for treatment of KS
1. Cosmetically disfiguring lesions
2. Symptomatic oral or visceral lesions
3. Pain or edema associated with lymphadenopathy
4. Extensive cutaneous disease
44
Local treatments for KS
1. Alitretinoin topical gel
2. Local irradiation
3. Intralesional chemotherapy injection
4. Cryotherapy
5. Laser therapy
6. Surgical excision
45
Cornerstone of treatment for AIDS-KS of all stages
HAART
46
Agents currently FDA approved for systemic treatment of KS
1. Liposomal anthracyclines (doxurubicin and daunorubicin)
2. Paclitaxel
3. Interefon-alpha
47
Other commonly used agents for systemic treatment of KS
1. Vinca alkaloids (vincristine, vinblastine, vinorelbine)
2. Bleomycin
3. Etoposide
48
Second behind KS as the most common cutaneous malignancy in HIV-positive population (1.8%)
BCC
49
True or False
CD4 count does not correlate with the incidence or severity of BCC but may play a more significant role in the development of cSCC
True
50
An additional risk factor for the development of cSCC
Use of voriconazole in the treatment of invasive fungal infections in TRs and in patients with HIV
51
Most common site of HNSCC in immunodeficient patients
Larynx—>oral cavity—>oropharynx
52
Cervical and anogenital cancer in immunodeficient patients is associated with
HPV types 16, 18, 31, and 45
53
Factors leading to increased rate of lymphoma in HIV-patients and TRs
1. Virally induced immunosuppression
2. Decreased immune surveillance
3. Altered cytokine exposure
4. Chronic antigenic stimulation
54
Most common type of lymphoma to develop in HIV-positive patients and TRs
EBV-associated NHL
55
WHO classification for AIDS-related lymphomas includes three categories
1. Lymphomas that also occur in immunocompetent patients
2. Lymphomas that occur specifically in HIV-positive patients
3. Lymphomas that also occur in other immunodeficiency states
56
Lymphomas that also occur in immunocompetent patients
1. Burkitt
2. Diffuse large Bcell
3. Hodgkin
57
Lymphomas that occur specifically in HIV-positive patients
1. Primary effusion lymphoma
2. Large B cell lymphoma arising in HHV8-associated multicentric Castleman disease
3. Plasmablastic lymphoma
58
True or False
Most AIDS-related NHLs are EBV-associated B-cell lymphomas such as Burkitt lymphoma, diffuse large B-cell lymphoma, and PBL
True
59
Alters tumor suppressor gene (TP53) expression and protein regulation
EBV
60
Second most likely cancer-related cause of mortality in the HIV-positive population, behind lung cancer
NHL
61
Most common manifestation of CNS involvement in NHL
Leptomeningeal disease
62
Clinical tool used to predict survival in NHL
International Prognostic Index
63
Factors associated with poor prognosis in NHL
1. Age over 60 years
2. Advanced tumor stage
3. Elevated serum lactate dehydrogenase
4. Poor performance status
5. More than one extranodal site of disease
64
A complication of solid-organ and stem cell transplantation marked by EBV-driven abnormal lymphoproliferation
Posttransplantation lymphoproliferative disorder
65
Is the second most common malignancy to develop in Trs, after cutaneous malignancy
Posttransplantation lymphoproliferative discorder
66
True or False
| Most PTLDs are NHL of the B-cell type
True
67
True or False
PTLD develops in the setting of severe immunosuppression, which impairs the formation of a cytotoxic T-lymphocyte immune response to EBV
True
68
Treatment of PTLD
Directed first toward decreasing immunosuppression regimens to allow an adequate T-cell response
69
True or False
PTLD: patients who fail to respond may require systemic therapy such as combination chemotherapy, cytokine therapy, or anti-CD 20 therapy (rituximab)
True
70
True or False
PTLD: surgery is reserved for management of local symptoms; upper airway obstruction caused by adenotonsillar hypertrophy
True
71
Risk factors for the development of HL in TRs include
1. Bone marrow transplantation
| 2. History of GVHD
72
Most common NADM that occurs in patients with HIV
HL
73
Characteristic pathologic cells seen in HL
Reed-Sternberg cells
74
The accepted standard of treatment for HIV-HL consist of
Combination chemotherapy and ART
75
True or False
Salivary flow rates have been shown to be diminished in the setting of HIV or GVHD, which leads to increased incidence of dental caries and impaired deglutition
True
76
Majority of salivary gland masses in HIV-positive patients are the result of a benign entity known as
Benign lymphoepithelial cyst (BLEC)
77
True or False
BLECs have cyst walls lined by hyperplastic and metaplastic squamous epithelium, and they contain aggregates of lymphoid proliferation
True
78
True of False
| HIV-associated BLECs typically do not require parotidectomy
True
79
True or False
Parotidectomy or enucleation of lesions may be considered in BLECs that undergo rapid size change, are disfiguring, or have significant pressure symptoms
True
80
Occurs in the setting of HIV and is marked by salivary gland enlargement with circulating and visceral CD8 lymphocytosis
Diffuse Infiltrative Lymphocytosis Syndrome
81
Second most common cause of cervical lymphadenopathy in HIV-positive patients after benign reactive lymphadenopathy
Extrapulmonary TB
82
Most common site of extrapulmonary TB involvement in HIV-positive patients
Lymph nodes
83
Most common pathogens in acute sinusitis (HIV)
1. Streptococcus pneumoniae
2. Haemophilus influenzae
3. Moraxella catarrhalis
84
Most common pathogens in chronic sinusitis (HIV)
1. Staphylococcus
2. Pseudomonas species
3. Anaerobes
85
Important pathogens in immunodeficiency-related sinusitis, because these organisms have the potential to cause invasive and oftentimes fatal disease
1. Rhizopus
| 2. Mucor
86
Most common fungal pathogen in invasive and noninvasive sinusitis for both immunosuppressed and immunocompromised patients
Aspergillus fumigatus
87
Suspicious findings for IFS on MRI
1. Obliteration or infiltration of periantral or orbital fat
2. Inflammatory changes in the EOMs
3. Leptomeningeal enhancement
88
True or False
Fungal sinusitis can extend via thrombophlebitic or hematologic spread and thus may enter into the orbit or intracranial cavity without histologic evidence of mucosal invasion
True
89
Aspergillus may allow extension of disease without evidence of bony destruction on imaging through
Angiocentric invasion pattern
90
Goal of management of sinusitis in immunocompromised patients include
1. Swift treatment of bacterial sinusitis
| 2. Early identification of fungal sinusitis or neoplasm
91
Initial medical management of acute bacterial sinusitis consists of
1. Broad-spectrum antibiotics
2. Decongestants
3. Saline irrigation
92
Ideal treatment involves three components
1. Systemic antifungal therapy
2. Surgical debridement of infected tissue
3. Restoration of immune function
93
True or False
The pathogenesis of SBO is further facilitated by the breakdown of the local cutaneous barrier in the EAC secondary to dermatologic lesions and self-induced trauma as a result of pruritus
True
94
Spreading to the skull base with resulting temporal bone osteomyelitis occurs via
1. Fissures of Santorini
| 2. Tympanomastoid suture
95
Risk factors for invasive aspergillosis of the temporal bone include
1. Low CD4 count
2. AIDS diagnosis
3. Neutropenia
4. Corticosteroid therapy
5. Antineoplastic therapy
6. Prolonged antibiotic therapy
96
Otoscopy on temporal bone osteomyelitis
White debris or granulation tissue at the bony cartilaginous junction of the EAC
97
More specific for osteomyelitis, and some suggest its use to monitor response to therapy
Gallium-67 citrate scintigraphy
98
Very sensitive but relatively nonspecific test for detecting increased osteoblastic activity
Technectium-99 scintigraphy
99
Treatment of choice in bacterial SBO (cure rates near 90%)
Fluoroquinolones
100
Subcortical dementia marked by memory loss, apathy, and difficulty with reading and comprehension in the early stages
HIV-associated dementia
101
True or False
HAD is thought to be caused by either repeated exposure to infected monocytes that cross the BBB or by autonomous viral production in the brain, which serves as a reservoir for the virus
True
102
Most common sensory neuropathy associated with HIV
Distal sensory polyneuropathy (DSP)
103
Characterized by symmetric polyneuropathy and axonal degeneration
Distal sensory polyneuropathy
104
Most common cranial nerve manifestation in cryptococcal meningitis
Hearing loss
105
Should be suspected in any HIV-infected patient who is seen with cochleovestibular complaints
Otosyphilis
106
True or False
| Hearing loss as a result of syphilis is usually bilateral, may be progressive or fluctuate, or may have a sudden onset
True
107
True or False
The audiometric curve in otosyphilis often shows a low-frequency hearing loss in association with diminished speech discrimination scores
True
108
The first priority in the evaluation of SNHL in a patient with HIV infection
Rule out potentially life-threatening disease
109
Most common oral manifestation of HIV infection in adults and children
Candida infection
110
3 most common forms of oral candidiasis
1. Pseudomembranous candidiasis
2. Erythematous candidiasis
3. Angular cheilitis
111
Presents as smooth white or cottage cheese-like plaques that can occur on any mucosal surface
Pseudomembranous candidiasis (thrush)
112
It is distinguished from other white lesions of the oropharynx in that the white plaques can be rubbed off; when the plaque is wiped off, an erythematous base remains
Pseudomembranous candidiasis
113
Marked by mild or moderately erythematous patches
Erythematous candidiasis
114
Presents as tender and erythematous fissures and ulcers at the oral commissure
Angular cheilitis
115
A white lesion with a corrugated and shaggy surface caused by EBV
Oral hairy leukoplakia
116
True or False
| OHL most frequently occurs on the lateral surface of the tongue
True
117
Risk factors for the development of oral hairy leukoplakia
1. Low CD4 count
2. High viral load
3. Presence of oral candidiasis
118
OHL is diagnosed on biopsy by the presence of
1. Hyperkeratosis
2. Acanthosis
3. Clear or “balloon” cells in the upper spinous cell layer with minimal inflammation
4. Presence of EBV in the basal epithelial cells
119
Most common manifestation of herpes simplex infection of the oral cavity
Herpes labialis
120
A herpes labialis which is larger and more numerous, persistent longer and recur more frequently
Fever blisters
121
Treatment of choice for acyclovir-resistant HSV
IV foscarnet
122
3 types of aphthous ulcers
1. Herpetiform ulcers
2. Minor aphthous ulcers
3. Major aphthous ulcers
123
Type of aphthous ulcer: smaller than 0.2 mm in diameter and are self-limited
Herpetiform ulcers
124
Type of aphthous ulcer: well circumscribed, painful ulcers less than 6mm in diameter with an erythematous halo; in the HIV-infected patient, ulcers frequently coalesce to form larger lesions that last about 2 weeks
Minor aphthous ulcers
125
Type of aphthous ulcer: larger than 6 mm in diameter, are painful, persist for weeks, and threaten nutritional intake
Major aphthous ulcers (Sutton disease)
126
Initial treatment of minor ulcers
Over the counter protective and analgesic medications
127
Treatment for major or nonhealing minor lesions
Thalidomide (200mg/day)
128
Periodontal disease associated with HIV infection is classified into:
1. Linear gingival erythema
2. Necrotizing periodontal disease
3. Enhanced progression of chronic periodontal disease
129
Presents with distinct linear erythema that does not respond to conventional periodontal therapy and is closely related to the presence of OC
Linear gingival eythema
130
Presents with ulceration of the interdental papilla associated with gingival bleeding and pain that may invade the alveolar bone
Necrotizing periodontal disease
131
Mainstay of therapy for HIV-related gingivitis and periodontitis
1. Dental plaque removal
| 2. Oral rinses with 10% povidone-iodine with 0.1% to 0.2% chlorhexidine gluconate
132
Refer to collectively to the changes in fat distribution that occur in HIV-positive patients who receive ART
HIV-associated lipodystrophy
133
Changes (HIV-associated lipodystrophy)
1. Peripheral lipoatrophy
2. Lipohypertrophy
3. Increased breast size and abdominal girth and increased visceral adipose tissue
4. Metabolic disturbances (hypertriglyceridemia, hypercholesterolemia, insulin resistance, T2Dm, elevated hepatic transaminases)
134
Fat distribution that affects the face and extremities
Peripheral lipoatrophy
135
Manifest as increased fat deposition in dorsocervical fat pads (“buffalo hump”) or the lateral and anterior neck (“bullfrog neck”)
Lipohypertrophy
136
Characterized by fat atrophy in the malar, buccal, melolabial, and temporal regions
Facial LA
137
Current FDA-approved treatments for facial LA
1. Calcium hydroxylapatite
| 2. Poly-L-lactic acid
