Frequent Oral Diseases in HIV Positive and AIDS Patients

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Oral Hairy Leukoplakia (OHL)

The classically described intraoral lesion of AIDS is oral hairy leukoplakia (OHL). This lesion as a rule develops on the lateral borders of the tongue generally bilaterally. Its clinical appearance is characterized by multiple, vertical, white to white-yellowish, hyperkeratinized lines which tend to follow the direction of the foliaceous papillae. These lesions can not be detached and do not present any symptomatology. Several degrees of clinical involvement can be seen in different patients as shown in the various photos presented here. OHL is produced by an Epstein-Barr virus of the herpes family. OHL occurs in around 20 to 30% of patients with ARC (AIDS related complex), which generally precedes the development of AIDS and also in patients with full blown AIDS. OHL also has been reported on the floor of the mouth or the buccal mucosa in AIDS patients. Sometimes Candida infection is superimposed to OHL, which will complicate the diagnosis. OHL also has been described in patients which are HIV- but are immunocompromised generally because of organ transplant or having an autoimmune disorder.

OHL tends to manifest in patients who's CD4+ cell count falls below 300 cells per cubic millimiter. There have been several studies which have demonstrated the importance of OHL as a determinant of the prognosis of AIDS. These studies have shown that patients with OHL have a shorter life span than those that do not present this lesion. This might implicate that the status of the immune system in those patients with OHL is at a lower level than those that do not have OHL. OHL is generally not treated unless it is requested by the patient because of aesthetics, masticatory or phonetic reasons. OHL resolve in patients which undergo treatment with AZT (zidovudine).

This 24 year-old man presented these barely visible, vertical striations on both sides of his tongue. Note their almost parallel orientation. These lesions did not rub off. The clinical diagnosis of OHL was established. Additionally, the patient had a large tonsilar abscess and a weight loss of 15 pounds in the last 2 months. He attibuted the loss of weight to change in his diet. The patient denied belonging to any AIDS risk group but a Western blot and ELISA test, when performed, were positive and his CD4+ cell count was 280 cells per cubic millimeter. Then, the diagnosis of AIDS was established.
These two patients were HIV+ and presented these tongue lesions bilaterally. Note that in addition to the vertical disposition of the lesions there are areas of compact accumulation of white plaques. Some of the white plaques rubbed off and a microscopic study as well as cultures in Sabouraud's agar media, demonstrated the presence of Candida albicans. Note that in both patients the white plaques extend to the dorsal surface of the tongue. The combination of this two lesions in the same patient is quite frequent and in some cases it is difficult to establish the proper clinical diagnosis. Biopsy of the lesion as well as smears and cultures are indicated to arrive to the proper diagnosis.

Therapeutic protocols for OHL include:

Systemic:

NOTE: OHL generally recurs when the medication is discontinued.

Local:

Instruct the patient to rinse with water one minute after the application is completed. Recall the patient one week after and if no improvement is noted, repeat application.

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References relevant to OHL

Classification