Prevalence of oral hairy leukoplakia and epithelial infection by Epstein-Barr virus in pregnant women and diabetes mellitus patients--cytopathologic and molecular study

Oral hairy leukoplakia (OHL) is generally reported in patients with severe immunosuppression, except for a few cases in individuals with moderate degree of immunodeficiency. It is a white lesion that appears mainly in the lateral border of the tongue, caused by Epstein-Barr virus (EBV). The nuclear changes caused by EBV (Cowdry A inclusion, ground glass and nuclear beading), observed in cytopathology, are specific and enough for the definitive diagnosis of OHL, independent of the identification of the virus. Here we investigated the prevalence of OHL and the presence of EBV-DNA in the lateral borders of the tongue from 90 pregnant women, 90 diabetes mellitus (DM) patients, 30 healthy individuals (negative group) and 30 HIV+ with OHL (positive group). Smears were analyzed by cytopathology and polymerase chain reaction (PCR). A case of subclinical OHL and candidiasis was identificated in a DM patient by cytopathologic analysis. PCR results demonstrated EBV-DNA in 65% of the pregnant women, in 35% of DM patients, and in 20% of the healthy individuals. We concluded that DM patients can develop OHL with a low prevalence. Furthermore, the prevalence of the EBV in lateral border of the tongue is larger in pregnant women than in healthy individuals.     

Polymerase chain reaction genotyping of Epstein-Barr virus in scraping samples of the tongue lateral border in HIV-1 seropositive patients

The Epstein-Barr virus (EBV) is the etiological agent of oral hairy leukoplakia (OHL), an oral lesion with important diagnostic and prognostic value in acquired immunodeficiency disease syndrome. The two EBV genotypes, EBV-1 and EBV-2, can be distinguished by divergent gene sequences encoding the EBNA-2, 3A, 3B, and 3C proteins. The purpose of this study was to identify the EBV genotype prevalent in 53 samples of scrapings from the lateral border of the tongue of HIV-1 seropositive patients, with and without OHL, and to correlate the genotypes with presence of clinical or subclinical OHL with the clinic data collected. EBV-1 and EBV-2 were identified through PCR and Nested-PCR based on sequence differences of the EBNA-2 gene. EBV-1 was identified in the 31 samples (15 without OHL, 7 with clinical OHL and 9 with subclinical OHL), EBV-2 in 12 samples (10 without OHL, 1 with clinical and 1 subclinical OHL), and a mixed infection in 10 samples (2 without OHL, 3 with clinical and 5 with subclinical OHL). The presence of EBV-1 was higher in women, but a significant statistical result relating one the EBV genotypes to the development of OHL was not found. We conclude that the oral epithelium in HIV-1 seropositive patients can be infected by EBV-1, EBV-2 or by a mixed viral population.     

Prevalence of oral lesions by Candida sp.: Their varieties and serotypes in a population of patients with AIDS under a highly active antiretroviral therapy.

The aim of this study has been to determine the prevalence of oral candidiasis and oral Candida carriers in an AIDS population under highly active antiretroviral therapy. Eighty-six AIDS patients treated with an antiretroviral combination (indinavir o ritonavir o saquinavir + zidovudine [AZT] + lamivudine [3TC]). Patients were grouped attending the predisposing factors for HIV infection in: intravenous drug users (IDU), heterosexuals, homosexuals, patients using hematological products or having unknown factors. Oral cavity was examined and an oral specimen was inoculated in a chromogenic culture medium (Albicans ID, bioMérieux, France). The prevalence of oral Candida lesions was 30.2% and Candida was isolated from 54.7% of patients. The predominant species was C. albicans serotype A in all the groups with the exception of homosexual patients, were C. albicans serotype B was the predominant. The IDU group showed the higher prevalence of Candida lesions and oral yeasts colonization, followed by the group of heterosexuals and homosexuals. An association was found between the presence of lesions and/or Candida spp. and the clinical stage or the viral concentration. The species Candida dubliniensis was isolated in the oral samples of two patients with candidosis and in two individuals without oral candidosis. The finding of this species in Spanish patients can be added to the data obtained in epidemiological studies in other countries.     

Oral candidiasis and oral yeast carriage among institutionalised South African paediatric HIV/AIDS patients

South Africa currently has an estimated 500,000 AIDS orphans, many of whom are HIV-positive. Oral candidiasis commonly occurs in both adult and paediatric HIV/AIDS patients. Published information on HIV-positive children in Africa mainly concerns hospitalised patients. The objective of this study was to determine the prevalence of oral candidiasis and oral yeast carriage among paediatric HIV/AIDS patients residing in orphanages in Gauteng, South Africa, and to compare the prevalence of isolated yeast species with species obtained from adult HIV/AIDS patients. Eighty-seven paediatric HIV/AIDS patients residing in five homes were examined and a swab taken from the dorsal surface of the tongue, cultured on CHROMagar and yeast isolates identified with the ATB 32C commercial system. The species prevalence of 57 identified isolates was compared with that of 330 isolates from adult HIV/AIDS patients. Twelve (13.8%) children presented with clinically detectable candidiasis. Yeasts were isolated from 0% to 53% of children in the individual homes, with Candida albicans (40.4%) and C. dubliniensis (26.3%) constituting the most frequently isolated species. Gentian violet prophylaxis was administered in one particular home and a higher carriage rate (66.6%) of non-C. albicans and non-C. dubliniensis was observed among these children. The prevalence of C. albicans was lower while the prevalence of C. dubliniensis, C. glabrata and C. tropicalis was significantly higher (p ≤ 0.001) among the children than among adult HIV/AIDS patients. These findings indicate a role for yeast culture and species determination in cases with candidiasis in institutionalized paediatric HIV/AIDS patients.     

Usefulness of oral cytopathology in the diagnosis of infectious diseases

P. H. Braz‐Silva, M. H. C. G. Magalhães, V. Hofman, K. L. Ortega, M. I. Ilie, G. Odin, P. Vielh and P. Hofman Usefulness of oral cytopathology in the diagnosis of infectious diseases In recent years, the incidence of oral opportunistic infections has increased, partly due to the widespread implementation of organ and bone marrow transplantation and the increase in the prevalence of human immunodeficiency virus (HIV) infection. Cytology can be used as a rapid, inexpensive and simple routine procedure in diagnosing infectious diseases of the mouth. Moreover, ancillary methods can be applied to cytological samples, increasing the specificity and sensitivity for the diagnosis of infectious diseases. This review describes the cytopathological features of the main viral, fungal, bacterial and parasitic infections of the mouth. Cytological techniques of specimen collection, identification of infectious agents by cytomorphological approaches and ancillary methods, and diagnostic pitfalls will be discussed.     

Evaluation of Epstein-Barr Virus Salivary Shedding in HIV/AIDS Patients and HAART Use: A Retrospective Cohort Study

Little data is available on the evaluation of the occurrence rates of Epstein-Barr virus(EBV) in saliva and relationship with highly active antiretroviral therapy(HAART) use in HIV/AIDS patients in China. We conducted a retrospective cohort study of EBV serological tests for HIV/AIDS patients who were treated in the hospitals for infectious diseases in Wuxi and Shanghai, China from May 2016 to April 2017. The EBV-seropositive samples were identified by ELISA. EBV-specific primers and probes were used for the quantitative detection of viral DNA from saliva via quantitative real-time polymerase chain reaction. CD4 cell counts of the HIV/AIDS patients were detected by a flow cytometry. A total of 372 HIV/AIDS patients were ultimately selected and categorized for this retrospective cohort study. For EBV IgG and IgM, the HIV/AIDS HAART use(H) and non-HAART use(NH) groups had significantly higher seropositive rates than the HIV-negative control group. The HIV/AIDS(NH) group had the highest seropositive rate(IgG, 94.27%; IgM, 68.98%) and the highest incidence of EBV reactivation or infection. For salivary EBV DNA-positive rates and quantities, the HIV/AIDS(H)(73.69%) and the HIV/AIDS(NH)(100%) groups showed significantly higher values than the HIV-negative control group(35.79%,[ twofold). Further, the salivary EBV DNA-negative population had significantly higher CD4 cell counts than the EBV DNA-positive population in the HIV/AIDS(H) group and the HIV/AIDS(NH) groups. Thus, HAART use is beneficial in decreasing the EBV salivary shedding in HIV/AIDS patients and indirectly decreases EBV transmission risk.     

Molecular evidence for rhesus lymphocryptovirus infection of epithelial cells in immunosuppressed rhesus macaques

Epstein-Barr virus (EBV) is a human oncogenic herpesvirus associated with epithelial cell and B-cell malignancies. EBV infection of B lymphocytes is essential for acute and persistent EBV infection in humans; however, the role of epithelial cell infection in the normal EBV life cycle remains controversial. The rhesus lymphocryptovirus (LCV) is an EBV-related herpesvirus that naturally infects rhesus macaques and can be used experimentally to model persistent B-cell infection and B-cell lymphomagenesis. We now show that the rhesus LCV can infect epithelial cells in immunosuppressed rhesus macaques and can induce epithelial cell lesions resembling oral hairy leukoplakia in AIDS patients. Electron microscopy, immunohistochemistry, and DNA-RNA in situ hybridization were used to identify the presence of a lytic rhesus LCV infection in these proliferative, hyperkeratotic, or parakeratotic epithelial cell lesions. These studies demonstrate that the rhesus LCV has tropism for epithelial cells, in addition to B cells, and is a relevant animal model system for studying the role of epithelial cell infection in EBV pathogenesis.     

Correlative detection of human immunodeficiency virus (HIV) antigen p24 and Epstein-Barr virus DNA in vitro: clinical influence on HIV infection.

The existence of molecular transactivations between EBV and HIV-1, as well as reactivations of EBV latent infections in AIDS patients, have been recently documented. In order to shed more light on the putative association between EBV and HIV, and its role in the evolution to AIDS, we have determined simultaneously p24 protein and EBV DNA in culture supernatants of peripheral blood mononuclear cells from 47 individuals suspected of having HIV infection. The results of the in vitro assays were correlated with the clinical stage of the individuals and their serologic status to EBV. Statistical analysis showed a concordance between HIV infection and in vitro detection of EBV DNA (P < 0.002); particularly, a strong correlation between the presence of EBV DNA and p24 in culture was observed (P < 0.001). These results are consistent with the occurrence of viral interactions, manifested in vitro. However, in our series, the appearance of EBV DNA in culture was not concomitant with an elevation of anti-VCA IgG titers, anti-EA titers or the development of symptomatology, suggestive of a reactivation of a latent EBV infection or a progression of HIV infection. Therefore we conclude that, although interaction between both viruses may take place at the molecular level, there is no clear evidence of the repercussion that this event may have on the clinical course of HIV infection.     

Diagnosis of HIV-Associated Oral Lesions in Relation to Early versus Delayed Antiretroviral Therapy: Results from the CIPRA HT001 Trial

Oral mucosal lesions that are associated with HIV infection can play an important role in guiding the decision to initiate antiretroviral therapy (ART). The incidence of these lesions relative to the timing of ART initiation has not been well characterized. A randomized controlled clinical trial was conducted at the GHESKIO Center in Port-au-Prince, Haiti between 2004 and 2009. 816 HIV-infected ART-naïve participants with CD4 T cell counts between 200 and 350 cells/mm³ were randomized to either immediate ART initiation (early group; N = 408), or initiation when CD4 T cell count was less than or equal 200 cells/mm³ or with the development of an AIDS-defining condition (delayed group; N = 408). Every 3 months, all participants underwent an oral examination. The incidence of oral lesions was 4.10 in the early group and 17.85 in the delayed group (p-value <0.01). In comparison to the early group, there was a significantly higher incidence of candidiasis, hairy leukoplakia, herpes labialis, and recurrent herpes simplex in the delayed group. The incidence of oral warts in delayed group was 0.97 before therapy and 4.27 post-ART initiation (p-value <0.01). In the delayed group the incidence of oral warts post-ART initiation was significantly higher than that seen in the early group (4.27 versus 1.09; p-value <0.01). The incidence of oral warts increased after ART was initiated, and relative to the early group there was a four-fold increase in oral warts if ART was initiated following an AIDS diagnosis. Based upon our findings, candidiasis, hairy leukoplakia, herpes labialis, and recurrent herpes simplex indicate immune suppression and the need to start ART. In contrast, oral warts are a sign of immune reconstitution following ART initiation.     

Upper gastrointestinal Kaposi's sarcoma in patients positive for HIV antibody without cutaneous disease

Six patients with antibodies to the human immunodeficiency virus (HIV) and with persistent gastrointestinal symptoms of HIV infection but without cutaneous lesions of Kaposi''s sarcoma underwent endoscopy. Four also underwent barium meal examination. In all six cases small lesions were seen in the stomach at endoscopy, and histological examination of biopsy specimens taken from the lesions confirmed the diagnosis of Kaposi''s sarcoma. The barium meal examinations were reported as normal in three patients and showed oesophageal candidiasis in the fourth.These findings suggest that Kaposi''s sarcoma of the upper gastrointestinal tract is common in patients positive for HIV antibody, even those without cutaneous lesions. Endoscopy, with biopsy of suspicious lesions, is necessary to make the diagnosis and is recommended in all HIV antibody positive patients with persistent upper gastrointestinal symptoms.     

Pulmonary Mycobacterium tuberculosis in acquired immune deficiency syndrome.

A case of pulmonary infection with Mycobacterium tuberculosis in a patient with the acquired immune deficiency syndrome (AIDS) was studied. Diagnosis of AIDS was confirmed by the finding of pulmonary M tuberculosis with oral and oesophageal candidiasis accompanied by characteristic immunological changes with evidence of infection with human T cell lymphotropic virus III. Treatment of this patient was complicated by an unusual drug interaction between rifampicin and ketoconazole, leading to subtherapeutic serum concentrations and poor clinical response to treatment. Intravenous treatment was more effective than oral treatment. This drug interaction should be studied in greater detail as ketoconazole and rifampicin may be used together to treat patients with candidiasis and infection with M tuberculosis.     

Compartmentalization and transmission of multiple epstein-barr virus strains in asymptomatic carriers

Infection with the Epstein-Barr virus (EBV) is often subclinical in the presence of a healthy immune response; thus, asymptomatic infection is largely uncharacterized. This study analyzed the nature of EBV infection in 20 asymptomatic immunocompetent hosts over time through the identification of EBV strain variants in the peripheral blood and oral cavity. A heteroduplex tracking assay specific for the EBV gene LMP1 precisely identified the presence of multiple EBV strains in each subject. The strains present in the peripheral blood and oral cavity were often completely discordant, indicating the existence of distinct infections, and the strains present and their relative abundance changed considerably between time points. The possible transmission of strains between the oral cavity and peripheral blood compartments could be tracked within subjects, suggesting that reactivation in the oral cavity and subsequent reinfection of B lymphocytes that reenter the periphery contribute to the maintenance of persistence. In addition, distinct virus strains persisted in the oral cavity over many time points, suggesting an important role for epithelial cells in the maintenance of persistence. Asymptomatic individuals without tonsillar tissue, which is believed to be an important source of virus for the oral cavity, also exhibited multiple strains and a cyclic pattern of transmission between compartments. This study revealed that the majority of patients with infectious mononucleosis were infected with multiple strains of EBV that were also compartmentalized, suggesting that primary infection involves the transmission of multiple strains. Both the primary and carrier states of infection with EBV are more complex than previously thought.     

Extrapulmonary Pneumocystis carinii infection in an AIDS patient: a case report

BACKGROUND: Extrapulmonary Pneumocystis carinii (EPC) infection is an uncommon condition, regardless of HIV status, and can occur as a complication of P carinii pneumonia (PCP). However, PCP is the most common severe opportunistic infection in patients with AIDS. The incidence of EPC is variable, and in HIV-1-infected individuals it has been estimated to be 0.06-2.5%. CASE: A case of generalized lymphadenopathy was referred to us for fine needle aspiration cytology (FNAC). The patient was a 9-year-old boy who had a toxic facies and manifested multiple skin lesions all over the body. Fever was present during the examination. HIV status was confirmed from the history and test report. FNAC was done from a cervical lymph node and smears stained with hematoxylin-eosin and with Giemsa and Papanicolaou stain. The presence of P carinii was suspected in Giemsa- and hematoxylin-eosin-stained smears, and silver methenamine stain was used to confirm the diagnosis. Fungal spores were seen as small, spherical cysts of variable sizes, more or less the size of erythrocytes. The diagnosis was thus established as EPC infection. CONCLUSION: Lymph node involvement is the most common site of pneumocystosis in AIDS patients. Fine needle aspiration diagnosis of EPC infection is a possibility in such cases with lymphadenopathy and must be included in the differential diagnosis of lymph node swellings in AIDS.     

Oral candidiasis mimicking an oral squamous cell carcinoma: report of a case

doi: 10.1111/j.1741‐2358.2010.00371.x Oral candidiasis mimicking an oral squamous cell carcinoma: report of a case Oral candidiasis is a significant problem in immune‐compromised patients. The most common forms of mucosal candidiasis are oropharyngeal, oesophageal and vaginal, and more than 90% of HIV positive persons will manifest at least one episode of oropharyngeal candidiasis. Local and systemic factors such as uninterrupted daily use of a prosthesis by patients, smoking habit, as well as high glucose intake may contribute to the development of the lesion. The aim of this article is to report an uncommon case of oral candidiasis presenting an aggressive clinical behaviour in a 64‐year‐old male patient, with a significant smoking habit and a medical history of non‐controlled diabetes. The lesion affected the hard and soft palate of the right side, revealing erythematous and ulcerated areas, elevated borders and central portions resembling necrosis, mimicking the clinical features of oral squamous cell carcinoma. However, the correct diagnosis of oral candidiasis was obtained after histopathological and cytological examinations and the patient was easily treated with traditional antifungal drugs and correction of his glucose levels.     

Point prevalence, microbiology and antifungal susceptibility patterns of oral Candida isolates colonizing or infecting Mexican HIV/AIDS patients and healthy persons

We have conducted a longitudinal study over a 3-year period to address the point prevalence, microbiological characteristics and antifungal susceptibility patterns of yeast isolates colonizing or infecting the oral cavities of 111 HIV-infected (51 adults, 60 children) and 201 non HIV-infected (109 adults, 92 children) Mexican persons. Regarding the epidemiology of oral candidiasis, Candida albicans was the most frequent species isolated. Seventy-one out of 85 isolates from colonized persons were C. albicans (83.5%), 27 isolates of them were from HIV-infected children and 44 from non HIV-infected patients. Sixty-two isolates belonged to serotype A which was the most prevalent serotype of C. albicans. Non-albicans species (Candida glabrata, Candida tropicalis and Candida parapsilosis, and Saccharomyces cerevisiae) were isolated from 16.5% of colonized patients and from 38.5% patients with candidiasis or Candida-related lesions. There were nine episodes of infection or colonization by at least 2 different yeast species. In the case of HIV/AIDS patients, it was determined that yeast carriage was not associated with the number of CD4+ cells or the viral load, but HAART reduced the prevalence of oral candidiasis. Overall, most patients harbored strains in vitro susceptible to fluconazole, however 10.8% of the yeasts were resistant to one or more azole antifungal agents and 29% were intermediate susceptible to them. On the contrary, 5-fluorocytosine was very active against all isolates tested, and amphotericin B was active against 97.9% of them.     

Manifestaciones mucocutáneas y su relación con el recuento de linfocitos T CD4 en pacientes infectados con el virus de inmunodeficiencia humana hospitalizados en Medellín,Colombia

Introduction.

About 80-95% of patients infected with the human immunodeficiency virus (HIV) develop skin manifestations, which are markers of the patients’ immune status. Objective. To describe the dermatologic manifestations and the clinical and sociodemographic factors of hospitalized patients diagnosed with HIV and their correlation with CD4 T-lymphocyte count.

Materials and methods.

We conducted an observational, cross-sectional, and retrospective study of the medical records of 227 adult patients with HIV diagnosis evaluated by dermatology in a hospital in Medellín, Colombia.

Results.

We included 227 patient records with 433 dermatologic manifestations, 64.4% of them infectious. The most frequent manifestations were oral candidiasis, condylomata acuminata, and drug reactions. Moreover, a statistically significant relationship was found between disseminated herpes zoster virus and secondary syphilis with a CD4 count between 200-499 cells/mm³ (p=0.04 and 0.028, respectively). There was also a statistically significant relationship between oral candidiasis and a CD4 count of less than 100 cells/ mm³ (p=0.008).

Conclusions.

The relationship between disseminated herpes zoster with CD4 between 200-499 cells/mm³ suggests that, despite having high CD4 counts, severe forms of the disease may occur due to possible T-cell dysfunction and depletion of the immune system. Additionally, the relationship between oral candidiasis and CD4 less than 100 cells/mm³ indicates the potential role of oral candidiasis as an essential marker of weakened immune status in HIV patients.     

Epstein-Barr virus (EBV)-infected monocytes facilitate dissemination of EBV within the oral mucosal epithelium

Epstein-Barr virus (EBV) causes hairy leukoplakia (HL), a benign lesion of oral epithelium that occurs primarily in the setting of human immunodeficiency virus (HIV)-associated immunodeficiency. However, the mechanisms of EBV infection of oral epithelium are poorly understood. Analysis of HL tissues shows a small number of EBV-positive intraepithelial macrophages and dendritic/Langerhans cells. To investigate a role for these cells in spreading EBV to epithelial cells, we used tongue and buccal explants infected ex vivo with EBV. We showed that EBV first infects submucosal CD14(+) monocytes, which then migrate into the epithelium and spread virus to oral epithelial cells, initiating productive viral infection within the terminally differentiated spinosum and granulosum layers. Incubation of EBV-infected monocytes and oral explants with antibodies to CCR2 receptor and monocyte chemotactic protein 1 prevented entry of monocytes into the epithelium and inhibited EBV infection of keratinocytes. B lymphocytes played little part in the spread of EBV to keratinocytes in our explant model. However, cocultivation of EBV-infected B lymphocytes with uninfected monocytes in vitro showed that EBV may spread from B lymphocytes to monocytes. Circulating EBV-positive monocytes were detected in most HIV-infected individuals, consistent with a model in which EBV may be spread from B lymphocytes to monocytes, which then enter the epithelium and initiate productive viral infection of keratinocytes.     

The extent of immune response impairment vs. the prevalence and clinical form of oral candidiasis in HIV patients

The objective of the study was a mycological and clinical evaluation of the course of oral cavity fungal infection in HIV patients in relation to the immune response impairment. The patients were examined physically (symptoms and signs) and mycologically (isolation and identification of fungi, semiquantitative evaluation their growth abundance in the cultures); the immunity status was expressed in terms of the number of CD4 lymphocytes. The most frequently isolated fungal species was Candida albicans. The decreasing immunity was conductive to more abundant fungal growth in the oral cavity as well as to more frequent occurrence of clinical manifestations of candidiasis.