HIV AND ENT HIV and ENT It has been well documented that 70 - 90% of patients with HIV will at some stage present with an ENT manifestation of the disease. According to World Health Organisation (WHO) statistics for the year 2002, there are an estimated 5.3 million South Africans living with HIV. Although south- ern Africa is home only to 2% of the world’s population, the region accounts for 30% of people living with HIV worldwide.1 It has been well documented that 70 - 90% of patients with HIV will at some stage present with an ENT manifestation of the disease. Most of them will initially present to the general practitioner and it is important that the ENT manifestations of HIV are recognised early and that appropriate management is instituted. Antiretroviral therapy can prevent and cure most of these diseases, but as this option is not readily available to the majority of South Africans we need to look D E LUBBE at alternative treatment. MB ChB, FCORL (SA) HIV-positive patients will be included, knowingly or unknowingly, in all general Senior Registrar practices and may present with a complaint totally unrelated to their underlying Division of Otorhinolaryngology disease or with an AIDS-defining opportunistic infection or malignancy. Routine Groote Schuur Hospital organisms predominate when it comes to infections of the ear, nose and throat, Cape Town which means that HIV-positive patients should be treated with the same antibiotic as HIV-negative patients, based on the most likely organism responsible for that specific infection. The most common ENT manifestations of HIV are listed in Dr Lubbe qualified as an ENT surgeon at Table I. the University of Cape Town in 2003 and is currently working as a senior registrar in ORAL CAVITY MANIFESTATIONS the Department of Otorhinolaryngology at Contrary to medical training in the pre-HIV era, multiple lesions can be present Groote Schuur Hospital. Her current MMed simultaneously in those infected with HIV. Recent studies have proved that there is project includes the investigation of otitis a decreased appearance in the occurrence of buccal lesions in those on triple 2 media with effusion in the HIV-positive pop- antiretroviral therapy. ulation to determine the natural progres- Oral candidiasis is one of the earliest and most common findings suggesting sion of the disease and to establish a treat- HIV infection and is characterised by a typical cottage cheese inflammatory ment protocol. appearance. These patients usually still appear healthy, but if a known HIV-posi- tive patient develops thrush, long-term survival appears to be diminished. Four different types of oral candidiasis can be identified: • Pseudomembranous candidiasis. This is the classic form identified by a white plaque that can be scraped off, leaving an erythematous, bleeding base. • Hyperplastic candidiasis. These lesions can easily be confused with leuko- plakia or oral hairy leukoplakia since they appear as thick white plaques that cannot be scraped off. If there is any doubt regarding the diagnosis, a biopsy is indicated. • Atrophic candidiasis. This presents as flat atrophic lesions involving the oral and oropharyngeal mucosa. • Angular cheilitis. These are oral commissure erythematous lesions that can involve the adjacent skin. Topical agents are usually effective in the early stages of HIV infection, but with advanced disease and increasing immune deficiency, systemic therapy (with flu- conazole and rarely amphotericin B) may be indicated. Oesophageal or pharyn- geal candidiasis is more common in this patient population and should be sus- pected in patients with oral candidiasis who develop a severe sore throat or diffi- culty in swallowing. 250 CME May 2004 Vol.22 No.5 HIV AND ENT Table I. ENT manifestations of HIV Oral Nose and paranasal Otological and sinuses neurotological Head and neck • Recurrent Cutaneous lesions • Otitis externa • Generalised lymphadenopathy aphthous ulcers • Kaposi’s sarcoma • Otitis media with • Neck mass • Candidiasis • Herpes simplex effusion Mycobacterium tuberculosis • Herpes simplex • Herpes zoster • Eustachian tube Mycobacterium avium • Gingivitis • Seborrhoeic dermatitis dysfunction Cryptococcosis • Stomatitis Non-cutaneous • Kaposi’s sarcoma Histoplasmosis • Periodontitis • Adenoid hypertrophy • Sensorineural Coccidioidomycosis • Condylomata • Eustachian tube hearing loss • Parotid gland cyst • Hairy leukoplakia obstruction • Bell’s palsy • Kaposi’s sarcoma • Allergic rhinitis • Non-Hodgkin’s • Acute AND chronic lymphoma sinusitis Oral hairy leukoplakia (Fig. 1) is Herpes simplex infections are viduals practise good oral hygiene a condition almost pathognomonic of more common in those infected with and that even a mild gingivitis be HIV infection and often indicates pro- HIV, with herpes labialis being the treated early and adequately. gression to AIDS. The lesion most fre- most common manifestation. These Treatment consists of rinsing the mouth quently appears on the lateral aspect ‘fever blisters’ are larger, more numer- with chlorhexidine solution, antibiotics of the tongue with a thick, vertically ous, recur more often and persist for against Gram-negative anaerobes and correlated (‘hairy’) whitish plaque, longer periods. Herpes simplex virus early referral to an oral surgeon if the very similar in appearance to the type 1 (HSV-1) is most commonly condition progresses. hyperplastic type of oral candidiasis. involved and usually begins as small Potassium hydroxide (KOH) prepara- bullae that rupture and then coalesce. Recurrent aphthous ulcers are tions of surface scrapings will identify It can extend onto the adjacent facial frequently encountered in the HIV-posi- the mycelia or hyphae seen in candidi- skin and form giant herpetic lesions. If tive patient and present as painful asis and can therefore be used to dif- the diagnosis is in doubt then smears ulcers on the non-keratinised unat- ferentiate between these two condi- or scrapings should be taken before tached oral mucosa. They vary in size tions. A biopsy of the lesion will be starting treatment. Mild oral herpes from 0.2 mm to > 6 mm. Treatment is diagnostic of oral hairy leukoplakia. infections can usually be treated con- aimed at symptomatic relief using anti- The Epstein-Barr virus has been identi- servatively, but high-dose oral aciclovir septic mouthwashes, topical steroids fied as the most likely causative agent. (up to 4 g/day) should be used for and topical anaesthetics. In cases of Oral hairy leukoplakia is typically more severe lesions. Aciclovir will only large ulcerative lesions and frequent asymptomatic and does not usually be effective in eradicating the lesions recurrences a biopsy should be consid- require any treatment, but it is a signif- if started within the first few days of ered if lesions do not respond to treat- icant finding because of its diagnostic infection. Prophylactic aciclovir can be ment. and prognostic implications. The used in the severely immunocompro- lesions have been successfully treated mised patient with frequent recur- AIDS patients have a much higher inci- with aciclovir (2 g/day), sulpha drugs, rences. dence of developing oral cavity zidovudine or topical retinoic acid Kaposi’s sarcoma and non-Hodgkin’s (Fig. 1). Periodontal disease, gingivitis lymphoma. and necrotising gingivitis are much more severe in the HIV-positive Kaposi’s sarcoma (Fig. 2) is the patient and can produce significant most common oral tumour in AIDS morbidity with extensive tissue destruc- patients and one of the AIDS-defining tion. HIV-associated gingivitis usually illnesses. These dark, purple/pink begins with erythematous, bleeding macular lesions can be found on gums after minor trauma and can then any oral mucosal surface, but the rapidly progress to a necrotising palate is involved in 95% of cases. process known as acute necrotising Although the diagnosis is usually easi- ulcerative gingivitis (ANUG), a condi- ly made based on clinical findings, an tion that has once again resurfaced in excisional biopsy is indicated, prefer- Fig. 1. Oral hairy leukoplakia (repro- the HIV-positive population. It is there- ably from a cutaneous lesion, as these duced with permission from Professor fore imperative that HIV-infected indi- lesions are vascular and can bleed Jos Hille). May 2004 Vol.22 No.5 CME 251 HIV AND ENT controversial. It has been noted, how- infection must be entertained. In HIV- ever, that there are many young HIV positive patients enlarged adenoids patients with no or moderate risk fac- are most commonly due to lymphoid tors for SCC who present with this hyperplasia and generalised lym- condition of the oral cavity.3 SCC phadenopathy and enlarged tonsils seems to present at an earlier age and are frequently part of the clinical pic- tends to be more aggressive in HIV- ture. The aetiology is thought to be positive patients compared with HIV- related to B-cell activation by HIV, negative patients in the same age Epstein-Barr virus or cytomegalovirus. Fig. 2. Kaposi’s sarcoma of the group. This suggests that there might Otitis media with effusion (OME), palate (reproduced with permission be a relationship between SCC and causing a conductive hearing loss, from Professor Jos Hille). HIV infection, although there is as yet often follows owing to obstruction of little evidence to support this. The lat- the Eustachian tubes by the lymphoid profusely. Treatment is mostly pallia- eral tongue is most frequently involved mass in the postnasal space. tive, as HIV-positive patients with and the lesion