Anwar R. Tappuni

Quantitative expression of the Candida albicans secreted aspartyl proteinase gene family in human oral and vaginal candidiasis

A quantitative real-time RT-PCR system was established to identify which secreted aspartyl proteinase (SAP) genes are most highly expressed and potentially contribute to Candida albicans infection of human epithelium in vitro and in vivo. C. albicans SC5314 SAP1-10 gene expression was monitored in organotypic reconstituted human epithelium (RHE) models, monolayers of oral epithelial cells, and patients with oral (n=17) or vaginal (n=17) candidiasis. SAP gene expression was also analysed in Deltasap1-3, Deltasap4-6, Deltaefg1 and Deltaefg1/cph1 mutants to determine whether compensatory SAP gene regulation occurs in the absence of distinct proteinase gene subfamilies. In monolayers, RHE models and patient samples SAP9 was consistently the most highly expressed gene in wild-type cells. SAP5 was the only gene significantly upregulated as infection progressed in both RHE models and was also highly expressed in patient samples. Interestingly, the SAP4-6 subfamily was generally more highly expressed in oral monolayers than in RHE models. SAP1 and SAP2 expression was largely unchanged in all model systems, and SAP3, SAP7 and SAP8 were expressed at low levels throughout. In Deltasap1-3, expression was compensated for by increased expression of SAP5, and in Deltasap4-6, expression was compensated for by SAP2: both were observed only in the oral RHE. Both Deltasap1-3 and Deltasap4-6 mutants caused RHE tissue damage comparable to the wild-type. However, addition of pepstatin A reduced tissue damage, indicating a role for the Sap family as a whole in inducing epithelial damage. With the hypha-deficient mutants, RHE tissue damage was significantly reduced in both Deltaefg1/cph1 and Deltaefg1, but SAP5 expression was only dramatically reduced in Deltaefg1/cph1 despite the absence of hyphal growth in both mutants. This indicates that hypha formation is the predominant cause of tissue damage, and that SAP5 expression can be hypha-independent and is not solely controlled by the Efg1 pathway but also by the Cph1 pathway. This is believed to be the first study to fully quantify SAP gene expression levels during human mucosal infections; the results suggest that SAP5 and SAP9 are the most highly expressed proteinase genes in vivo. However, the overall contribution of the Sap1-3 and Sap4-6 subfamilies individually in inducing epithelial damage in the RHE models appears to be low.

A scoring system for mucosal disease severity with special reference to oral lichen planus

Background  To date, there is only weak evidence for the superiority of any interventions over placebo for the palliation of symptomatic oral lichen planus (LP). Further research involving large placebo‐controlled, randomized clinical trials is needed. These will require carefully selected and standardized outcome measures.

Implication of Epstein‐Barr Virus Infection in Disease‐Specific Autoreactive B Cell Activation in Ectopic Lymphoid Structures of Sjögren's Syndrome

To examine whether the B cell tropic γ‐herpesvirus Epstein‐Barr virus (EBV) is aberrantly expressed in its latent and lytic forms within ectopic lymphoid structures (ELS) in the salivary glands of patients with Sjögrens syndrome (SS), and to investigate the relationship between EBV dysregulation, B cell activation, in situ differentiation of autoreactive plasma cells, disease‐specific autoantibody production, and cytotoxicity.

Distribution and Isolation Frequency of Eight Streptococcal Species in Saliva from Predentate and Dentate Children and Adults

The isolation frequency and distribution of eight recently defined streptococcal species have been investigated in the saliva of adults and that of both predentate and dentate children. The effects of frequency of sugar intake and tooth presence on the distribution of streptococcal species were also analyzed. Saliva samples were collected from 121 subjects divided into three study groups: (a) 56 predentate children (predentate group), (b) 37 dentate children (dentate group), and (c) 28 adults (adult group). Up to 17 biochemical and enzymatic tests were used to categorize streptococcal isolates into S. mitis, S. oralis, S. salivarius, S. anginosus, S. sanguis, S. vestibularis, S. mutans, and S. gordonii. The mean total and streptococcal salivary colony-forming units (CFU) were lowest in the predentate group and highest in the adult group. Streptococci were found in all the study subjects, and there was no obvious relationship between the total or streptococcal CFU and the number of teeth or the frequency of sugar intake. There was a wide variation in the isolation frequency of streptococcal species in the three study groups. S. mitis, S. oralis, and S. salivarius were the most frequent species isolated, and together they comprised 83% of the total streptococcal isolates. In contrast to studies using older classifications, S. sanguis was a minor species in the saliva though found more often in adults than in children (p < 0.04). S. anginosus was a minor species found in about 10% of adults and children. S. gordonii was detected rarely and only in dentate subjects. S. mutans was detected only in dentate subjects, significantly greater in adults (57.1%) than in children (5.4%, p < 0.001). In contrast, S. vestibularis was found in both dentate and predentate children but not in adults. No relationship between the isolation frequency of any of the species and sugar intake in children was demonstrated. The new classification of streptococci has revealed major differences in isolation frequency and distribution of the individual species and should prove useful in future studies of ecological factors affecting oral flora.

B3) Markers of immunodeficiency and mechanisms of HAART therapy on oral lesions.

Highly active anti-retroviral therapy (HAART) has revolutionized the treatment and prognosis of HIV disease and AIDS in those who can take advantage of the treatment. There are currently 20 different anti-retroviral drugs in 4 different classes that are used in specific combinations. Suppression of HIV replication and immune reconstitution are goals of therapy. Since the prevalence of some easily detectable oral manifestations of HIV/AIDS (OMHIV/AIDS) decreases with HAART, it has been suggested that they might be clinically useful surrogate markers of HAART efficacy and immune status. This might be particularly useful if their recurrence presaged or accompanied HAART failure. To date, there has been little work in this area, but its potential value to the clinical management of HIV/AIDS is apparent, especially if frequent measures of viral load and CD4 cell counts are not readily available. However, the usefulness of OMHIV/AIDS as signals for HAART failure is complicated by three phenomena: the immune reconstitution syndrome, the similarity of some adverse reactions of HAART to OMHIV/AIDS, and the direct inhibitory effect of HAART medications on some OMHIV/AIDS (e.g., inhibition of oral candidosis by protease inhibitors). This workshop considered the current evidence and proposed pertinent research questions.

Oral Kaposi sarcoma: a case of immune reconstitution inflammatory syndrome

Wider use of highly active antiretroviral treatment (HAART) for human immunodeficiency virus-1 (HIV-1)-infected patients has significantly altered the pattern of acquired immunodeficiency syndrome (AIDS)-related clinical signs and symptoms and has revolutionized the therapeutic modalities for these patients. Immune reconstitution inflammatory syndrome (IRIS) is a paradox of clinical worsening of opportunistic infections in the context of response to HAART and immunological recovery. Here we present a case of oral IRIS-related Kaposi sarcoma (KS) that appeared in an advanced HIV-1-infected patient introduced to HAART and was treated by surgical removal and antiretroviral therapy.

Systemic conditions associated with areca nut usage: A literature review

Aim: The adverse effects of areca nut (AN) chewing habit on oral health have been reported. However, the hazards related to the habit are not restricted to the oral cavity but they can also jeopardise the systemic health. Since no review reporting the harmful effects of AN chewing on systemic health is yet available, the aim of the present study was to review the systemic conditions associated with AN usage. Methods: To address the focused question ‘‘What are the deleterious effects of AN usage on systemic health?’’, the MEDLINE PubMed databases were explored from 1966 up to and including May 2010. The eligibility criteria included: human studies, individuals using AN, use of controls, and articles published in English. Hand-searching was also performed. Unpublished data was excluded. Results: The review included 28 articles. Seven studies associated AN chewing with cardiovascular disorders and three studies related the habit with cerebrovascular disorders. Eight studies related AN chewing with obesity, hyperglycaemia, metabolic syndrome, and type 2 diabetes mellitus. Five studies related AN chewing with the development of hepatic disorders. Two studies associated the chewing habit with oesophageal inflammation and fibrosis. Three studies associated AN chewing with respiratory discomfort. Renal disorders were related with the chewing abuse in two studies. Two studies showed an adverse effect of AN chewing on birth outcome. Conclusions: AN chewing adversely affects systemic health by damaging the vital organs.

Immune Reconstitution Inflammatory Syndrome

Immune reconstitution inflammatory syndrome (IRIS) is a phenomenon observed in patients recovering from immunodeficiency. The clinical presentation of IRIS involves the unmasking of covert infections or the worsening of overt conditions. Several causes and pathways have been suggested, most recognizing an inflammatory flare component occurring in the context of rapid immune reconstitution. In HIV-infected patients, IRIS inadvertently occurs as the consequence of successful antiretroviral therapy, and it is affiliated with improvement of the immune function, complicating the course of the disease and presenting treatment challenges to clinicians. The pathogenesis of IRIS is poorly understood, but in recovering HIV patients, its initiation and progression seem to be primarily linked to an increase in CD4+ T-helper and CD8+ T-suppressor cell count and a reduction in T-regulatory cells, all endorsed by exaggerated cytokine release and activity. The clinical presentation of IRIS is usually atypical. The manifestations depend on the trigger antigen, which can be an infective agent (viable or nonviable), a host antigen, or a tumor antigen. Most IRIS cases are self-limiting, but a few cases can be overwhelming and life-threatening; hence, early recognition is important. In most cases, there is no need to discontinue the antiretroviral therapy, although in the more severe cases, other clinical intervention may be necessary.

Ultrasound of the salivary glands is a strong predictor of labial gland biopsy histopathology in patients with sicca symptoms

BACKGROUND The international classification criteria for Sjögrens syndrome necessitate the presence of either extractable nuclear antibody or a characteristic focal inflammatory infiltrate in a minor salivary gland. Thus, patients who are extractable nuclear antibody-negative will need to have a labial salivary gland biopsy, which is an invasive procedure associated with morbidity. The aim of this study was to evaluate the viability of ultrasound imaging of the major salivary glands as a predictor of the histology to explore whether ultrasound can help in stratifying Sjögrens patients and reduce the need for biopsy. METHODS The records of 85 patients suspected of having Sjögrens syndrome and who have had biopsy and ultrasound were analysed retrospectively. The histology and the ultrasound were reported by experts independently. The reporting was impartial as the examiners were blinded to the results of the other investigations and to the diagnosis. RESULTS Out of the 85 patients, 34 had positive ultrasound, 29 of whom also had positive histology. Fifty-one patients had negative ultrasound, of whom 49 were also negative for histological features of Sjögrens syndrome. The results show that the ultrasound had a positive predictive value of 85% and a striking negative predicative value of 96% of the histology results. The overall concordance between the ultrasound and the histology was 91% (Kappa = 0.826). CONCLUSIONS Our study shows that potentially the ultrasound has a role in stratifying patients who are extractable nuclear antibody-negative and can help to prioritize the biopsy for those who have sonographic evidence of SS.

Clinical Markers of Immunodeficiency and Mechanism of Immune Reconstitution Inflammatory Syndrome and Highly Active Antiretroviral Therapy on HIV Workshop 3A

Antiretroviral therapy (ART) has improved survival and changed the disease pattern of HIV infection. However, ART may cause serious side effects, such as metabolic and cardiovascular complications. In addition, immune reconstitution inflammatory syndrome (IRIS) is being increasingly reported in relation to ART. The article presents the consensus of a workshop around 4 key issues: (1) the differences in the response of adults and children to highly active antiretroviral therapy, (2) the mechanism of the new HIV entry inhibitors and its effect on oral markers, (3) the pathogenesis of IRIS and the contradictory findings of the possible oral lesions related with IRIS, (4) and the benefits and barriers associated with using ART in the developing and developed world. The consensus of the workshop was that there is a need for future studies on the oral manifestations of HIV in individuals treated with new ARTs—especially, children. IRIS was considered a promising field for future research; as such, workshop attendees recommended formulating an IRIS–oral lesions case definition and following strict criteria for its diagnosis.