Nutrition and Oral Medicine (Nutrition and Health)

Chapter 13 / HIV 227may produce thrombotic thrombocytopenic purpura and hemolytic uremic syndrome inthis patient population.3.1.2. CMVCMV, human herpes virus 5, can cause multiorgan dysfunction in an immunocompromisedpatient (15,16). The intraoral presentation of CMV indicates severe immunosuppression,as measured by the CD4 cell count of less than 100 mm 3 and is usually linkedwith disseminated CMV infection (2,17,18). The lesions are generally nonspecific ulcersthat range from a few millimeters to 1 to 2 cm in diameter, primarily on the gingiva orthe palate, but they can also be found on other mucosal surfaces. The ulcers may beshallow or deep with an eroded base and tend to be extremely painful (19). Because ofthe ulcers, the nutritional status of the patient may be severely compromised. Pain addedto prolonged healing of the ulcers may cause dehydration because of inadequate oral andnutritional intake.The differential diagnoses should include recurrent aphthous ulcers and HSV lesions.To make a definitive diagnosis, a biopsy demonstrating perivascular inflammation andlarge basophilic intranuclear inclusions of CMV is required. An diagnosis of oral CMVrequires additional workup to rule out ophthalmologic or other CMV-related disease and/or lesions (20). Intraoral manifestations of CMV can be treated with ganciclovir (21).3.1.3. VZVVZV causes two well-defined diseases: chickenpox (varicella) and shingles (herpeszoster). After an initial infection, the virus remains latent in the dorsal root ganglia.Reactivation produces shingles in adult and immunocompromised patients. Shingles maycommonly be seen during the progression of an individual’s HIV disease. Although intraorallesions have been noted, they are not common. If lesions do appear intraorally, theyare typically found unilaterally along a division of the fifth cranial nerve, generally on thepalate (14). Lesions tend to resemble HSV-associated ulcers, but they are typically clusteredunilaterally and are larger in size, and they too are painful. A significant correlationbetween intraoral VZV presentation and the immune status of an individual with HIV hasyet to be shown (22). Because of the painful nature of the lesions, especially in the acutephase, oral intake and consequently nutrition status may be affected. Treatment is usuallysupportive and preventive in nature. Although oral valacyclovir has been utilized, intravenousacyclovir may be indicated in severely immunocompromised patients (14).3.1.4. EPSTEIN-BARR VIRUSInitially described in HIV-infected males, oral hairy leukoplakia (OHL), a lesion associatedwith Epstein-Barr virus (EBV), was initially thought to be an HIV-specific manifestation(23,24). However, OHL is found not only among HIV-infected individuals, buthas also been reported among other immunocompromised groups, and occasionally inimmunocompetent individuals (25,26). For an individual presenting with OHL and anunknown HIV status, an HIV test is strongly recommended, as the occurrence of OHL inindividuals with HIV far exceeds the incidence of the lesion among other groups ofpatients.OHL is commonly seen on the lateral borders of the tongue as white, vertical, hyperkeratoticstriae sometimes extending onto the ventral or dorsal surfaces. The lesioncannot be wiped or rubbed off. As it is asymptomatic, the patient may not be aware of its