ORAL MANIFESTATION OF AIDS

ORAL MANIFESTATION OF HIV/ AIDSBLOK ORAL BIOMEDIC TA. 2012/2013JURUSAN KEDOKTERAN GIGI - UNSOED

PENYAKIT HIV/ AIDS (Human Immunodeficiency Virus/ Acquired Immuno Deficiency Syndrome) Penyakit HIV/ AIDS pertama kali dikenal pd thn 1981

Penyakit HIV/ AIDS disebabkan oleh HIV retrovirus (virus RNA) dr famili lentivirus

RNA virus tdk dapat bereplikasi di luar sel host (limfosit Th CD4+)

Transmisi infeksi melalui body fluids (darah, semen, vaginal fluid, ASI) dg cara :- kontak seksual- parenteral dan ibu ke anak

Pd thn 1995, Dr. David Ho menemukan HAART (Highly Active Anti Retroviral Therapy)

Perkembangan perjalanan penyakit HIV dimonitor menggunakan 2 laboratory markers: 1. angka CD4+ lymphocyte 2. jumlah HIV viralPhases of HIV/AIDS1. Infection2. Window period5. HIV/AIDS-related illness4. Asymptomatic Period3. Seroconversion6. AIDSWINDOW PERIODDurasi : 3 bln tanda & gejala penyakitTes HIV negatifVirus bereplikasi sangat cepat pasien sangat infeksius

SEROCONVERSION

Tes HIV positif tubuh mulai membuat Ab

3 bulan stlh infeksi

Timbul penyakit flu-like ringan (1-2 minggu)

ASYMPTOMATIC PERIOD

Durasi bervariasi : < 1 thn s.d. > 15 thn

Sebagian besar org tetap sehat (asimtomatik) selama 3 thn

Angka CD4 > 500 sel/ml

HIV/AIDS-related Illness

Durasi bervariasi : 5 thn

Keluhan sakit mula2 ringan meningkat frekuensi & keparahan-nya

Angka CD4 200-500 sel/ml

AIDS

Fase final dr penyakit HIV/AIDS Durasi : - tanpa obat antiretroviral : < 2 thn - dg obat antiretroviral : bisa berthn2 Angka CD4 < 200 sel/mm3 Virelemi tinggi pasien sangat infeksius

Grafik 1. Course of HIV Infection

Photo: Kumar, Cotran, Robbins. Robbins Basic pathology, 7th ed., Saunders, Philadelphia, 2003.Manifestasi Oral HIV/AIDSBerbagai kondisi oral terkait dengan penyakit HIV 70%-90% penderita menunjukkan min. 1 manifestasi oral sepanjang perjalanan penyakit.

Faktor predisposisi penyakit oral terkait HIV :1. jumlah sel CD4+ < 200/mL, level plasma HIV-RNA viral > 3000copies/mL2. xerostomia3. poor oral hygiene4. smoking

Terdapat 2 sistem klasifikasi lesi oral terkait infeksi HIV :1. Berdasarkan etiologi lesi oral 2. Berdasarkan degree of the association with HIV infection pd adult dan pediatriETIOLOGILESI ORAL1. INFEKSI FUNGAL- Candidiasis- Histoplasmosis2. INFEKSI VIRAL Herpes Simpleks Herpes Zoster lesi Human Papilloma Virus Cytomegalovirus Hairy Leukoplakia and Eipstein-Barr Virus 3. INFEKSI BAKTERIPeriodontal diseases4. NEOPLASMA- Kaposis Sarkoma Limfoma Non-Hodgkin SCC5. LAIN-LAINTabel 1. Klasifikasi lesi oral terkait infeksi HIV berdasarkan etiologiLesions strongly associated with HIV infection Candidiasis Non-Hodgkins lymphoma Erythematous Periodontal disease Pseudomembranous Linear gingival erythema Hairy leukoplakia Necrotizing (ulcerative) gingivitis Kaposis sarcoma Necrotizing (ulcerative) periodontitis Lesions less commonly associated with HIV infection Bacterial infections Viral infections Mycobacterium avium-intracellulare Herpes simplex virus Mycobacterium tuberculosis Human papillomavirus (wart-like lesions) Melanotic hyperpigmentation Condyloma acuminatum (HPV) Necrotizing (ulcerative) stomatitis Focal epithelial hyperplasia Salivary gland disease Verruca vulgaris Dry mouth due to decreased salivary flow rate Varicella zoster virus Unilateral or bilateral swelling of the major Herpes zoster salivary glands Varicella Thrombocytopenic purpura Ulceration NOS (not otherwise specified) Table 2. Orofacial lesions associated with HIV/AIDS in adults 12Lesions seen in HIV infection Bacterial infections Fungal infection other than candidiasis Actinomyces Israel Cryptococcus neoformans Escherichia coli Geotrichum candidum Klebsiella pneumoniae Histoplasma capsulatum Cat-scratch disease Mucoraceae (mucormycosis/ zygomycosis) Drug reactions (ulcerative, erythema Aspergillus flavus multiforme, Lichenoid, toxic epidermolysis Recurrent aphthous stomatitis Epithelioid (bacillary) angiomatosis Viral infections Neurologic disturbances Cytomegalovirus Facial palsy Molluscum contagiosum Trigeminal neuralgia

Table 2. Orofacial lesions associated with HIV/AIDS in adults (contd) 3 EC Clearinghouse on Oral Problems Related to HIV Infection and WHO Collaborating Centre on Oral Manifestations of the Human Immunodeficiency VirusLesions commonly associated with pediatric HIV infection Oral candidiasis Parotid enlargement Pseudomembranous Recurrent aphthous ulcers Erythematous Minor Angular cheilitis Major Herpes simplex virus infection Herpetiform Linear gingival erythema Lesions less commonly associated with pediatric HIV infection Bacterial infections of oral tissues Viral infections Periodontal diseases Cytomegalovirus Necrotizing ulcerative gingivitis Human papillomavirus Necrotizing ulcerative periodontitis Molluscum contagiosum Necrotizing stomatitis Varicella zoster virus Xerostomia Herpes zoster Seborrheic dermatitis Varicella Table 3. Orofacial lesions associated with pediatric HIV infection12Lesions strongly associated with HIV infection but rare in children Neoplasms Kaposis sarcoma and non-Hodgkins lymphoma Oral hairy leukoplakia Tuberculosis-related ulcers

Table 3. Orofacial lesions associated with pediatric HIV infection (contd) 3 EC Clearinghouse on Oral Problems Related to HIV Infection and WHO Collaborating Centre on Oral Manifestations of the Human Immunodeficiency VirusORAL CANDIDIASIS (OC)Candidiasis seringkali mrpkn manifestasi awal infeksi HIV.

Faktor predisposisi : xerostomia

Infeksi Candidiasis dapat muncul pd awal tahap disfungsi imun dlm 2 bentuk :1. Erythematous candidiasis (EC) muncul pd angka CD4+ sel T yg masih tinggi (400 sel/ml)2. diikuti dg pseudomembranous candidiasis (PC) yg umumnya muncul saat angka CD4+ T cell menurun hingga sekitar 200 sel/ml

Figure 1. Erythematous candidiasis (Reznik, 2005)

Figure 2. Erythematous candidiasis (Reznik, 2005)

Figure 3. Pseudomembranous candidiasis - mild or moderate disease (Reznik, 2005)

Figure 4. Pseudomembranous candidiasis on lips and gums

Figure 5. Pseudomembranous candidiasis in an HIV-infected child (Vaseliu dkk,2010)a. Erythematous candidiasisGambaran klinis : - lesi patches merah, datar, multiple kecil maupun 1 lebar- asimptomatik hingga pasien mengeluhkan sensasi terbakar makanan asin/ pedas atau minuman asam- lokasi : dorsal lidah, palatum durum, palatum molle

Erythematous candidiasis may develop in patients taking broad-spectrum antimicrobials.

Penegakan diagnosis :- gambaran klinis- PMH- status virologi- tes laboratoris : preparat potassium hydroxide (KOH) ditemukan hifa fungi atau blastospora

b. Pseudomembranous candidiasis (or thrush)Gambaran klinis :Plak putih halusPlak mudah hilang saat diusap permukaan merah atau perdarahanLokasi : mukosa bukal, lidah, serta permukaan mukosa oral lainnya

Organisme yg paling umum terlibat Candida albicans

Angular cheilitis dan hyperplastic candidiasis dpt jg terlihat pd infeksi HIV.

Gambaran klinis angular cheilitis : - fisur eritematus pd sudut mulut.- Dpt muncul bersama atau tanpa erythematous/ pseudomembranous candidiasis

Gambaran klinis hyperplastic candidiasis :- putih, hiperplasi, tidak bisa dikerok- prevalensi jarang

Figure 6. Angular cheilitis (Reznik, 2005)

Figure 7. Hiperplastic Candidiasis How about this lesions?

Figure 8. Pseudomembranous Candidiasis & Angular Cheilitis Treatment Oral Candidiasis : krim antifungal topikal (4x/hari)

Masalah dlm perawatan Oral Candidiasis resistensi dan interaksi dg obat lain.

Figure 9. Oral candidiasis due to fluconazole-resistant Candida albicans (Reznik, 2005)

Figure 10. Oral candidiasis due to fluconazole-resistant Candida glabrata (Reznik, 2005)Oral Hairy Leukoplakia (OHL)OHL khas pd pasien infeksi HIV dg imunokompeten rendah shg prevalensi > deep jaw pain- gigi tanggal, perdarahan, halitosis

Treatment : - menghilangkan plak-kalkulus gigi, jar. lunak nekrosis dg 0.12% chlorhexidine gluconate atau 10% povidone-iodine- antibiotik- simptomatik

d. Necrotizing stomatitisMrpk lesi lanjutan dr NUP yg tidak diobati

Gambaran klinis :lesi ulceronekrotik akut dan sakit pd mukosa oral tulang alveolar di bawahnya terbuka

Figure 18. Necrotizing gingivitis and stomatitis in a 30-year-old man with AIDS. Kaposis Sarcoma (KS)Kaposis sarcoma mrpkn malignansi oral terkait HIV yg paling sering terjadi.

Kaposis sarcoma berkaitan dg Herpes Virus sbg agen etiologi.

Gambaran klinis :- lesi makula, nodula, atau peninggian dan ulserasi - warna merah hingga ungu.- lesi awal : datar, merah, asimtomatik- lokasi oral : umumnya di palatal.

Figure 19. Kaposis sarcoma (Reznik, 2005)

Figure 20. Kaposis sarcoma (Reznik, 2005)

Figure 21. HIV-positive patient presented with an intraoral Kaposis sarcoma lesion with an overlying candidiasis infectionLesi KS dapat mjd simptomatik bila terjadi trauma atau infeksi.

Penegakan diagnosis biopsi

Treatment :- injeksi lokal agen kemoterapetik (vinblastine sulfate)- surgical removal- OH >>- Kemoterapi sistemik lesi KS extraoral and intraoral

Figure 22. Extra Oral Kaposis Sarcoma lesion

Oral WartsHuman PapillomaVirus InfectionSalah satu lesinya : Condyloma Acuminatum

Insidensi meningkat seiring era terapi antiretroviral/ pemulihan imun perubahan fungsi thd m.o patogen CD8+ T cell diffuse infiltrative syndrome

Gambaran klinis : - lesi single atau seringkali multiple- kecil, sessile, batas tegas, ukuran 0,5-1 cm- massa exophytic berbentuk : cauliflower-like, berduri, atau raised dg permukaan rata- warna keputihan maupun normal - asimtomatik- lokasi umumnya pd mukosa labial dan bukal, lidah, gingiva, palatum molle

Figure 23. HPV-associated warts (Reznik, 2005)

Figure 24. HPV-associated warts (Reznik, 2005)

Figure 25. Multiple condylomata acuminata of the gingiva (Laskaris, 2006)Treatment :- agen topikal dan sistemik- surgery, laser surgery, atau cryotherapy.

Lesi dapat rekuren setelah treatmentHerpes Simplex Virus InfectionInfeksi herpes simplex virus (HSV) dpt berupa :1. infeksi primer : herpetic gingivostomatitis 2. infeksi sekunder : herpes labialis

Durasi infeksi HSV > 1 bln kondisi AIDS

Gambaran klinis :- vesikel pd mukosa berkeratin (palatum keras, gingiva) dan/ atau- vermilion border bibir- kulit perioral

Vesikel ruptur irregular painful ulcers

Treatment : antiviral sistemik interaksi obat acyclovir & ganciclovir dg HAART : toksisitas

Figure 26. HSV-1 lesion (Reznik, 2005)

Figure 27. HSV-1 lesion (Reznik, 2005)

Figure 28. Recurrent Herpes Simplex in an HIV-infected childAphthous UlcerationLesi recurrent aphthous umumnya muncul saat angka CD4+ lymphocyte < 100 cells/ml.

Gambaran klinis :- ulkus dg halo eritematus dan dilapisi pseudomembran kuning keabuan- sangat sakit- pd pasien infeksi HIV : durasi > 7-14 hr- lokasi : mukosa tidak berkeratin (bibir, mukosa bukal, dasar mulut, ventral lidah, orofaring posterior, vestibulum)

Treatment : kortikosteroid topikal/ sistemik

Figure 29. Aphthous Ulceration (Reznik, 2005)Parotid Enlargement dan XerostomiaPembesaran gl. Parotid umumnya terkait dg infeksi HIV pd anak2 muncul pd tahap akhir infeksi HIV

Etiologi : infiltrasi limfosit CD8 pd glandula efek HAART

Gambaran klinis :- pembengkakan unilateral maupun bilateral- asimtomatik- disertai penurunan salivary flow xerostomia

Xerostomia pd pasien infeksi HIV seringkali jg disebabkan oleh medikasi (antihistamines, antianxiety, antidepressants, dan bbrp antiretroviral drugs/ didanosine dan zalcitabine).

Treatment : diperlukan hanya pd kasus parah analgesik sistemik, antiinflamasi, antibiotik, dan/ atau steroid.Jadi, kapankah manifestasi oral mulai muncul???

Photo: Kumar, Cotran, Robbins. Robbins Basic pathology, 7th ed., Saunders, Philadelphia, 2003.

KESIMPULAN

Manifestasi oral HIV/AIDS dapat digunakan sbg : indikator klinis infeksi HIV pd pasien terinfeksi HIV yg terlihat sehat dan belum terdiagnosis gambaran klinis awal infeksi HIV tanda klinis untuk klasifikasi dan stage penyakit HIV prediktor perkembangan penyakit HIV

REFERENSILaskaris, G. 2006. Pocket Atlas of Oral Disease, 2nd ed, Thieme, Germany.

Reznik, D.A. 2005. Perspective - Oral Manifestations of HIV disease. International AIDS Society, 13(5): 143-8.

Vaseliu, N., Kamiru, H., Kabue M. 2010. HIV Curriculum for the Health Proffesional, Baylor College of Medicine, Texas.