Necrotising stomatitis as a presenting symptom of HIV

doi:10.4236/ojst.2011.14025

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Open Journal of Stomatology, 2011, 1, 168-171

doi:10.4236/ojst.2011.14025 Published Online December 2011 (http://www.SciRP.org/journal/ojst/ OJST

Published Online December 2011 in SciRes. http://www.scirp.org/journal/OJST

Necrotising stomatitis as a presenting symptom of HIV

Gbemisola A. Agbelusi, Olutola M. Eweka

Department of Preventive Dentistry, College of Medicine, University of Lagos, Lagos, Nigeria.

Email: [email protected]

Received 23 August 2011; revised 30 September 2011; accepted 17 October 2011.

ABSTRACT

Background: Necrotising Stomatitis is an uncommon

oral infection associated with diminished systemic

resistance (immunocompromised state) including HIV

infection. Significant predisposing factors include poor

oral hygiene, unusual life stress, recent illness (e.g.

Measles), malnutrition, smoking and even inadequate

sleep. It occurs commonly in developing nations with

poor living conditions. Objective: To present a case o f

severe Necrotising Stomatitis in a previously undiag-

nosed HIV Seropositive patient. Patient and Method:

This case report describes severe, rapidly spreading

necrotising stomatitis in a 35 years old lady, the con-

dition which led to her being diagnosed with HIV.

The treatment modalities, challenges of management

and the differential diagnosis were discussed. Result:

During the course of her management, patient’s oral

condition improved. However, later recurrence was

seen due to severe anaemia caused by malnutrition

and aggravated by Zidovudine antiretroviral drug.

Conclusions: There is need for interdisciplinary in-

teractions between the dentists and the physicians

managing HIV patients, to allow effective manage-

ment and afford patient the best treatment.

Keywords: Necrotizing Stomatitis, HIV, Anaemia, Zido-

vudine

1. INTRODUCTION

Necrotising Stomatitis (NS) is an inflammatory disease

of the mouth characterised by the destruction of epithet-

lium, connective tissue and papillae. The disease may

cause a loss of periodontal attachment and the destruct-

tion of bone, in advanced stages it may lead to cancrum

oris [1]. It is an uncommon oral infection associated with

diminished systemic resistance, immunocompromised s t at e

including HIV infection.

Necrotising Stomatitis (NS) also called Necro tising Ul-

cerative Stomatitis is very difficult to differentiate from

Necrotising Ulcerative Periodontitis (NUP). NS is gen-

erally localised, very rapidly destructive disease of the

oral mucosa, alveolar bone and overlying gingivae, al-

though considered less severe deep pain. NS may also

involve the palatal mucosa [2]. Significant predisposing

factors include poor oral hygiene, unusual life stress,

recent illness (e.g. Measles), malnutrition, smoking and

even inadequate sleep has been implicated. It occurs

commonly in develop ing nations with poor livin g condi-

tion [3].

NS is rarely seen in HIV seronegative patients espe-

cially where there is no underlying medical conditions.

However, it is more commonly seen in HIV seropositive

patients and could be a pointer to the diagnosis of HIV

in undiagnosed patients as is described in this case re-

port.

Signs and symptoms include, painful ulcers with ne-

crotic base, foul taste, halitosis, fever, associated infla-

med and painful gingivae/oral mucosa, sequestrum for-

mation and cervical lymphadenopathy. Patient experien-

ces difficulty in eating and swallowing.

Treatment is generally highly effective and life-saving,

if early diagnosis is made. Th i s reduces subsequent disabi-

lity or even death. The treatment of NS is identical to

that utilised to treat NUP. Treatment protocol includes

irrigation and debridement of necrotic areas, oral hygi-

ene instructions and use of mouthwashes, metronidazole

antibiotics and analgesics for pain [4]. As these diseases

are often associated with systemic medical conditions,

proper management of the systemic disorders is appro-

priate as highlighted in this report.

Recall visits are very important to monitor progress of

treatment and institute rehabilitation where necessary.

2. CASE REPORT

A 35 years old female patient, Miss P, presented at the

Oral Medicine Clinic of the Lagos University Teaching

Hospital on 13/11/2006 with a 2 week h istory of sor es in

her mouth.

She noticed the whitish ulcers in her mouth which she

claimed was getting bigger and deeper, there was associ-

ated severe pain, fever, malaise and painful throat, but

G. A. Agbelusi et al. / Open Journal of Stomatology 1 (2011) 168-171 169

there was no pus dischar ge nor bleeding.

It was her first visit to the dental clinic. She had no re-

levant past medical history, she was single, a caterer who

neither drank alcohol nor smoked cigarette.

On examination, patient was markedly pale with swol-

len lower lip which was diffuse and tender to touch. Sub-

mandibular lymph nodes were enlarged and tender. In-

tra-orally, the oral hygiene was poor with marked halito-

sis and generalised marginal gingivitis. A large irregular

ulcer measuring about 15 mm in diameter was seen on the

left side of the lower lip. Ulcer was tender with a ne-

crotic base and erythematous border. A smaller ulcer was

also seen on the buccal mucosa of the right cheek about

12 mm in diameter, oval in shape and also covered with

necrotic tissue. (Figures 1 and 2). There was a whitish

hair-like corrugated patch on the lateral borders of the

tongue which did not wipe off.

An impression of Necrotising Stomatitis and Hairy

Leukoplakia was made.

Differential diagnosis: Major Aphthous ulcer.

Investigations: The following investigations were or-

dered:

1) Haematological profile (full blood count and

differentials).

2) HIV screening for HIV I & II with pre and post.

Figure 1. Lesion on the labial mucosa at presentation.

Figure 2. Lesion seen on the right buccal mucosa test coun-

selling.

3) Histological examination was not carried out sin ce

the clinical presentation was adequate for diag-

nosis.

Treatment:

1) Counselling and reassurance.

2) Local treatment:

 0.2% Chlorhexidine mouth wash (clear

Breath) 8 hrly × 1/52 to alternate with Hy-

drogen peroxide mouth rinse.

 Xylocaine gel fo r top i cal a pplication.

3) Systemic treatment:

 Tabs. Ciprofloxacin 500 mg bd × 1/52.

 Tabs Metronidazole 400 mg tds × 1/52.

 Tabs Vit C 300 mg tds × 1/52.

 Tabs folic acid i daily × 1/52.

 Tabs fergon i tds × 1/52.

 Tabs paracetamol ii tds × 3/7.

Patient was given one week appointment for review.

Result of investigations after on e week:

 HIV screening was PO SITIVE for HIV I.

HB—9.4 g/dl, MCV—79.8, MCH—25.3, Neu-

trophils—49.3, Platelets—170 × 103, WBC—

2.7 × 103. (Hypochromic Microcytic anaemia).

 CD4 count was 33 cells/mm3 (22/1 1/06).

3. FOLLOW UP VISITS

Subsequent visits, the oral ulcers were reducing in size

and healing satisfactorily. Pallor and hairy leukoplakia

had cleared. Patient was feeling much better and was re-

ferred to HIV Clinic where she commenced Highly Ac-

tive Antiretroviral Therapy (H AART) in December 2006.

Antibiotics were discontinued but she continued with the

supportive therap y (haematinics and mouth rinses).

Two months later (January, 2007), she presented with

fresh lesions on the upper left labial mucosa of about 5

cm which was increasing in size. Her CD4 had risen to

37 cells/mm3, oral hairy leukoplakia was again present

on the lateral border of the tongue. She commenced anti-

biotics and supportive therapy.

On further review (22/01/2007), she was extremely

pale, left side of the lip was swollen with large necrotic

ulcers on the buccal mucosa, extending from the angle of

the mouth to the area of the second upper molar. There

was also spread of the necrotic lesio n to the gingivae on

the same side and also on the palate.

A clinical impression of recurrent necrotizing stomati-

tis was made.

The oral lesions were treated and she was referred

back to the HIV Clinic for possible admission and blood

transfusion for the anaemia. On further investigation, it

was noted that she had been on Zidovudine (one of the

combination ARV drugs) which is not compatible with

presence of anaemia. This was therefore responsible for

G. A. Agbelusi et al. / Open Journal of Stomatology 1 (2011) 168-171

170

her worsening anaemia and subsequent recurrent necro-

tising stomatitis.

The medication was changed and she has since im-

proved with no other episode of the lesion. Her CD4 co-

unt as at 22/9/08 was 448 cells/mm3 and she has had no

further recurrence. She had about 15 follow-up visits

after the first presentation.

4. DISCUSSION

Necrotising Stomatitis is a rare condition, which is seen

in immunocompromised patients e.g. in HIV infection.

Compared to other ulcerative and necrotising lesions

seen in HIV infected patients, NS is the most uncommon

seen in our environment.

A study carried out by Wright and Agbelusi, 2005 [5]

citing groups II and III lesions in 100 HIV positive Nige-

rians had no record of the lesion, other studies carried

out in Lagos by Agbelusi and Wright [6] among routine

dental patients presenting with oral lesions suggestive of

HIV/AIDS did not reveal any manifestation of NS. Also

in Jos, in Northern Nigeria no case of NS was seen as a

manifestation of HIV infection [7]. Benin City in Edo

state also had no record of NS in studies carried out

among HIV positive patients seen [8]. This is to show

that NS is a very uncommon lesion, even in HIV posi-

tive patients in Nigeria.

Though patient was unaware of her HIV status at the

time of presentation , the nature o f the lesion with the wi-

de spread presentation and the presence of Oral hairy

leukoplakia gave a pointer that she could be HIV posi-

tive, this was confirmed with the test result and the CD4

count of 32 cells/mm3 which also revealed that patient

was in full blown AIDS. This fact underscores the fact

that oral lesions may be the first presentation of HIV in-

fection and may lead to a diagno s is of HIV.

The aetiology of this condition had been seen to be

multifactorial. Anaerobic bacteria as the causative agent,

coupled with the underlying HIV infection, malnutrition

due to pain from the ulcer in the mouth resulting in an-

aemia, which is further complicated by side effects of

Zidovudine were all factors that predisposed her to the

condition.

The diagnosis of the lesion was based on its clinical

presentation and response to therapy. Correct diagnosis

is of utmost importance as an incorrect diagnosis and

treatment would have worsened the condition and may

result in fatality. For example, if the lesion had been

misdiagnosed as apthous major ulcer or erythema multi-

forme, administration of steroids would have worsened

the condition as the patient was already severely immu-

nocompromised.

Histologic features of NS are generally reported to be

non-specific and usually include surface ulceration cov-

ered by a fibro-purulent membrane with an acute or mix-

ed inflammatory cell infilterate and extensive hyperae-

mia of underlying lamina propria [9]. Since the histo-

logic feature of NS is not pathognomic, a biopsy is usu-

ally not indicated [10].

The use of oxidizing mouthwash and anaerobic anti-

microbial is paramount to the successful management of

the condition. Hydrogen peroxide helped in debriding

the lesion and hastened the healing.

Side effects of Zidovudine worsened her condition as

the patient had a recurrence of the lesion and a worsen-

ing of the anaemia. Also the CD4 count did not improve

initially as expected with the use of HAART. Vigilance

on the part of the dentist and due consultation with the

haematologist revealed the problem which was promptly

rectified with dramatic improvement in the patient’s

condition. This demonstrates the need for interdiscipli-

nary management of patients so that the patient can get

the best care.

Patient had worked as a caterer in a reputable hotel for

6 years, but had to take some time off when the illness

started. The severity and recurrence of the lesions led to

prolonged absenteeism at work which eventually caused

her her job and she was faced with financial difficulties

in keeping up her daily needs and more importantly main-

taining her health.

5. CONCLUSIONS

This presentation highlights this uncommon oral mani-

festation of HIV in a previously undiagnosed HIV pa-

tient, the role of multi-factorial aetiology in the appear-

ance of the condition, interdisciplinary management by

the oral physician and the haematologist resulting in

proper diagnosis and ulti mately i mpro ving her co nditio n.

The consequences of wrong diagnosis and improper ma-

nagement could have led to further spread of the lesion

with fatal consequences.

We cannot underestimate the role of detailed history,

proper clinical examination and correct diagnosis, which

ultimately determined the management protocol.

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