HIV infection is characterized by progressive immunosuppression due to low absolute CD4 counts and the perturbed cytokine network which manifest havoc at clinical level. The clinical consequences of HIV infection encompass a spectrum ranging from an acute syndrome associated with primary infection to prolonged asymptomatic state to advanced disease (). The oral health status of an HIV-infected patient at presentation is an extremely important parameter, as it may reveal important information regarding the immune status of the individual. Oral disorders occur in about 64–80% cases of HIV/AIDS in India [2
] and may present as a wide range of lesions, notably fungal, viral, and bacterial infections and malignant neoplasms such as Kaposi's sarcoma and nonspecific presentations such as aphthous ulcerations and salivary gland disease as would be expected in severe defect of T-lymphocyte-mediated immunity. Factors which predispose expression of oral lesions include CD4 counts less than 200
, viral load greater than 3000
copies/mL, xerostomia, poor oral hygiene, and smoking [3
Revised CDC classification and case definition among adults (1993).
The most common HIV-related oral disorder is oral candidiasis which occurs in 17–43% cases with HIV infection and in more than 90% of cases with AIDS [4
]. Oropharyngeal candidiasis is among the initial manifestations of HIV-induced immunodeficiency and typically affects the majority of persons with advanced untreated HIV infection. Presenting months or years before more severe opportunistic infections, it may be a sentinel event indicating the presence or progression of HIV disease.
Infection with Candida albicans
presents mainly four forms: pseudomembranous candidiasis, hyperplastic candidiasis, erythematous candidiasis, and angular cheilitis. Patients may exhibit one or a combination of any of these presentations. In patients with fully blown AIDS, the pseudomembranous form of candidiasis is most common, while in patients infected with HIV, the erythematous type is dominant [3
] as was seen in the present case. Erythematous candidiasis presents as red macular lesions typically on the palate and dorsum of the tongue. Pseudomembranous candidiasis appears as creamy white curd-like plaques on the buccal mucosa, tongue, and other oral mucosal surfaces that can be wiped away, leaving a red or bleeding underlying surface while the hyperplastic type of oral candidiasis is characterized by white plaques that cannot be removed by scraping and is common in the buccal mucosa. Angular cheilitis presents as cracking, peeling, or ulceration involving the corners of the mouth and is frequently present in combination with other forms of candidiasis.
HIV infection presents with a plethora of oral manifestations which are shown by all patients at some point of their disease. It has been shown by various studies on HIV and AIDS that oral candidiasis is the most common opportunistic infection [2
]. These oral manifestations can also be the initial indicator of underlying HIV infection. In our case, the patient appeared apparently healthy and was completely unaware of his immunologic status. It was the burning sensation on the tongue and cheeks which made him obtain a dental opinion. The patient presented with the typical features of erythematous candidiasis including burning sensation along with angular cheilitis, and these findings triggered investigations for HIV infection. This discovery was similar to the cases observed in the past where candidiasis was the sole initial manifestation of HIV infection leading to its diagnosis [7
]. There also have been reports where the rarer oral infection of histoplasmosis has aided in identifying the HIV status of an individual [9
]. Tuberculosis was found to be the most frequently occurring systemic coinfection in AIDS [6
Identification of the fungal pseudohyphae within exfoliative cytologic preparations, often utilizing periodic acid schiff and/or-Papanicolaou-stained preparations, is the optimal standard for the diagnosis of all candidiasis, although the highest yield of positive cytology smears is with pseudomembranous candidiasis [11
]. In general, the frequency of isolation of candida species increases with increasing severity of HIV disease and with lower CD4
CD8 ratio [12
]. Oral manifestations especially candidiasis has been found to be significantly correlated to a reduced CD4 cell count below 200
]. Management is based on the extent of the infection with topical therapies consisting of clotrimazole troches, nystatin oral suspension, and nystatin pastilles utilized for mild to moderate cases. Systemic agents are reserved for moderate to severe disease and include fluconazole, the most widely used drug, itraconazole, and voriconazole; the latter should be reserved for fluconazole-resistant cases. HIV-infected patients usually have associated esophageal candidiasis along with oral candidiasis and hence require a longer and higher dose of antifungals [12
]. Undeniably, it was the presence of erythematous candidiasis, angular cheilitis, and periodontitis and the unresponsiveness of the patient to topical antifungals that prompted us to elicit his lifestyle habits and carry out investigations leading to a diagnosis of HIV infection.