27th June 2023

Oral and oesophageal presentations

Oral lesions are early indicators of infection and can predict progression to AIDS. There are numerous lesions seen in HIV affecting the oral cavity, including:

• Oral hairy leukoplakia
• Pseudomembranous candidiasis
• Herpes simplex infection
• Kaposi’s sarcoma
• Ulcers, including aphthous ulcers

Oral candidiasis is usually caused by Candida albicans and is very common in HIV-l, affecting 80-90% of patients. ~15 species cause candidiasis, and in HIV is caused more commonly by C. dubliniensis relative to other patients. Oral candidiasis infection usually starts on the dorsum of the tongue. Pseudomembranous candidiasis is the common ‘thrush’ pattern of Candida infection. It features white-yellow plaques in the oral mucosa, which show an erythematous base when scraped off. Other risk factors for candidiasis include steroids, smoking, dentures, and poor saliva production. Management of oral candidiasis in HIV is with oral fluconazole, advice on hygiene and smoking cessation.

Oesophageal candida infection is more specific for HIV, affecting 10% of patients with HIV, usually at CD4+ T cell counts <100/μL. Symptoms include:

• Painful swallowing
• Difficulty swallowing
• Retrosternal pain
• Abdominal pain
• Asymptomatic finding

Differentials include viral oesophagitis, and so diagnosis requires visualisation (i.e. endoscopy) and histology (biopsy or brushing the oesophageal mucosa). An alternative is radiological examination with barium swallow – a ‘double swallow’ is needed and is about 90% sensitive. Management involves antifungal therapy with fluconazole PO or IV if swallowing is not possible, it is taken for 2-3 weeks.

Oral hairy leukoplakia is more specifically associated with immunosuppression, usually by HIV. It is caused by Epstein-Barr virus (EBV) and characteristically causes a white lesion on one side of the tongue. It is ‘shaggy’ in appearance, usually unilateral, and cannot be rubbed off. Over 90% of the adult population has EBV. It is treated with topical antiviral agents, which are generally effective and safe. Treatment options include:

• Combined 25% podophyllin and 5% acyclovir cream
• Gentain violet 2%
• Surgical excision
• Cryotherapy

Overall, the clinical significance of oral hairy leukoplakia is primarily as an indicator of progression towards AIDS, and its development should prompt testing if there is no HIV diagnosis.