oral manifestations of hiv: case studies
TRANSCRIPT
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NORTHWEST AIDS EDUCATION AND TRAINING CENTER
Oral Manifestations of HIV: Case Studies
David Spach, MD Principal Investigator and Clinical Director, Northwest AETC Professor of Medicine, Division of Infectious Diseases University of Washington School of Medicine
Last Updated: July 8, 2014
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Case 1
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Case History
Source: Photograph from David Spach, MD
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Case History
Source: Photograph from David Spach, MD
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Question 1: Which virus is associated with this disorder?
A. Herpes simplex virus type 2 B. Epstein-Barr Virus C. Human herpes virus type 8 D. Human papillomavirus
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Oral Hairy Leukoplakia
• Cause - Epstein-Barr virus
• Significance - Indicates significant level of immunosuppression - Rare other than HIV infection
• Therapy - None generally required
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Case 2
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Case History
Source: Photograph from David Spach, MD
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Question 2: What would recommend for treatment?
A. Oral Valacyclovir B. Oral Doxycycline C. Oral Fluconazole D. IM Penicillin G
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Oral Candidiasis: Erythematous
Source: Photograph from David Spach, MD
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Oral Candidiasis: Pseudomembranous
Source: Photograph from David Spach, MD
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Oral Candidiasis: Pseudomembranous
Source: Photograph from David Spach, MD
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Oral Candidiasis: Angular Chelitis
Source: Photograph from David Spach, MD
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Oral Candidiasis
• Types - Pseudomembranous - Erythematous (Atrophic) - Angular Cheilitis
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Source: Opportunistic Infections Guidelines. 2013
Oral Candidiasis
Treatment of Oropharyngeal Candidiasis; Initial Therapy (For 7-14 Days)
Preferred Therapy Alternative Therapy
Oral Therapy
• Fluconazole 100 mg PO daily (AI) • Itraconazole oral solution 200 mg PO daily (BI) or
• Posaconazole oral solution 400 mg PO BID for 1 day, then 400 mg daily (BI)
Topical Therapy
• Clotrimazole troches, 10 mg PO 5 times daily (BI) or
• Miconazole mucoadhesive buccal 50-mg tablet once daily (do not swallow, chew, or crush) (BI)
• Nystatin suspension 4–6 mL QID or 1–2 flavored pastilles 4– 5 times daily (BII)
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Case 3
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Case History
Source: Photograph from David Spach, MD
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Question 3
• What is in your differential diagnosis?
1. ______________________
2. ______________________
3. ______________________
4. ______________________
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Orolabial Herpes Simplex Virus
Source: Photograph from David Spach, MD
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Orolabial Herpes Simplex Virus
Source: Photograph from David Spach, MD
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Orolabial Herpes Simplex Virus
Source: Photograph from David Spach, MD
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Orolabial Herpes Simplex Virus
Source: Photograph from David Spach, MD
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Recommendations for Treating Orolabial HSV in HIV-Infected Persons
Therapy for Orolabial Lesions
Valacyclovir: 1000 mg PO twice daily x 5-10 days
Famciclovir: 500 mg PO twice daily x 5-10 days
Acyclovir: 400 mg PO three times daily x 5-10 days
Chronic Suppressive Therapy
Valacyclovir: 500 mg PO twice daily
Famciclovir: 500 mg PO twice daily
Acyclovir: 400 mg PO twice daily
Source: Opportunistic Infections Guidelines. 2013
Therapy for Initial or Recurrent Orolabial HSV
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Case 4
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Aphthous Stomatitis
Source: Photograph from David Spach, MD
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Question 4
• This 32-year-old man has severe extremely painful aphthous stomatitis that has not responded to topical anesthetics, or topical corticosteroids. He has required repeat courses of oral prednisone.
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What other systemic therapy is effective in treating severe aphthous stomatitis?
A. Thalidomide B. Methotrexate C. Hydroxychloroquine D. Naproxen
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Thalidomide for Aphthous Lesions Study Design
Source: Jacobson JM et al. N Engl J Med 1997;336:1487-93.
Study Design
Protocol
- Double blind, placebo controlled
- N = 57
- HIV-infected
- Aphthous lesions > 5 mm
- 4 week oral treatment course
- Thalidomide 200 mg daily versus placebo
- Excluded if pregnant or breastfeeding
55
7
0
20
40
60
80
Com
plet
e H
ealin
g (%
)
Thalidomide Placebo
16/29 2/28
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Aphthous Stomatitis
• Cause - Unknown
• Therapy - Topical anesthetics - Topical coating agents - Topical corticosteroids - Systemic (Prednisone; Thalidomide)
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Case 5
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Case History
Source: Photograph from David Spach, MD
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Case History
Source: Photograph from David Spach, MD
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Oral Kaposi’s Sarcoma
Source: Photograph from David Spach, MD
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Oral Kaposi’s Sarcoma
Source: Photograph from David Spach, MD
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Question 5: What is the most likely diagnosis these HIV-infected persons share in common?
A. Oral squamous cell cancer B. Bacillary angiomatosis C. Kaposi’s sarcoma D. Pigmented viral warts
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Oral Kaposi’s Sarcoma
• Cause - Human herpes virus type 8 (HHV-8)
• Significance - Indicates immune suppression - AIDS-defining condition - May be associated with systemic Kaposi’s sarcoma
• Therapy - Antiretroviral therapy - Local therapy - Systemic cytotoxic chemotherapy in severe cases
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Questions