HIV IN ENT

Introduction
AIDS is one of the deadliest epidemics in human history AIDS remains a major medical challenge, despite all the research efforts. Almost all cases will have some ENT manifestation or the other. The 5-year mortality rate from the time of diagnosis of AIDS is approximately 80%. The cause of death in most cases is overwhelming infection

AIDS in general
AIDS is caused by the HIV. HIV is a retrovirus, which has an affinity for cells with the CD4+ cell surface marker
T-helper lymphocytes macrophages

The primary reservoir of HIV is the T-helper lymphocyte (CD4+ cell) After HIV infects these cells, there is a period of dormancy, after which these lymphocytes are activated. This results in replication of the viral genome and shedding of viral progeny, which infect other cells.

Effects on the immune system

Components of immune system Effects of HIV Infection T-helper lymphocytes Decreased Macrophages Impaired antigen presentation, phagocytosis, and chemotaxis Dysfunctional or decreased Decreased antigen-specific immunoglobulin production Defective

Neutrophils B lymphocytes Complement activation

Diagnosis & Classification

HIV infection is diagnosed when anti-HIV antibodies are detected by
ELISA Western blot.

Antibodies against HIV appear within 3 months of infection

The classification for HIV infection is based:

Clinical manifestations CD4+ count.

Diagnosis & Classification

(A) Asymptomatic HIV infection, (B) ARC (AIDS related complex) Symptomatic conditions that are attributed to HIV infection but that are not in category (C), (C) AIDS. Conditions that define acquired immunodeficiency syndrome

AIDS in ENT
Cat A - Asymptomatic HIV Disease Patient is asymptomatic CD4 count has never dropped below 500 cells/ml.

AIDS in ENT
Cat B- ARC or AIDS RELATED COMPLEX CD4 count is between 200-499 cells/ml. Symptomatic diseases attributed to HIV, but not included into Cat C. They include:
Candidiasis, oropharyngeal (thrush) Candidiasis, vulvovaginal; persistent, frequent, or poorly responsive to therapy Constitutional symptoms, such as fever (38.5 C) or diarrhea lasting greater than 1 month Hairy leukoplakia, oral Herpes zoster (shingles), involving at least two distinct episodes or more than one dermatome Idiopathic thrombocytopenic purpura Pelvic inflammatory disease, particularly if complicated by tubo-ovarian abscess Peripheral neuropathy

AIDS in ENT
Cat C- AIDS CD4 count is below 200 cells/ml. Has had one of the AIDS defining diseases such as:
Coccidioidomycosis, disseminated or extrapulmonary Cryptococcosis, extrapulmonary Cryptosporidiosis, chronic intestinal (> 1 month) Cytomegalovirus disease Cytomegalovirus retinitis Encephalopathy, human immunodeficiency virusrelated Herpes simplex, chronic ulcers (> 1 month), Histoplasmosis, disseminated or extrapulmonary Isosporiasis, chronic intestinal (> 1 month)

AIDS in ENT
AIDS defining diseases (Contd) :
Isosporiasis, chronic intestinal (> 1 month) Kaposis sarcoma Non-Hodgkins lymphoma Mycobacterium avium complex, disseminated or extrapulmonary Mycobacterium tuberculosis, any site Pneumocystis carinii pneumonia Pneumonia, recurrent Progressive multifocal leukoencephalopathy Salmonella septicemia, recurrent Toxoplasmosis of brain Wasting syndrome caused by human immunodeficiency virus

Lesions in the Neck

Persistent Generalised Lymphadenopathy (PGL):
The commonest manifestation. Cervical lymphnodes are 3rd commonest after axillary & inguinal 85% involve the posterior triangle. They also are usually asymptomatic. However, other causes of cervical lymphadenitis must be considered and in HIV infections they can be

Cervical lymphadenopathy
Causes for cervical lymphadenopathy: 1. Infectious: Mycobacterial lymphadenitis: tuberculous* and atypical organisms Pneumocystis lymphadenitis* Pneumocystis thyroiditis* Viral lymphadenitis: cytomegalovirus, Epstein-Barr virus Toxoplasma lymphadenitis Bacterial lymphadenitis or abscess secondary to oropharyngeal infection Cat-scratch disease

2. Neoplastic Lymphoma
Non-Hodgkins Hodgkins disease

Metastatic Kaposis sarcoma Metastatic carcinoma Metastatic melanoma Salivary gland tumors Thyroid tumors

3. Idiopathic: Persistent generalized lymphadenopathy

Cervical lymphadenopathy
Diagnosis by FNAC However, open biopsy is advocated when
Fine-needle aspiration cytology suggestive of malignancy Fine-needle aspiration cytology negative and any of the following:
Enlarging node Asymmetric, localized or unilateral adenopathy Nodes larger than 2 cm Low CD4+ count and new lymphadenopathy Fever, night sweats, weight loss Significant mediastinal or abdominal adenopathy

SINONASAL DISEASE
68% of HIV patients develop sinusitis Increased incidence of complications (X2) Sinusitis occurs because of
Impaired systemic and local immunity Mucociliary dysfunction Increased atopy

Increased incidence of fungal sinusitis Will require to be treated with surgical debridement and antifungal therapy

SINONASAL DISEASE
68% of HIV patients develop sinusitis Increased incidence of complications (X2) Sinusitis occurs because of
Impaired systemic and local immunity Mucociliary dysfunction Increased atopy

Increased incidence of fungal sinusitis

SINONASAL DISEASE
Diagnosis of fungal sinusitis H/O
Immunocompromised state

Local Exam
Nasal mucosa ischemic or necrotic Septum, hard palate eroded or perforated

Lab Inv
CD4+ less than 150 cells/ml Neutropenia, positive or negative Hyphae
Aspergillus: septate, 45 branching Mucor: aseptate, 90 branching, bulbous endings

Radio
CT Scan shows sinus erosion

EAR DISEASE
1. OTITIS EXTERNA
OE & malignant OE incidence is increased Increased incidence of localised skin lesions leading to OE Can lead to severe perichondritis Malignant OE can lead to osteomylitis of temporal bone

EAR DISEASE
2. OTITIS MEDIA
ET obstruction caused by adenoidal hypertrophy or sinonasal disease is more in HIV-infected children and adults. Increased incidence of OM commonly occurs in the HIV-infected population, particularly in children. SOM and conductive hearing loss (CHL) are more prevalent in adults and older children AOM frequently occurs in young children. Tend to develop complications such as mastoiditis, petrositis Require aggressive therapy

EAR DISEASE
3. DEAFNESS: Early onset of deafness
Causes Otosyphilis Cryptococcal meningitis* Central nervous system toxoplasmosis* Mycobacterial meningitis* Central effects of HIV infection
Aseptic meningitis Autoimmune demyelination of the cochlear nerve Subacute encephalitis*

Progressive multifocal leukoencephalopathy* Hodgkins lymphoma NHL of the brain and meninges Mass lesions of the CP angle Ototoxicity CVA Idiopathic

ORAL DISEASE
Oral lesions occur in almost all HIV patients Multiple lesions due to multiple causes can exist Can initially present to ENT for an oral lesion. Diagnosis helped by
(1) by being familiar with the oral lesions that commonly occur in HIV patients, (2) by performing biopsies of all lesions that are suspicious (3) by not assuming that multiple lesions have the same pathogenesis.

ORAL DISEASE
DD of oral lesions Oral candidiasis Oral hairy leukoplakia Herpes stomatitis Gingival and periodontal disease Acute necrotizing ulcerative gingivitis* Aphthous ulcers Squamous cell carcinoma* Leukoplakia Non-Hodgkins lymphoma* Kaposis sarcoma

ORAL DISEASE
> 2 HIV-related oral lesions suggest a CD4+ count of less than 200 cells/ml Rule out malignancy with early biopsy of new lesions Complications of gingival and periodontal disease can be prevented by early periodontal consultation Aphthous ulcers are of three types,
Herpetiform ulcers Minor aphthous ulcers (<6mm). Major aphthous ulcers (Suttons disease >6 mm)

ORAL DISEASE
Major aphthous ulcers 14 % incidence in HIV patients. They are:
> 6 mm They are painful Persist for weeks threaten nutritional intake.

Aphthous ulcers- treated with topical corticosteroids, such as triamcinolone in a topical base & applied up to six times per day.

ORAL DISEASE
Kaposis sarcoma is the most common malignancy in AIDS Multiple red-purple nodules or plaques on oral mucosa Lesions often involve the perioral skin, hard palate, gingiva, or tongue. Oral lesions range from asymptomatic plaques to ulcerated nodules. Local therapy of symptomatic lesions includes surgical excision, laser ablation, or radiotherapy.

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