Human immunodeficiency virus induced oral candidiasis.

Human immunodeficiency virus (HIV) infection is a worldwide health problem, which affects in both developing and developed countries. The oral lesions caused due to this disease can drastically change the life of the patient, in terms of quality. We can also know the progression of the disease and also the important immune status of the patient. Lots of information on HIV is known in the developed countries and very less reports are available in the developing countries. The morbidity of HIV disease is due to its association with opportunistic fungal infection and the most common among them is oral candidiasis. Here, we present a case report on an apparently healthy male patient of 39 years, who had oral candidiasis and was one of the indicators for HIV infection.

Human immunodeficiency virus (HIV) is a major global health problem since its discovery in 1981. HIV, which is a disease of the human immune system, causes acquired immune deficiency syndrome (AIDS).[1] One of the largest and most populated countries in the world with over one billion inhabitants is India and out of which approximately 5 million are living with HIV. This epidemic is affecting all the sections of Indian society and not pertaining to the groups such as sex workers and truck drivers with, which it was originally associated.[2] Oral lesions are not only the earliest, but they can also predict the progression into AIDS.[3] One of the most common infections is oral candidiasis, which is seen in persons with HIV or AIDS. This infection is caused by fungal organism called Candida albicans, which is present in the oral cavity of majority of healthy individuals in nonpathogenic forms, but it can change into a disease-causing pathogenic form due to favorable conditions.[1]

Case Report

A 39-year-old male patient had come to the Department of Oral Medicine and Radiology with a chief complaint of burning sensation throughout the oral cavity for the past 1-year. History revealed that initially the burning sensation was mild in intensity but gradually increased to the present state. He had also visited a local dentist for the same and had been given topical application and medication following which there was symptomatic relief during application only. He had no significant medical and dental history. Going on to details of his personal history it revealed that he was single and working as an agent for a financial company. Patient gave a history of smoking 8–10 cigarettes/day for past 15 years and also consumes alcohol around 90 ml/week for the past 10 years. On further probing, he gave a history of having sexual contact with multiple partners for the past 8 years. However, he also gave a history of having protected sex.

Intraoral examination revealed multiple raised white patches interspersed with areas of erythema in multiple sites of the oral cavity. These lesions were abundantly seen in the palate and tongue [Figures 1 and 2]. The other areas included upper and lower labial and alveolar mucosa and floor of the mouth [Figures 3–5]. The areas were mildly tender and the white patches were scrapable and leaving a raw area behind. The history and the above clinical features led to a provisional diagnosis of erythematous candidiasis.

Figure 1

Multiple raised white patches with areas of erythema seen on the palate

Figure 2

Multiple raised white patches with areas of erythema seen on the tongue

Figure 3

Few white patches with areas of erythema seen in upper labial and alveolar mucosa

Figure 5

Few white patches with areas of erythema seen in floor of the mouth

Few white patches with areas of erythema seen in lower labial and alveolar mucosa

The routine hematological examination was normal except for the erythrocyte sedimentation rate level of 36 and 75 in half an hour and 1 h duration. An exfoliative cytology was performed which revealed plenty of candidal hyphae with spores confirming the diagnosis of candidiasis [Figure 6]. Furthermore, special investigation of HIV, ELISA was done, which turned to be positive and the report was read as antibodies to HIV I and II reactive. Thus, a final diagnosis HIV-induced erythematous candidiasis was made.

Figure 6

Exfoliative smear showing plenty of candidal hyphae with spores

Discussion

Human immunodeficiency virus is characterized by low CD4 counts due the continuous immunosuppression. This leads to a variety of clinical conditions which ranges from a primary infective state to the advanced disease. The oral health status is an extremely important parameter for HIV individual because it reveals the individuals immune status, which is a very vital information.[1]

In HIV patient, oral manifestations are the most important and earliest indicators. The internationally identified and accepted seven cardinal signs of HIV infection are oral candidiasis, hairy leukoplakia, Kaposi sarcoma, linear gingival erythema, necrotizing ulcerative gingivitis, necrotizing ulcerative periodontitis, and non-Hodgkin lymphoma. The features mentioned above are present in 50% of patients with HIV infection and 80% in patients with AIDS.[3]

In cases of adult and pediatric patients, the most common opportunistic infection remains oral candidiasis.[4] Oro-esophageal candidiasis is known to be an indicator of AIDS.[5] Apart from the oral involvement HIV infection also produces a variety of mucocutaneous manifestation.[6] Candidiasis is caused due to C. albicans, which are a yeast-like fungal organism.[7] There are four forms of candidal infection which includes pseudomembranous candidiasis, erythematous candidiasis, hyperplastic candidiasis, and angular cheilitis. It has been noted that one or more combination of the above said may be present in patients.[1] Low CD4 count is present in all the above four forms of candidiasis.[8] The most common form of candidiasis occurring in fully blown AIDS patient is pseudomembranous candidiasis and in the case of patient infected with HIV, the erythematous candidiasis is seen more, as seen in our case.

Angular cheilitis occurs in the corners of the mouth and presents as erythema or fissuring. It can stay for long period of time if untreated. It can occur with or without association with pseudomembranous or erythematous candidiasis. Pseudomembranous candidiasis manifests like a whitish creamy curd-like plaques, which can occur in any oral mucosal surfaces but the most common area includes buccal mucosa and tongue. These plaques can be wiped away and it leaves an erythematous or bleeding underlying mucosa.[9] Hyperplastic candidiasis is characterized by white plaques which is more commonly seen in the buccal mucosa and cannot be removed by scraping.[1] Erythematous candidiasis is the most missed and misdiagnosed oral feature of HIV which is characterized by the presence of red lesions which is flat and seen on the dorsal aspect of tongue and also on the hard or soft palates. If on tongue lesions are present, then the presence of a matching lesion should be examined in the palate and if present it is called as “kissing lesions.” This is a symptomatic condition with patient complaining of burning sensation while eating hot, spicy or salty foods, and drinking acid beverages.[9]

The candidal organism can be identified by doing exfoliative cytology or biopsy and can be seen microscopically. Candidal hyphae and yeast can be readily identified on staining with periodic acid-Schiff. The candidal organisms can be easily identified by the bright magenta color and for confirmatory diagnosis of candidiasis, candidal hyphae or pseudo hyphae has to be present. To rapidly evaluate specimen for the presence of fungal organism, 10–20% potassium hydroxide (KOH) preparation can be used. This technique will allow the more resistant type of hyphae to be visualized because the KOH lyses the background of epithelial cells.[7]

Management depends on the extent of infection. Tremendous improvement has taken in the medical management of HIV, by turning the fatal infection to a manageable chronic illness.[10] The commonly used topical application depends on the severity of the disease. In mild to moderate cases nystatin oral suspension, clotrimazole troches, and nystatin pastilles can be used. In moderate to severe cases systemic drug fluconazole is used. The other common systemic drug, which can be used in fluconazole-resistant cases is itraconazole and voriconazole.[1] The therapeutic breakthrough came when highly active antiretroviral therapy (HAART) was introduced. It is seen that following the HAART there is not only significant decrease in the opportunistic infection but also other oral manifestation of HIV.[11]

Conclusion

One of the earliest manifestations of HIV infection is oral candidiasis. The oral presentation of this condition should be well aware by the dentist, due to which there can be immediate management. This prompt management is important for maintaining health and increasing the lives of HIV-infected patients.