|Year : 2015 | Volume
| Issue : 1 | Page : 7-10
Association of Oral Lesions and Immunosuppression in Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome Patients Not Taking Antiretroviral Therapy in Pakistan
Saima Qadir, Mohyman Sarfraz, Nadia Naseem, Abdul Hannan Nagi
Department of Oral Pathology, Morbid Anatomy and Histopathology, University of Health Sciences, Lahore, Pakistan
|Date of Web Publication||17-Jun-2015|
Department of Oral Pathology, Morbid Anatomy and Histopathology, University of Health Sciences, Lahore
Source of Support: None, Conflict of Interest: None
Background: Oral lesions, especially oral candidiasis, oral hairy leukoplakia, necrotizing periodontal conditions and variety of other viral and bacterial infections are essentially presented in human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) patients due to low CD4+ count. Aims: This study was designed to determine various oral clinical and cytological mucosal changes seen in HIV/AIDS patients not taking antiretroviral therapy (ART) in Pakistan and their relation to CD4+ lymphocyte count as no study has been reported yet in our country. Materials and Methods: Patients were clinically examined and staged according to World Health Organization (WHO) staging system. Oral smears, from n = 25 patients not taking ART, were prepared and examined microscopically using hematoxylin and eosin, periodic acid-Schiff and Papanicolaou stains. The CD4+ lymphocyte count was determined using flow cytometry. Result: Oral lesions were present in 36% of the patients with chronic periodontitis in 20%, oral candidiasis in 12%, oral pigmentation in 8% and oral ulcers in 4% patients. On cytological examination, fungi were detected in 56% smears. Inflammation was seen in 60% smears, micronuclei in 72%, nuclear atypia in 44% and dysplastic changes in 16% (grade 1 in 12% and grade 2 in 4%) smears. The mean CD4+ lymphocyte count was 338.12 127 cells/mm 3 . The CD4+ lymphocyte count was grouped as < 350 cells/mm 3 (Group 1) and > 350 cells/mm 3 (Group 2). Group 1 comprised of n = 15 while Group 2 had n = 10 patients. Most of the oral lesions were seen in CD4+ Group 1 having low CD4+ count. When the cytopathological variables were compared with WHO clinical stages, a statistically significant association (P < 0.05) was observed in the case of pseudomembranous candidiasis clinically and dysplasia and presence of fungi cytologicaly. Conclusion: This study highlights the importance of oral lesions as a marker of HIV/AIDS progression and immunosuppression as oral lesions were frequent with low CD4+ count especially < 350 cells/mm 3 .
Keywords: Human immunodeficiency virus/acquired immune deficiency syndrome, immunosuppression, oral lesions, Pakistan
|How to cite this article:|
Qadir S, Sarfraz M, Naseem N, Nagi AH. Association of Oral Lesions and Immunosuppression in Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome Patients Not Taking Antiretroviral Therapy in Pakistan. Indian J Oral Health Res 2015;1:7-10
|How to cite this URL:|
Qadir S, Sarfraz M, Naseem N, Nagi AH. Association of Oral Lesions and Immunosuppression in Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome Patients Not Taking Antiretroviral Therapy in Pakistan. Indian J Oral Health Res [serial online] 2015 [cited 2019 Jan 24];1:7-10. Available from: http://www.ijohr.org/text.asp?2015/1/1/7/158902
| Introduction|| |
Numbers of human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) patients are increasing in Pakistan especially due to high risk groups including sex workers and injecting drug users along with their spouses and children, which are becoming a bridging population in the society.  Oral lesions including oral candidiasis, oral hairy leukoplakia, recurrent ulcerative conditions, severe periodontal diseases, different viral infections (including human papilloma virus and herpes simplex) and variety of oral cancers, especially Kaposi sarcomas are essentially related to the entire HIV/AIDS disease course.  These oral lesions are considered to be the reliable predictors of severe immunosuppression and disease progression along with low CD4+ lymphocyte count in HIV/AIDS patients.  No study has been reported from Pakistan that describes oral lesions present in HIV/AIDS population. Hence, this study was designed to find out clinical as well as cytological changes in the oral mucosa of these patients and their relation to CD4+ lymphocyte count.
| Materials and Methods|| |
This study was approved by the Ethical Review Board of the University of Health Sciences Lahore. A total of 25 HIV/AIDS positive patients reporting to HIV Voluntary Counseling and Testing Centers working under Punjab AIDS Control Programme (PACP) Pakistan from April to September, 2013, were selected after taking written informed consent. All the patients were carefully examined for oral mucosal changes and relevant selected clinical history was recorded. Patients were staged according to World Health Organization (WHO) clinical staging system.  The oral lesions were diagnosed according to the criteria by Oral HIV/AIDS Research Alliance.  After oral examination, normal saline was given to the patients to rinse the oral cavity, and oral smears were taken by scrapping the buccal mucosa. All the slides were fixed in 95% ethanol and then stained with hematoxylin and eosin, Papanicolaou stain by the recommended procedures. Periodic acid-Schiff and Grocott's methenamine silver stains were applied where fungal infection was suspected. Blood samples were taken from all patients, and CD4+ Cell Count was determined through flow cytometry at the Department of Immunology, UHS Lahore, Pakistan.
Results were analyzed using Statistical Package for Social Sciences Software Version 18. Chi-square tests were used to find out the associations between different variables. P ≤ 0.05 was considered as statistically significant.
| Results|| |
Mean age of the patients was 33.08 ± 8.3 (range: 21-52) years. About 88% (n = 22) of the patients were males, 8% (n = 2) were females while 4% (n = 1) were transgender (Hijra). Male:female ratio was 7.3:1. After a careful history taking and examination of oral mucosal changes, the patients were classified according to WHO clinical staging system.  It was observed that about 84% (n = 21) patients were in clinical stage 1, 8% (n = 2) each in clinical stages 2 and 3 while none of the patients in the clinical stage 4 was seen. Oral lesions were found in 36% (n = 9) of the patients while 64% (n = 16) had no lesion. Clinical and cytological changes found in the oral cavity of HIV/AIDS patients are summarized in [Table 1].
|Table 1: Oral clinical and cytological mucosal changes in HIV/AIDS patients not taking ART|
Click here to view
CD4+ lymphocyte count was quantitatively grouped as Group 1 with CD4+ lymphocyte count < 350 cells/mm 3 and Group 2 having CD4+ lymphocyte count > 350 cells/mm 3 . This cut point of 350 cells/mm 3 was used because it is considered as the level of advanced immunosuppression according to WHO immunological classification.  Mean CD4+ lymphocyte count was 338.12 ± 127 cells/mm 3 .
Clinical and cytological variables were compared to CD4+ lymphocyte groups by applying Chi-square tests [Table 2]. Inflammation was significantly associated (P = 0.03) with CD4+ lymphocyte Group 1 while all other variables yielded insignificant associations but most of them were present in Group 1 with < 350 cells/mm 3 .
|Table 2: Association between clinical-cytological variables and CD4+groups|
Click here to view
When the cytopathological variables were compared to WHO clinical stages [Table 3], a statistically significant association (P < 0.05) was observed in the case of pseudomembranous candidiasis clinically and dysplasia and presence of fungi cytologicaly. Frequencies of many clinicocytopathological variables were increased with increase in clinical stage, which shows an increase in oral mucosal pathological changes with increased immunosuppression (low CD4+ count).
|Table 3: Association between clinical-cytological variables and WHO clinical stages|
Click here to view
| Discussion|| |
Oral lesions in the present study are found in 36% patients which is in accordance to the results of Noce et al.  when he reported the oral lesions in 37% patients in his study. Chronic periodontitis (presence of periodontal pockets > 4 mm) was seen in 20% of the patients in this study but Rath and Raj from India have reported a higher prevalence (29%) than this study.  Pseudomembranous candidiasis (scrapable white plaque revealing an erythematous base) was observed in 12% of the patients in the present study while Shiboski et al.  have reported it up to 6% patients, which is about half of the results of the present study. Oral pigmentation (asymmetrical oral mucosal hyperpigmentation of > 1 cm) was seen in 8% of the patients in this study, but Bravo et al.  had reported a higher frequency (38%) than the present study. Oral ulcers are observed in 4% of the patients in the present study, which is the same reported by Greenspan et al.  No study has been carried out that describes the cytological changes in the oral mucosa of HIV/AIDS patients hence the results of the cytological changes cannot be compared to other studies. In this study, most common cytological change observed was the presence of micronuclei found in 72% smears. Micronucleus is an extra small nucleus that has well defined nuclear membrane and is present in the vicinity of the main nucleus or may be united with it. Micronucleus has the same color intensity as that of the main nucleus.  Shimura et al.  reported that Vpr an accessory gene of HIV may be involved in micronucleation while Casartelli et al.  reported that a gradual increase in micronucleus counts from normal mucosa to precancerous lesions to carcinomas suggests a link of this biomarker with neoplastic progression.
Inflammation of mild to moderate severity was found in 60% of the cases. It has been reported that HIV infection leads to long-term immune activation, chronic inflammation and high levels of inflammation associated diseases.  Fungi were detected in 56% of the patients. The most common was the Candida albicans. No study has been reported that describes the frequency of fungi in the oral squamous cells of HIV/AIDS patients. Hence, the results of the present study cannot be compared to the other studies. Nuclear atypia showing altered N/C, nuclear pleomorphism, increased typical mitosis, prominent nucleoli, binucleation, multinucleation, karyorrhexis, and karyolysis was seen in 44% of the cases. Dysplasia showing features of atypical mitosis, hyperchromasia, nuclear pleomorphism, multinucleation was seen in 16% patients. Dysplasia and atypical nuclear changes in the oral squamous cells may lead to oral malignancies. Shiels et al.  reported that HIV/AIDS positive patients are at increased risk of developing oral cancers. Pineda and Welton  reported that abnormal cytological changes including nuclear atypia and dysplasia may be mostly seen with low CD4+ lymphocyte count, especially < 200 cells/mm 3 .
When the clinical and cytological variables were compared with the CD4+ lymphocyte groups using Chi-square test inflammation was found to be statistically significant (P = 0.03). All other variables yielded insignificant associations, but most of the clinical and cytological changes were seen in CD4+ lymphocyte Group 1 having CD4+ count < 350 cells/mm 3 which is the state of advanced immunosuppression according to WHO immunological classification. Hence, it can be inferred that oral changes are frequent with low CD4+ count. This finding is concordant with the different studies reported in the literature. , When the clinical and cytological variables were compared with WHO clinical stages using Chi-square test, oral candidiasis, fungi and dysplasia were significantly (P < 0.05) increased in CD4+ Group 1. Furthermore many clinical and cytological variables were increased with the advancing WHO clinical stage, which may show that oral changes may be increased with increasing immunosuppression. This finding is in accordance with the results of Hegde et al. 
| Conclusion|| |
Varied oral mucosal changes were observed in the HIV/AIDS patients including oral ulcers, pseudomembranous candidiasis, chronic periodontitis and oral pigmentation clinically while mild to moderate inflammation, fungi, micronuclei, nuclear atypia and dysplasia cytologicaly. Oral clinical and cytological mucosal changes were frequent with the low CD4+ lymphocyte count especially < 350 cells/mm 3 hence these oral changes can be used as noninvasive and cost effective markers of immunosuppression and disease progression.
| Acknowledgments|| |
Authors acknowledge PACP Pakistan and laboratory staff of Department of Immunology and Oral Pathology, University of Health Sciences Pakistan for their technical and logistic support.
| References|| |
Bokhari A, Nizamani NM, Jackson DJ, Rehan NE, Rahman M, Muzaffar R, et al.
HIV risk in Karachi and Lahore, Pakistan: An emerging epidemic in injecting and commercial sex networks. Int J STD AIDS 2007;18:486-92.
Shiboski CH, Patton LL, Webster-Cyriaque JY, Greenspan D, Traboulsi RS, Ghannoum M, et al.
The Oral HIV/AIDS Research Alliance: Updated case definitions of oral disease endpoints. J Oral Pathol Med 2009;38:481-8.
Bravo IM, Correnti M, Escalona L, Perrone M, Brito A, Tovar V, et al.
Prevalence of oral lesions in HIV patients related to CD4 cell count and viral load in a Venezuelan population. Med Oral Patol Oral Cir Bucal 2006;11:E33-9.
WHO. WHO Case Definitions of HIV for surveillance and revised clinical staging and immunological classification of HIV-related disease in adults and children. World Health Organization; 2007. Available from: http://www.who.int/hiv/pub/guidelines/HIVstaging150307.pdf
. [Last accessed on 2013 Aug 03].
Speight PM. Update on oral epithelial dysplasia and progression to cancer. Head Neck Pathol 2007;1:61-6.
Hegde MN, Hegde ND, Malhotra A. Prevalence of oral lesions in HIV infected adult population of Mangalore, Karnataka, India. Biodiscovery 2012;4:3.
Noce CW, Ferreira SM, Silva Júnior A, Dias EP. Association between socioeconomic status and HIV-associated oral lesions in Rio de Janeiro from 1997 to 2004. Braz Oral Res 2009;23:149-54.
Rath H, Raj SC. Assessment of oral health status and Treatment needs of HIV/AIDS patients visiting Government Hospitals and Rehabilitation centers in Banglore city. Indian J Sex Transm Dis 2013;34:59-60.
Greenspan D, Canchola AJ, MacPhail LA, Cheikh B, Greenspan JS. Effect of highly active antiretroviral therapy on frequency of oral warts. Lancet 2001;357:1411-2.
Koneru A, Hallikeri K, Naikmasur VG. Comparative study of oral micronucleated cell frequency in oral submucous fibrosis patients and healthy. J Clin Exp Dent 2011;3:201-6.
Shimura M, Tanaka Y, Nakamura S, Minemoto Y, Yamashita K, Hatake K, et al
. Micronuclei formation and aneuploidy induced by Vpr, an accessory gene of human immunodeficiency virus type 1. FASEB J 1999;13:621-37.
Casartelli G, Bonatti S, De Ferrari M, Scala M, Mereu P, Margarino G, et al.
Micronucleus frequencies in exfoliated buccal cells in normal mucosa, precancerous lesions and squamous cell carcinoma. Anal Quant Cytol Histol 2000;22:486-92.
Highleyman L. Inflammation, immune activation, and HIV. BETA 2010;22:12-26.
Shiels MS, Cole SR, Kirk GD, Poole C. A meta-analysis of the incidence of non-AIDS cancers in HIV-infected individuals. J Acquir Immune Defic Syndr 2009;52:611-22.
Pineda CE, Welton ML. Management of anal squamous intraepithelial lesions. Clin Colon Rectal Surg 2009;22:94-101.
Sontakke SA, Umarji HR, Karjodkar F. Comparison of oral manifestations with CD4 count in HIV-infected patients. Indian J Dent Res 2011;22:732.
Gaurav S, Keerthilatha PM, Archna N. Prevalence of oral manifestations and their association with CD4/CD8 ratio and HIV viral load in South India. Int J Dent 2011;2011:964278.
[Table 1], [Table 2], [Table 3]