Kaposi sarcoma

Kaposi sarcoma (KS) is a neoplasm that was extremely uncommon in the United States before the discovery of AIDS. KS is the most common malignancy in patients who are HIV positive. Prior to the introduction of HAART, KS occurred in nearly 15% of patients with AIDS, but this has decreased dramatically in the age of HAART.

Oral KS in patients not on immunosuppressive therapy is correlated with a lowered CD4 count and is diagnostic for AIDS. Intraorally, KS appears as brown, bluish, purple, or red patches or papules on the hard palate, mucosa, and gingiva. The initial lesions are flat macules or patches on the mucosal surface, but, over time, they become nodular and often ulcerate and bleed. KS can also manifest on the skin, with lymph node enlargement, and in the salivary glands. Edema commonly occurs in association with extensive cutaneous involvement.

A biopsy should be performed to definitively diagnose KS. Histologically, KS is characterized by increased vascularity, spindle-shaped cells with little mitotic activity, and hemosiderin deposition. Treatment is accomplished through a variety of methods. Lesions may be injected with sclerosing agents such as vinblastine or sodium tetradecyl sulfate. Advanced cases may require treatment with radiation and/or chemotherapeutic agents such as doxorubicin. The course of the disease can be aggressive, and death due to lung involvement may occur.

Cytomegalovirus

Cytomegalovirus (CMV) is a double-stranded DNA virus that is fairly common in the general population, with approximately 60% of people being seropositive but asymptomatic. Symptomatic disease does not usually occur unless the patient has undergone organ or bone marrow transplantation, has HIV disease, or is immunocompromised in some other way. CMV retinitis occurs in 30% of patients with AIDS, causing blindness. CMV pneumonia occurs in 5% of patients with AIDS. Pneumonia and adrenalitis due to CMV may be a leading cause of death in patients with AIDS. CMV may also be a cause of subacute encephalitis, resulting in headaches and personality changes in patients with AIDS.

In patients who are immunocompromised, the infection rarely manifests intraorally. However, when it does, CMV produces deep, penetrating oral ulcerations on the lips, tongue, pharynx, or any mucosal site (Greenspan, 1993; Itin, 1993). The aphthouslike ulcerations have a punched-out look with rolled, erythematous borders. Diagnosis is definitive upon detection of the characteristic "owl's eye" appearance of cellular inclusions during the histologic examination. CMV is treated with intravenous agents such as ganciclovir or cidofovir.

Human papillomavirus

As with the human herpesviruses, human papilloma virus (HPV) infections are more common in individuals with HIV disease. The papillomas or condylomas appear on the gingiva and sometimes the lips and labial mucosa; they are soft pink masses with a characteristic papillary surface texture. These can be treated by excision, laser ablation, or chemical means (eg, 5-fluorouracil, imiquimod). One study showed that a combination regimen of intralesional and subcutaneous injections of interferon alfa produced resolution of lesions.

Also of interest is that although the incidence of lesions is declining in the age of HAART, most studies agree that the incidence of HPV infection is actually increasing. The reason for this phenomenon is unclear.