Lilly Esquivel-Pedraza

The Changing Clinical Spectrum of Human Immunodeficiency Virus (HIV)-Related Oral Lesions in 1,000 Consecutive Patients: A 12-Year Study in a Referral Center in Mexico.

In developing countries, the variations in the clinical spectrum of human immunodeficiency virus (HIV)-related oral lesions over time, and the possible effects of antiretroviral therapy, have not been described. In this study we evaluate the clinical spectrum of oral lesions in a series of HIV-infected patients when first examined at the acquired immunodeficiency syndrome (AIDS) clinic of a tertiary care institution in Mexico City, Mexico, and the changes observed over 12 years.All HIV-infected adult patients had an oral examination performed by specialists in oral pathology and medicine who used established clinical diagnostic criteria for oral lesions. Four periods were defined according to the evolving pattern of antiretroviral use: the first 2 were before the introduction of highly active antiretroviral therapy (HAART) and the last 2 were during more established use of HAART.For the statistical analysis the chi-square test for contingency tables and the chi-square test for trend were utilized. For dimensional variables, except age, the Kruskal-Wallis or Mann-Whitney rank sum tests were used when applicable and trend was tested with the Spearman correlation coefficient. Age was tested through analysis of variance (ANOVA) and linear regression analysis. Alpha value was set at p = 0.05 for each test.In the 12-year study, 1,000 HIV-infected patients were included (87.9% male). At the baseline examination, oral lesions strongly associated with HIV were present in 47.1% of HIV-infected patients. Oral candidosis (31.6%), hairy leukoplakia (22.6%), erythematous candidosis (21.0%), and pseudomembranous candidosis (15.8%) were the most frequent lesions. Oral Kaposi sarcoma (2.3%), HIV-associated periodontal disease (1.7%), and oral non-Hodgkin lymphoma (0.1%) were less frequent.HIV-related oral lesions decreased systematically—by half during the course of the 4 study periods (p < 0.001). Except for Kaposi sarcoma, all oral lesions strongly associated with HIV showed a trend to decrease significantly during the study period. No apparent variation in the occurrence of salivary gland disease or human papillomavirus-associated oral lesions was found.A significant trend to a lower prevalence was observed in the group of patients who were already taking antiretroviral therapy, non-HAART and HAART (p < 0.001 and p = 0.004, respectively). Only a discrete reduction, barely significant, was noted among untreated patients (p = 0.060). By Period IV (1999–2001), those who received HAART showed the lowest prevalence of oral lesions strongly associated with HIV (p < 0.001).Patients with oral lesions strongly associated with HIV had significantly lower median CD4+ counts and higher viral loads than those without oral lesions strongly associated with HIV (p < 0.001 and p = 0.005, respectively). When CD4+ counts were correlated with prevalence of oral candidosis, a consistently negative association was found; this association prevailed even after the study group was partitioned according to period. In this selected cohort of 1,000 patients with HIV infection, the clinical spectrum of HIV-related oral lesions has changed over the 12-year study, with a decreased prevalence of most oral lesions. Our findings probably represent improvements in medical care of HIV-infected persons, earlier detection of HIV-infected patients at the AIDS clinic, the increasing use of prophylactic drugs to prevent secondary AIDS-related opportunistic infections, and, perhaps most important, the availability of potent antiretroviral therapy in recent years, since the introduction of HAART.

Frequency of oral conditions in a dermatology clinic

Background Oral mucosal manifestations may be the initial feature, the most florid clinical feature, or the only sign of mucocutaneous diseases.

Thalidomide as Therapy for Human Immunodeficiency Virus—Related Oral Ulcers: A Double-Blind Placebo-Controlled Clinical Trial

A double-blind, randomized, placebo-controlled clinical trial was performed in Mexico City to evaluate the efficacy of thalidomide in treating oral recurrent aphthae in human immunodeficiency virus (HIV)-infected subjects. Sixteen HIV-infected patients with clinical and histological diagnosis of oral recurrent aphthous ulcerations received randomly an 8-week course of either thalidomide or placebo, with an initial oral dosage of 400 mg/d for 1 week, followed by 200 mg/d for 7 weeks. Ten subjects received thalidomide and six received placebo. At 8 weeks, nine subjects (90%) in the thalidomide group had complete healing of their ulcers, compared with two (33.3%) of the six patients in the placebo group (P = .03). There was a significant reduction in largest ulcer diameter in the thalidomide group. Rash was observed in 80% of the thalidomide patients. Although thalidomide demonstrated an unquestionable benefit in treatment of oral ulcers in HIV patients, caution must be taken given the frequent occurrence of side effects.

Oral clinical markers and viral load in a prospective cohort of Mexican HIV-infected patients.

Recent cross-sectional studies have suggested that oral candidosis (OC) and hairy leukoplakia (HL) could be considered as clinical markers of high viral load levels and CD4 cell depletion in HIV infection [1-3]. However this association has not been documented in a prospective longitudinal study. Hence a cohort study was conducted to determine the association of the occurrence of OC and HL with HIV-ribonucleic acid plasma levels and CD4 T cell counts in Mexican HIV-infected individuals. Patients were examined for clinical evidences of current OC or HL at baseline and monthly during follow-up. Results revealed that the development of OC and HL in HIV-infected individuals with no treatment or under non-highly active antiretroviral therapy combinations appeared to be associated with the viral load values and lower CD4 cell counts. In conclusion the presence of these lesions may be considered to be good clinical indirect markers of the status of viral replication.

Asociación de lesiones bucales con el estado serológico para el VIH

Ramirez-Amador V, Esquivel-Pedraza L, Irigoyen-Camacho E, Anaya-Saavedra G, Gonzalez-Ramirez I. Asociacion de lesiones bucales con el estado serologico para el VIH. Salud Publica Mex 2002;44:87-91. El texto completo en ingles de este articulo esta disponible en: http://www.insp.mx/salud/index.html Resumen Objetivo. Estimar la prevalencia de lesiones bucales y su asociacion con el estado serologico del VIH. Material y metodos. Estudio transversal, descriptivo y doble ciego, hecho, entre 1998 y 1999 en Mexico, D.F., con 512 personas que acudieron a dos centros de informacion del Centro Nacional para la Prevencion del VIH/SIDA e ITS (CONASIDA) y a quienes se les practico examen bucal sin conocer aun su estado serologico con respecto al VIH. Se utilizaron las pruebas de t-Student, exacta de Fisher y χ 2 . Se calculo la razon de productos cruzados. Resultados. Se examinaron 512 individuos, 68 resultaron positivos al VIH. En 65% (44/68), se observaron lesiones bucales asociadas con el VIH (LB), 95% correspondieron a candidosis bucal (CB) y leucoplasia vellosa (LV). La asociacion de CB y LV con el estado serologico positivo al VIH fue estrecha. Conclusiones. La CB y la LV fueron las lesiones mas fuertemente asociadas con el VIH. El texto completo en ingles de este articulo esta disponible en: http://www.insp.mx/salud/ index.html

Clinical Spectrum of Oral Secondary Syphilis in HIV-Infected Patients

Background. Oral lesions may constitute the first clinical manifestation in secondary syphilis, but detailed descriptions in HIV-infected individuals are scarce. Objective. To describe the clinical characteristics of oral secondary syphilis in HIV-infected patients and its relevance in the early diagnosis of syphilis. Methods. Twenty HIV/AIDS adult subjects with oral secondary syphilis lesions presenting at two HIV/AIDS referral centers in Mexico City (2003–2011) are described. An oral examination was performed by specialists in oral pathology and medicine; when possible, a punch biopsy was done, and Warthin-Starry stain and immunohistochemistry were completed. Intraoral herpes virus infection and erythematous candidosis were ruled out by cytological analysis. Diagnosis of oral syphilis was confirmed with positive nontreponemal test (VDRL), and, if possible, fluorescent treponemal antibody test. Results. Twenty male patients (median age 31.5, 21–59 years) with oral secondary syphilis lesions were included. Oral lesions were the first clinical sign of syphilis in 16 (80%) cases. Mucous patch was the most common oral manifestation (17, 85.5%), followed by shallow ulcers (2, 10%) and macular lesions (1, 5%). Conclusions. Due to the recent rise in HIV-syphilis coinfection, dental and medical practitioners should consider secondary syphilis in the differential diagnosis of oral lesions, particularly in HIV-infected patients.

Pemphigus foliaceus with circinated plaques and neutrophil pustules.

Pemphigus is a group of autoimmune intraepidermal bullous diseases; being pemphigus foliaceus (PF) and pemphigus vulgaris (PV) the most common subtypes. Pustular variants are scarcely reported for both PV and PF. The purpose of this manuscript was to describe the clinical, microscopic and immunologic findings of an atypical case of PF presenting with pustules, including a review of the literature. PF is described as blisters and because this entity is rare, it is not known for the general medical community that they are other clinical features that can be seen as this one we present here with pustules.

Porocarcinoma on the Face: A Rare Location. Review of the Literature to Explore Its Biological Behavior

The 5-year survival rate of SDM is 73% for patients with localized disease, 67% for patients with nodal involvement, and 22% for patients with distant metastasis, but PDM is biologically less aggressive than primary cutaneous melanoma of similar Breslow thickness and is associated with long survival. In the Asian population, only one Japanese woman, initially misdiagnosed with an epidermal cyst, has been reported. The patient was a 38-year-old woman with a subcutaneous tumor on her left thigh. Preoperative surveillance showed no evidence of lymph nodes or distant metastasis. Distant bone and pulmonary metastasis developed 11 months after surgery, even with adjuvant chemotherapy. We report a second case of presumed PDM in a young Asian man, with better outcome to date. The patient has been disease free for longer 12 months, without receiving any adjuvant therapy. Consideration of PDM in the differential diagnosis of dermal nodules or cystic appearing lesions may aid in detection of this rare entity. References

Recurrent Aphthous Ulcers: Experience from a Tertiary Care Center

Background: The frequency of recurrent aphthous ulcers (RAU) and their relationship with comorbidities has been scarcely described. Methods: We conducted a retrospective analytical study of patients with a presumptive diagnosis of RAU, in order to know the frequency of misdiagnosis of RAU, to delineate the clinical and biochemical characteristics of RAU, and to analyze their correlation with systemic diseases. Three groups of recurrent ulcers were analyzed: a) RAU, b) RAU associated to Behçet ́s disease, and c) other recurrent ulcers misdiagnosed as RAU (OU). We recorded clinical and laboratory data. Statistics included Mantel-Haenszel chi square test, Kruskall-Wallis test, and Student ́s t test. Results: A total of 141 patients (106 women) were referred with a presumptive diagnosis of RAU: 56 cases (39.7%) with RAU; 10 (7.1%) with RAU in Behçet ́s disease, and 75 (53.2%) with OU. RAU subjects presented a lower frequency of rheumatologic diseases than patients with Behçet ́s disease ulcers [30.4% vs 70.0%; (p=0.03)] and patients with OU [30.4% vs 54.7%; (p=0.007)]. Additionally, immune deficiency was less common among patients with RAU in comparison to Behçet ́s disease [3.6% vs 40.0%; (p=0.003)] and OU [3.6% vs 28.0%; (p‹0.001)]. Higher levels of serum leukocytes were seen in Behçet ́s disease [median=8.9 (range 5.3-9.7) × 103 cells/mm3] when compared to RAU [median=6.0 (range 3.2-21.2) × 103 cells/mm3] and OU [median=6.0 (range 2.3-14.8) × 103 cells/mm3] (p<0.04). Conclusions: Misdiagnosis of RAU was frequent; an individual pattern of association to specific groups of systemic diseases was observed in each studied group of recurrent ulcers. RAU and Behçet ́s disease ulcers showed clinical and laboratory differences.

Recalcitrant oral squamous cell papilloma lesions in two HIV-infected patients successfully treated with topical imiquimod.

BACKGROUND Squamous cell papilloma is a benign mucosal disease associated with human papillomavirus. Its presence in human immunodeficiency virus (HIV)-infected patients has rarely been reported. Therapeutic modalities for oral squamous cell papilloma have limited success and recurrences are frequent in HIV-infected subjects. Imiquimod, is a topical immunomodulator successfully used in some human papillomavirus-related oral lesions. However, its use for oral squamous cell papillomas in HIV-infected individuals has never been described. OBSERVATIONS We report two male adult patients with HIV-infection, B2 and C3 stage respectively, undergoing antiretroviral therapy, with multiple recalcitrant oral squamous cell papillomas, predominantly affecting the masticatory mucosa. These lesions were successfully treated with daily topical imiquimod 5% cream for a few weeks, with only mild and well-tolerated side effects. No recurrences were observed after a follow-up period of over 20 months. CONCLUSIONS Our cases highlight the value of imiquimod for the non-invasive treatment of multiple persistent oral squamous cell papillomas in two HIV-infected patients.