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HIV: Infection Control/Exposure Control Issues for Oral Healthcare Personnel

Course Number: 97

Clinical Manifestations

Available scientific evidence suggests a dynamic process in which initial and ongoing immunological responses to HIV infection are not only unsuccessful in clearing HIV but, paradoxically, they are paralleled by a progressive reduction in immunocompetence.7 Individual variations exist, but a pattern of disease progression has been established as consisting of three phases: (1) primary infection, (2) a period of clinical latency, and, finally, (3) clinically apparent disease.7

ce97 - Content - Clinical Manifestations - Figure 1
Image: HIV disease progression pattern.

After an incubation period of 1 to 3 weeks, 50% to 80% of patients experience an ill-defined Acute Retroviral Syndrome characterized by fever, lethargy, malaise, sore throat, arthralgia, myalgia, headaches, photophobia, maculopapular rash, and lymphadenopathy.7,8 Antibodies can be detected 3 to 6 months after exposure. During clinical latency (8 to 24 months), the patient is free of overt signs and symptoms. Without appropriate antiretroviral therapy, an HIV-infected patient is at risk of developing a multitude of opportunistic infections, the most common of which are summarized in Table 1.9

Table 1. Opportunistic illnesses (AIDS-defining conditions).9

  1. Bacterial infections, multiple or recurrent*
  2. Candidiasis of bronchi, trachea, or lungs
  3. Candidiasis, esophageal
  4. Cervical cancer, invasive†
  5. Coccidioidomycosis, disseminated or extrapulmonary
  6. Cryptococcosis, extrapulmonary
  7. Cryptosporidiosis, chronic intestinal (> one month’s duration)
  8. Cytomegalovirus disease (other than liver, spleen, or nodes), onset at age > 1 month
  9. Cytomegalovirus retinitis (with loss of vision)
  10. Encephalopathy attributed to HIV§
  11. Herpes simplex: chronic ulcer(s) (> month’s duration); or bronchitis,pneumonitis, or esophagitis (onset at age >1 month)
  12. Histoplasmosis, disseminated or extrapulmonary
  13. Isosporiasis, chronic intestinal (greater than one month’s duration)
  14. Kaposi sarcoma
  15. Lymphoma, Burkitt’s (or equivalent term)
  16. Lymphoma, immunoblastic (or equivalent term)
  17. Lymphoma, primary, of brain
  18. Mycobacterium avium complex or Mycobacterium kansasii, disseminated or extrapulmonary
  19. Mycobacterium tuberculosis of any site, pulmonary† or extrapulmonary
  20. Mycobacterium, other species or unidentified species, disseminated or extrapulmonary
  21. Pneumocystis jirovecii (previously known as Pneumocystis carinii) pneumonia
  22. Pneumonia, recurrent†
  23. Progressive multifocal leukoencephalopathy
  24. Salmonella septicemia, recurrent
  25. Toxoplasmosis of brain, onset at age > 1 month
  26. Wasting syndrome attributed to HIV§
* Only among children aged <6 years
 Only among adults, adolescents, and children aged ≥6 years
§ Suggested diagnostic criteria for these illnesses, which might be particularly important for HIV encephalopathy and HIV wasting syndrome, are described in the following references:

CDC. 1994 Revised classification system for human immunodeficiency virus infection in children less than 13 years of age. MMWR 1994;43(No. RR-12).
CDC. 1993 Revised classification system for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults. MMWR 1992;41(No. RR-17).

HIV-induced immunosuppression places the patient at risk for numerous oral conditions (Table 2). The most notable are candidiasis (erythematous, pseudomembranous), hairy leukoplakia, Kaposi’s sarcoma, non-Hodgkin’s lymphoma, and periodontal disease (linear gingival erythema, necrotizing ulcerative periodontitis).10-11 Hairy leukoplakia and oral candidiasis are positive predictors of HIV disease progression. Contemporary antiretroviral therapy significantly decreases this risk.12 Indeed, for a patient on an antiretroviral regimen, the development of an HIV-associated oral manifestation may signal therapeutic failure.11 If this occurs, the patient should be promptly referred to their managing physician for evaluation.

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Table 2. Oral Lesions Associated with HIV Infection.10,23

Group 1
Lesions strongly associated with HIV infection
Hairy leukoplakia
Kaposi’s sarcoma
Non-Hodgkin’s lymphoma
Periodontal disease
     Linear gingival erythema
     Necrotizing (ulcerative) gingivitis
     Necrotizing (ulcerative) periodontitis
Group 2
Lesions less commonly associated with HIV infection
Bacterial infections
Mycobacterium avium-intracellularae
Mycobacterium tuberculosis
Melanotic hyperpigmentation
Necrotizing (ulcerative) stomatitis
Salivary gland disease
     Dry mouth due to decreased salivary flow rate
     Swelling of major salivary glands
Thrombocytopenia purpura
Ulceration NOS (not otherwise specified)
Viral infections
     Herpes simplex virus
     Human papillomavirus (warty-like) lesions
Condyloma acuminatum
          Focal epithelial hyperplasia
          Verruca vulgaris
     Varicella-zoster virus
          Herpes zoster
Group 3
Lesions seen in HIV infection
     Actinomyces israelii
     Escherichia coli
     Klebsiella pneumonia
Cat-scratch disease
Drug reactions (ulcerative, erythema multiforme,
     lichenoid, toxic epidermolysis)
Epithelioid (bacillary) angiomatosis
Fungal infection other than candidiasis
     Cryptococcus neoformans
     Geotrichum candidum
     Histoplasma capsulatum
     Mucoraceae (mucormycosis zygomycosis)
     Aspergillus flavus
Neurological disturbances
     Facial palsy
     Trigeminal neuralgia
Recurrent aphthous stomatitis
Viral infections
Molluscum contagiosum