Acquired Immunodeficiency Syndrome Question And Answers

Acquired Immunodeficiency Syndrome Question And Answers

Question 1. Write short note on oral manifestations of AIDS.
Or
Discuss oral manifestation of AIDS.
Or
Write short note on oral manifestations of acquired immunodeficiency syndrome.
Or
Write short note on oral manifestations of HIV.
Or
Describe in detail the oral manifestations of AIDS.
Or
Write short note on oral manifestations of HIV virus.
Or
Write short answer on oral manifestation of AIDS.
Or
Write short answer on oral manifestations of HIV.
Answer. Oral manifestations of HIV disease are common and include oral lesions and presentation of previously known opportunistic diseases.

E.C. Clearinghouse Classification of Oral Manifestations of HIV Diseases

Group 1: Strongly Associated with HIV Infection

• Candidiasis: Erythematous, pseudomembranous, angular cheilitis
• Hairy leukoplakia
• Kaposi’s sarcoma
• Non-Hodgkin’s lymphoma
• Periodontal diseases: Linear gingival erythema, necrotizing gingivitis, necrotizing periodontitis

Group 2: Less Commonly Associated with HIV Infection

• Bacterial infections: Mycobacterium avium- intracellulare, Mycobacterium tuberculosis
• Melanotic hyperpigmentation
• Necrotizing ulcerative stomatitis
• Salivary gland disease: Dry mouth, unilateral or bilateral swelling of major salivary glands
• Thrombocytopenia purpura
• Oral ulcerations NOS (not otherwise specified)
• Viral infections: Herpes simplex, human papillomavirus, varicella zoster

Read And Learn More: Oral Medicine Question And Answers

Group 3: Seen in HIV Infection

• Bacterial infections: Actinomyces israelii, Escherichia coli, Klebsiella, pneumoniae
• Cat-scratch disease (Bartonella henselae)
• Epithelioid (bacillary) angiomatosis (Bartonella henselae)
• Drug reactions: ulcerative, erythema multiforme, lichenoid, toxic epidermolysis
• Fungal infections other than candidiasis: Cryptococcus neoformans, Geotrichum candidum, Histoplasma capsulatum, Mucoraceae (mucormycosis/zygomycosis), Aspergillus flavus
• Neurologic disturbances: Facial palsy, trigeminal neuralgia
• Recurrent aphthous stomatitis
• Viral infections: Cytomegalovirus, molluscum contagiosum.

Oral Manifestations of HIV/AIDS in Detail

Candidiasis

This is the most common finding in the persons suffering from HIV.

Oral Manifestations of HIV/AIDS  Clinical Features

• In HIV lesion is present over hard palate, tongue and the soft palate.
• Four clinical patterns are appreciated in patient of HIV i.e. pseudomembranous, hyperplastic, erythematous and angular cheilitis.
• There is presence of burning sensation in the mouth along with change in taste.
• Pseudomembranous candidiasis show creamy white removable plaques on oral mucosa. Mucosa can appear red when plaque is removed. This can involve any part of mouth or pharynx.
• Erythematous candidiasis is seen as red patches of variable sizes. It is seen over palate or dorsum of tongue.
• Angular cheilitis is seen as red, ulcerated and fissured, present unilaterally or bilaterally at corner of lips.

Management of oral manifestations of AIDS

• Topical clotrimazole should be applied which is given in doses of 10 mg: 50 Troches. 1 troche should be dissolved 5 times a day. Topical itraconazole is also effective.
• Systemically anti-fungals should be given when patient is not taking retroviral therapy or CD4+ count is below 50%. Fluconazole 100 mg two tablets per day and 1 tablet for next 15 days.

Atypical Periodontal Disease

It is common problem in both symptomatic and asymptomatic patients.

Atypical Periodontal Disease Types

• Linear gingival erythema: Presence of distinct linear band of erythema.
• Necrotizing ulcerative gingivitis: Presence of ulceration and necrosis of inter-dental papillae
• Necrotizing ulcerative periodontitis: Presence of rapid loss of periodontal attachment.

Atypical Periodontal Disease Clinical Features

• Linear gingival erythema: It occurs in hygienically clean mouth. Here gingiva becomes red and edematous. In some cases alveolar gingiva and mucosa demonstrate punctuate diffuse erythema.
• Necrotizing ulcerative gingivitis: Ulcers are seen at tip of interdental papilla and at gingival margins. Severe pain is present. Ulcers get healed and leave gingival papillae with characteristic cratered appearance.
• Necrotizing ulcerative periodontitis: It presents as rapid loss of supporting bone and tissue. Loss of bone and tissue occur with no formation of gingival pockets, sometimes only the isolated areas of mouth are involved.
• Necrotizing stomatitis: Areas of necrotic bone are seen at gingival margin. Bone can sequestrate, this resembles NOMA.

Management of oral manifestations of AIDS

• Removal of necrotic tissue is carried out and irrigation with povidone iodine solution is done.
• Periodic scaling and root planning should be done.
• Chlorhexidine mouthwash is used once or twice daily.
• In necrotizing ulcerative periodontitis, metronidazole 250 mg four times a should be given, combination of amoxicillin and clavulanic acid 375 or 625 mg three times a day or clindamycin 300 mg thrice a day is given.

Herpes Simplex Infection

• It occurs as herpes labialis and recurrent intraoral herpes.
• In herpes labialis, a lesion occurs on lip consisting of vesicles over the erythematous base which heals in 7 to 10 days.
• Systemic acyclovir 30 mg/kg/day should be given.

Herpes Zoster

• It mainly occurs in HIV infected persons.
• Unilateral vesicles occur which break and scab. It persists for longer period of time.
• Intraoral lesions causes bone sequestration as well as loss of teeth. Pain is severe.
• Acyclovir is given 15 to 30 mg/kg/day I.V. 8 hourly for 10 to 15 days.

Hairy Leukoplakia

For details refer to Ans 3 of same chapter.

Kaposi’s Sarcoma

It is also called as angioreticuloendothelioma.

It is the most common tumor associated with the AIDS and is seen occurring in one third of HIV affected patients.

Clinical Features

• It occurs in 5th and 7th decades of life. It occurs most commonly in man. In Africa it occurs in children too.
• It occur commonly in head and neck region. Tip of the nose is most frequent location. It involves soft tissues,lymph nodes, extremities, lung, liver, pancreas, spleen and adrenal gland.
• It start as multinucleated neoplastic process that manifest as multiple red or purple macules and in more advanced stage.
• Size of the sarcoma is from few millimeters to centimeter and is tender on palpation.

Oral Manifestations

• It involve oral cavity also, with hard palate as most common site. Lesions may also occur on gingiva, soft palate, buccal mucosa and oropharynx.
• It can appear as red, blue, or propulsive lesion, It can be flat or raised solitary or multiple, yellow mucosa surrounds lesion. Lesion may enlarge, ulcerate and get infected.
• During eating and speaking patient complaints of pain and also interference with these activities.
• On palpation lesions are tender. After some amount of time, plaque or nodule can occur in the particular region.
• If the sarcoma invades the bone, it leads to mobility of tooth.

Management

• Thorough dental prophylaxis is done before initiating therapy for lesions involving gingiva. Response to therapy is improved, if all local plaque and calculus is removed. Local application of scalloping agents may reduce size of oral leisons.
• Oral lesion can be treated surgically or with localized intralesional chemotherapy.
• Surgical removal should be done under local anesthesia with blade or carbon dioxide laser.
• Radiation therapy is indicated for large multiple lesion. A single dose of 800 cGy is given.
• 4 interferon-alpha and sclerotherapy with 3 % sodium tetradecyl sulfate.
• Intralesional injection of sodium tetradecyl sulphate which is a sclerosing agent is very effective for oral lesion.

 

Question 2. Write short note on laboratory test for HIV infection.
Answer.

Enzyme Linked Immunosorbent Assay (ELISA)

ELISA is a initial screening test.

• Mechanism: Here the HIV virus particle which is an antigen binds with antibodies to HIV virus in an infected human serum. Serum attained from blood sample of the patient consists of antibodies which are incorporated to ELISA plate, which is then washed clear of inactive antibodies which do not bind to antigens. Second layer of antibodies known as conjugate should be added to detect primary antibody from the human serum. Excessive antibodies are than washed and clear of the plate, and finally substrate i.e. chromogen is added to make reactions occur.
• Positive result: Positive test means that HIV antigens act on substrate and change its color.
• Negative result: It means that antibodies will not bind to HIV antigen, so there is no enzyme to change the color of substrate.
• ELISA is not 100% reliable as this is not specific for only HIV antibodies and may also react with other viral antibodies. If result of ELISA test is positive, more specific western blot method should be carried out.

Western Blot Method

This test is given as follow up test to positive ELISA test.

This test is used to eliminate false positive result of ELISA.

• Mechanism: Here, the viral proteins from blood sample are passed via gel. Different proteins migrate via the gel at different speed i.e. small proteins migrate at faster rate while large proteins migrate at slow rate. As proteins get separated, they are now passed via electric current so that they can transfer on a solid film strip in order of their speed. Add human serum and any of the existing HIV antibody bind to HIV antigen. Chemical which reacts upon contact with protin-antibody-enzyme layer change the color of band. According to common “3-band rule” if there is appearance of three or more bands, HIV antibodies are detected.
• Positive result: HIV-specific nitrocellulose strips are exposed to infected human serum and goat anti-human antibody strip characteristic band detected for each of three groups of viral protein.
• Negative result: No reaction with any viral protein.
• Indeterminate test: Those which react with one of the three groups of antigen.

Viral Load Testing

It measures presence of amount of HIV virus in human body. This is not the diagnostic test.

This test provide the information about progression of HIV on the basis of CD4 cell count, this predict the future course of disease and guides for the treatment.

• Mechanism: Viral load tests are of two types i.e. polymerase chain reaction (PCR) and branched DNA (bDNA). It is important to use same type of viral load test every time and do not switch between these two, values between the two are not comparable.
• High viral load: It is between 5000 and one million copies or more.
• Low viral load: It is between 200 and 500 copies
• Increase in the count indicates worsening of infection while decrease in the count is indicative of suppression of HIV infection.

Alternative Diagnostic Test

• Indirect immunofluorescence and microfiltration enzyme assay system: This is rapid and expensive.
• p24 antigen capture assay: It detects HIV DNA which is integrated in host DNA. The test detect HIV antibody within 45 days after exposure.
• Surrogate marker: Absolute CD4 + T cell lymphocyte count correlate best with progression of HIV – I related immune dysfunction. Other serum used are neopterin beta-2-microreceptor HIV p24 antigen, interleukin-2 receptor IgA and impaired delayed type of hypersensitivity can be used.
• OraSure: It absorbs blood derived fluid from gingival tissue. It is the only FDA approved HIV antibody.

 

Question 3. Write short note on hairy leukoplakia.
Or
Write short answer on hairy leukoplakia.
Answer. Oral hairy leukoplakia is the condition which is present with non-movable corrugated or hairy white leison on the lateral margins of the tongue.

This condition occurs in 20% of patients with asymptomatic HIV infections and becomes more common as CD4+ T cell count falls.

Etiology

Epstein-Barr virus is identified in these lesions. Exact etiology is unknown.

Hairy Leukoplakia Clinical Features

• Unique and significant lesion which primarily occurs unilaterally or bilaterally on lateral border of tongue. It can occur on dorsum of tongue, buccal mucosa, floor of mouth, retromolar area, soft palate.
• There is presence of characteristic corrugated and white appearance.
• The surface is irregular and has projections, resembling hairs.
• They may spread downward onto ventral surface of tongue, where they appear flat.

Hairy Leukoplakia Clinical Features Management

• Acyclovir 2.5 to 3 mg per day for 2 to 3 weeks.
• Antifungal agents, i.e. cotrimazole 10 mg five times a day.
• Nystatin 10,000 units per gram 5 times a day.
• Ketoconazole 200 mg twice a day.
• Therapy of HIV by zidovudine affect Epstein-Barr virus which lead to the regression of hairy leukoplakia.
• Topically retinoid and podophyllin resins provide temporary remission of hairy leukoplakia.

 

Question 4. Write short note on AIDS.
Answer. AIDS is defined as the disease indicative of a defect in cell mediated immunity occurring in a person with no known cause for immunodeficiency other than the presence of HIV.

Oral Manifestations of AIDS

For details refer to Ans 1 of same chapter.

Investigations for AIDS

For details refer to Ans 2 of same chapter.

Prophylactic Measures to be Adopted by Dental Surgeon While Treating AIDS Patient.

In OPD

• Any patient with open wound, gloves are worn when examining a patient.
• During laryngoscopy, gloves should be worn.
• Hand gloves and eye protection during flexible endoscopy.
• Use disposable instruments.
• Reusable instruments are cleaned in soap and water and emerged in glutaraldehyde.
• No surgical procedure involving sharp instruments is performed in OPD.

In Operating Room

• Operating table is covered with a single sheet of polythene.
• The number of personnel in operating room should be reduced to minimum.
• The staff with abrasion or lacerations on their hands is not allowed inside the operating room.
• Staff who enter the theater wear overshoes, gloves and disposable water resistant gowns and eye protectors.

Management of AIDS

• Inactivation of HIV virus is done by heat produced in an autoclave or hot air oven, 2% glutaraldehyde, etc.
• Interferon: It has antiviral, antiproliferative and immunomodulatory activity.
• Thymic replacement therapy: This basically corrects the immune defect.
• Lymphokines and cytokines
• Bone marrow transplantation
• Monoclonal antibody therapy
• Intravenous immunoglobulin therapy
• Antiviral therapy or HAART therapy

Nucleoside reverse transcriptase inhibitor (NRTI): Zidovudine, didanosine, abacavir, lamivudine, stavudine.

Non-nucleoside reverse transcriptase inhibitor (NNRTI): Nevirapine, delavirdine.

• Protease inhibitors (PI): Ritonavir, indinavir, amprenavir.
• Virus adsorption inhibitors: They interfere with the virus binding to cell surface by shielding positively charged sites on gp-120 glycoprotein like polyanionic compounds.
• Counseling of HIV patients and their families.
• Life-expectancy after initial HIV infection is 8–10 years.