Photogallery. Pathology of the oral mucosa in patients with HIV infection

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Abstract

Lesions of the oral mucosa in people living with Human immunodeficiency virus (HIV) are characterized by a wide variety and high frequency of occurrence. According to some data, they are registered in half of HIV-positive individuals and in 80% of patients in the later stages of HIV infection. Publications on this topic report on more than twenty different types of diseases of the oral mucosa, most often diagnosed in HIV-infected individuals. Candidiasis is the earliest and most common secondary disease of HIV infection. While the spectrum of pathology has significant regional differences, candidiasis is the most common nosology on all continents. Diseases of the oral mucosa can be indicators of infection with the human immunodeficiency virus, early clinical symptoms of HIV infection, and also indicate its progression. The severity of lesions of the oral mucosa correlates with the level of immunosuppression: the lower the number of CD4+ T-lymphocytes, the more extensive the pathological process and the higher the relapse rate. Timely detection of diseases such as oral candidiases, hairy leukoplakia, Kaposi's sarcoma helps to establish the stage and phase of HIV infection in patients in accordance with the Russian clinical classification, and their regression or decrease in clinical manifestations indicates the effectiveness of antiretroviral therapy.

The photo gallery presents various diseases of the oral mucosa in HIV-positive patients, including lesions often associated with HIV infection (hairy leukoplakia, Kaposi's sarcoma, non-Hodgkin's lymphoma, case series of various clinical variants of candidiasis). From the archive of author's. The photographs are published for the first time.

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About the authors

Sergey V. Prozherin

Sverdlovsk Regional Center for Prevention and Control of AIDS

Author for correspondence.
Email: progsherin@mail.ru
ORCID iD: 0000-0001-9956-4700
SPIN-code: 5354-4893
Scopus Author ID: 57221442199

dermatovenereologist

Russian Federation, 46 Yasnaya st., 620102 Yekaterinburg

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2. Fig. 1. Patient A., 34 years old. Pseudomembranous oral candidiasis. On the mucous membrane of the upper lip and gums of the upper jaw (a), the lower lip and gums of the lower jaw (b), the mucous membrane of the cheeks and lips (c) ― focal, on the tongue (d) ― a solid white coating with a creamy tint, which is removed when scraped and reveals a hyperemic, swollen surface. After 2 weeks of daily oral administration of fluconazole at a daily dose of 100 mg, the process completely regressed.

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3. Fig. 2. Patient M., 43 years old. Pseudomembranous oral candidiasis. The entire mucous membrane of the oral cavity is covered with foci of white-gray plaque, which is easily removed with a spatula, revealing a bright red, swollen, moderately bleeding surface. Despite the increasing role of non-albicans Candida species in the development of this disease, the most common pathogen is Candida albicans. This species was detected in a patient.

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4. Fig. 3. Patient L., 34 years old. Pseudomembranous oral candidiasis. Only the mucous membrane of the hard and soft palate is involved in the pathological process. Foci of white plaque resemble “curdled masses” and in some places merge with each other. Oral candidiasis in people living with HIV is the basis for establishing stage 2V of HIV infection (acute HIV infection with secondary diseases) or 4A stage of secondary diseases according to its Russian clinical classification, depending on the duration of infection with the HIV.

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5. Fig. 4. Patient F., 28 years old. Atrophic oral candidiasis. Angular cheilitis. The mucous membrane of the mouth is crimson-red, shiny, and there is no plaque; on the back of the tongue the papillae are smoothed (the so-called “rubber tongue”). In the corners of the mouth there are cracks, erythema, yellowish-brown crusts. Atrophic candidiasis is often combined with angular cheilitis.

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6. Fig. 5. Patient O., 31 years old. Hyperplastic oral candidiasis. This clinical variant of candidiasis is characterized by the formation of a focal white plaque, which is firmly held on the surface of the lesions.

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7. Fig. 6. Patient P., 39 years old. Angular cheilitis of candidal etiology. Erythema, radial cracks in the corners of the mouth, surrounded by a fringe of slightly raised whitened epidermis, a cheesy coating. The process is usually symmetrical. It is combined with candidiasis of the oral mucosa or develops independently.

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8. Fig. 7. Patient K., 31 years old. Hairy leukoplakia of the tongue. White plaques with a rough, “corrugated” surface on the right (a) and left (b) lateral surfaces of the tongue with a transition to its back, which cannot be removed with a spatula. The development of the disease is directly related to the active replication of the Epstein-Barr virus. In most cases, the diagnosis of hairy leukoplakia is made based on the typical clinical picture. It occurs predominantly in patients with late stages of HIV infection who are not taking antiretroviral therapy. The formation of hairy leukoplakia indicates the transition of HIV infection to stage 4B of secondary diseases.

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9. Fig. 8. Patient I., 39 years old. A combination of hairy leukoplakia of the oral mucosa and hyperplastic oral candidiasis. Fungi of the genus Candida are often found in foci of hairy leukoplakia. For this reason, hairy leukoplakia is sometimes mistaken for candidiasis and vice versa. In doubtful cases, it is advisable to supplement microscopy of scrapings from the lesion with testing for the Epstein–Barr virus using molecular biological methods.

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10. Fig. 9. Patient B., 60 years old. Epidemic Kaposi’s sarcoma. A red-violet color is an exophytic tumor focus in the area of the left half of the hard palate, the gums of the upper jaw and spotted elements on the hard palate. Purple spots and papules on the skin of the face. With epidemic Kaposi’s sarcoma, the oral mucosa is involved in the pathological process in 10–30% of cases. Localized Kaposi’s sarcoma indicates stage 4B of secondary diseases of HIV infection, and generalized ― stage 4V.

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11. Fig. 10. Patient N., 29 years old. Plasmablastic lymphoma of the oral cavity. Immunodeficiency caused by HIV infection contributes to the development of tumors. At the time of diagnosis of plasmablastic lymphoma, the level of CD4+ T-lymphocytes usually does not exceed 200 cells/μl, and the HIV viral load in the blood plasma reaches about 250 thousand copies/ml. In this case, the indicated indicators were 88 and 355 thousand, respectively.

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12. Fig. 11. Patient Z., 54 years old. Squamous cell carcinoma of the tongue that developed against the background of verrucous leukoplakia. Exophytic formation of a round shape with a diameter of about 1.5 cm on the left lateral surface of the tongue. Around there are gray-white lesions with an uneven surface, protruding above the level of the surrounding mucous membrane. Leukoplakia belongs to the category of potentially malignant diseases. With immunosuppression, the risk of its transformation into squamous cell carcinoma exceeds population indicators.

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13. Fig. 12. Patient M., 54 years old. Recurrent aphthous stomatitis. Round-shaped painful erosions on the mucous membrane of the lower lip and the tip of the tongue, covered with a gray-white fibrin layer and surrounded by a ring of hyperemia. HIV infection is one of the diseases that may be associated with this pathology. However, the etiology of aphthous stomatitis has not yet been established.

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14. Fig. 13. Patient R., 44 years old. Secondary syphilis. On the mucous membrane of the tongue there are irregularly shaped papules covered with a whitish coating. In the corners of the mouth there are cracks with raised edges due to infiltration at their base.

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15. Fig. 14. Patient A., 39 years old. Recurrent infection caused by the herpes simplex virus, vermilion border of the lips and perioral area. During exacerbations of herpes simplex, the immune system is activated, which can lead to the progression of HIV infection. There is a direct correlation between the severity of herpetic lesions and the degree of immunosuppression.

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