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Table of Contents   
CASE REPORT  
Year : 2013  |  Volume : 6  |  Issue : 6  |  Page : 664-667
An unusual case report showing combination of melanotic oral pigmentation and nonspecific ulcer in human immunodeficiency virus positive patient


1 Department of Oral Pathology and Microbiology, Bharati Vidyapeeth Deemed University Dental College and Hospital, Pune, India
2 Department of Pedodontics and Preventive Dentistry, Bharati Vidyapeeth Deemed University Dental College and Hospital, Pune, India
3 Department of Oral Diagnosis, Medicine and Radiology, Vidyashikshan Prasarak Mandals (VSPM) Dental College and Hospital, Digdoh Hills, Nagpur, Maharashtra, India

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Date of Web Publication6-Sep-2014
 

   Abstract 

Human immunodeficiency virus (HIV) infection has caused a severe degree of morbidity and mortality amongst the individuals worldwide. Those affected usually belong to low socioeconomic status especially from developing countries like India. There are numerous diagnostic criteria and thousands of tests to detect HIV positivity. One such criterion is European Commission Clearinghouse, wherein HIV positivity may be detected by thorough clinical observation of the oral cavity. This criterion is being followed worldwide and has been proven to be effective for dental professionals and general physicians, as it is stated that these oral lesions precede the other lesions of HIV positivity. We report one such case of unusual combination of melanotic hyperpigmentation and nonspecific ulcer in an adult patient, where HIV positivity was confirmed later by Western blot. To our knowledge, none such case has been reported in literature previously.

Keywords: HIV, non-specific ulcer, oral pigmentation

How to cite this article:
Chaudhary M, Chaudhary SD, Choudhary A. An unusual case report showing combination of melanotic oral pigmentation and nonspecific ulcer in human immunodeficiency virus positive patient. Ann Trop Med Public Health 2013;6:664-7

How to cite this URL:
Chaudhary M, Chaudhary SD, Choudhary A. An unusual case report showing combination of melanotic oral pigmentation and nonspecific ulcer in human immunodeficiency virus positive patient. Ann Trop Med Public Health [serial online] 2013 [cited 2019 Dec 14];6:664-7. Available from: http://www.atmph.org/text.asp?2013/6/6/664/140250

   Introduction Top


Human immunodeficiency virus (HIV) infection among the individuals is of greater concern in the developing countries, especially India. The dearth of knowledge in past few decades regarding the oral manifestation of HIV infections has lead to a formation of clinical diagnostic criteria [European Commission Clearinghouse (ECC) criteria] for prompt diagnosis of specific oral lesions that might reveal the underlying stage and prognosis of HIV. The occurrence of oral lesions, for example, acute pseudomembranous candidiasis, melanotic hyperpigmentation, nonspecific ulcers, and so on may incur one to be suspicious of being HIV positive. We report here an unusual case of an adult female showing combination of two such oral lesions (melanotic hyperpigmentation, nonspecific ulcers) that lead us to the suspicion of HIV positivity which was later confirmed by Western blot.


   Case Report Top


A 35-year-old female patient reported to a private institution with a chief complaint of ulceration on lateral border of tongue since 2 months and black pigmentation on the dorsum as well as lateral border of tongue and bilaterally on buccal mucosa. There was no history of any traumatic bite, stress, use of chemotherapeutic drug, or any other relevant underlying systemic cause for pigmentation and ulcer. On thorough clinical examination, a suspicion of HIV positivity was felt. Patient was advised for routine hemogram and confirmatory HIV positivity test Western blot. Patient was found to be positive for HIV. Patient later on revealed a history of sexual contact with multiple sex partners. The patient's family history was noncontributory. A detailed oral examination revealed poor oral hygiene status with stains, calculus, carious teeth, missing upper right first molar tooth, generalized attrition, and localized periodontitis in lower anterior region. Soft tissue examination of the oral cavity revealed a single, well-circumscribed, yellowish-white ulcer measuring 0.4-0.5 cm on lateral border of tongue, melanotic hyperpigmentation bilaterally on buccal mucosa, dorsum of tongue, and lateral border of tongue [Figure 1],[Figure 2],[Figure 3] and [Figure 4]. Informed consent was obtained from the patient for laboratory investigations and various dental treatment procedures and also for publication of a case report without revealing the identity. The laboratory investigations for underlying bacterial, viral, and fungal infection were performed by swabbing the ulcerated lesion and sending it to laboratory. For viral culture, swab was inserted into 4 mL of Hank's balanced salt solution and sent to the laboratory where it was further cultured on primary human embryonic kidney cells and primary rabbit kidney cells. All the three cultures were found to be negative. All the above findings led to our conclusion of a non specific ulcer observed on lateral border of the tongue. Patient was advised application of triamcenolone TESS buccal paste three times a day for a week and then recalled. The ulcer did not subside after application of triamcinolone TESS buccal paste three times a day for a week. Patient refused to undergo systemic steroid therapy and also biopsy under local anesthesia, also the follow-up was not possible because of lack of cooperation on the part of the patient. To our knowledge, none of such case report has been reported wherein a combined lesion of melanotic hyperpigmentation and nonspecific ulcer is seen that may aid in diagnosis of HIV positivity for general practitioners.
Figure 1: Melanotic hyperpigmentation on the dorsum of tongue

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Figure 2: Melanotic hyperpigmentation on right buccal mucosa

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Figure 3: Melanotic hyperpigmentation on left buccal mucosa

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Figure 4: Melanotic hyperpigmemtation and nonspecifi culcer on lateral border of tongue

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   Discussion Top


A set of definitions and diagnostic criteria for more commonly seen oral manifestations of HIV infection was proposed initially by Greenspan and Sciubba in 1992. [1] Later in 1993, a classification and diagnostic criteria for oral lesions in HIV infection was introduced by ECC and accepted worldwide. [2] Since then, there were numerous studies that have used oral manifestations as a diagnostic criterion for detection of HIV positivity as these lesions have been considered to be useful in epidemiologic surveys. [3],[4],[5],[6],[7],[8] Oral ulcers associated with HIV infection had been already reported in past. [1] They have been classified as Group II lesions as per European comission (EC)-Clearinghouse classification (1993). [2] The numerous etiological factors for formation of oral ulcers include viral infections (e.g., herpes simplex virus, cytomegalovirus, varicella zoster virus, human papilloma virus), bacterial infections (e.g., acute necrotizing ulcerative gingivitis, enterobacteriaceae infection), fungal infections (e.g., candidiasis, cryptococcosis, histoplasmosis), drug induced (foscarnet, interferon, clofazamine, and ketokonazole). [9] The ulcers seen in HIV infection may be single or multiple, yellowish in color with or without erythematous halo, occurring on keratinized or nonkeratinized mucosa and ranging from 0.2 to 0.5cm and above. [1] In our current case, the ulcer was single, well-circumscribed, yellowish-white, measuring 0.4-0.5 cm on lateral border of tongue. All other possible etiological factors were sorted out and we concluded the ulcer to be a nonspecific one. A systematic diagnostic process and its interrelationship with treatment modalities for recurrent aphthous ulcers in HIV had been described earlier, [10] based upon which, we advised application of triamcenolone (TESS buccal paste) three times a day for a week and then recalled. The ulcer did not subside after application of triamcenolone (TESS buccal paste) three times a day for a week. Patient refused to undergo systemic steroid therapy and also biopsy under local anesthesia.

Melanotic hyperpigmentation is another oral lesion that is less commonly associated with HIV. The causes related to this hyperpigmentation are systemic medication with clofazamine and ketokonazole, [11] use of certain antiretroviral and antifungal drugs, Addison's disease, increased release of α-melanocyte stimulating hormone, and so on. There are reports that say even melanotic hyperpigmentation is also seen in HIV patients not on any medication. Due to immunosuppression, the adrenocortical gland may get infected by numerous parasites and results in melanotic hyperpigmentation. Pigmentation in HIV may be seen on skin, nails, and mucous membranes. The actual cause of melanotic hyperpigmentation in HIV is still remains undetermined. [12] In one study, melanin pigment was found in basal epithelial cells and in subepithelial connective tissue under microscopic examination. The same study reported presence of premature melanosomes in subepithelial keratinocytes when the cells were observed under ultramicroscope. [11] In our case, melanotic hyperpigmentation was seen on buccal mucosa, dorsum, and lateral border of tongue. After ruling out all other causes and the case history given by the patient, the cause could not be established might be because patient refrained from performing any invasive procedure.

The peculiarity of this case lies on the fact that till date, there is none such case reported in literature where nonspecific ulcer and melanotic hyperpigmentation occur simultaneously when compared with the other studies [Table 1] and [Table 2]. There are reports in literature to compare CD4 counts with oral manifestations of HIV infection. [8] But since, patient desisted from any invasive procedure; the comparison could not be established.
Table 1: Comparison of the present case with other cases

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Table 2: Comparison of the present case with other cases

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   Conclusion Top


Oral manifestations of HIV have been considered as the prognostic factors in monitoring the progress of the infection to full blown acquired immunodeficiency syndrome. The most common and strongly associated being candidiasis, oral hairy leukoplakia, necrotizing gingivitis, and so on. When it comes to the diagnosis of HIV by clinically observing oral manifestations, two such lesions viz; melanotic hyperpigmentation and nonspecific ulcers should not be neglected as these simple occurring lesions may be mistaken for pigmentation and ulcers due to intake of certain drugs or nutritional deficiency. The lack of knowledge about such lesions amongst dental professionals and general practitioners may lead to spread of infections among them if proper infection control protocol is not followed. We report an unusual case of melanotic hyperpigmentation and nonspecific ulcer in HIV positive patient to create awareness among the dental professionals and general practitioners for prompt diagnosis and proper infection control practices. The main etiology behind occurrence of such lesions is still irresolute and further research is required pertaining to this field.[20]

 
   References Top

1.Greenspan JS, Barr CE, Sciubba JJ, Winkler JR. Oral manifestations of HIV infection. Definitions, diagnostic criteria, and principles of therapy. The U.S.A. Oral AIDS Collaborative Group. Oral Surg Oral Med Oral Pathol 1992;73:142-4.  Back to cited text no. 1
    
2.Classification and diagnostic criteria for oral lesions in HIV infection. EC-Clearinghouse on Oral Problems Related to HIV infection and WHO Collaborating Centre on Oral Manifestations of Immunodeficiency Virus. J Oral Pathol Med 1993;22:289-91.  Back to cited text no. 2
    
3.Anil S, Challacombe SJ. Oral lesions of HIV and AIDS in Asia: An overview. Oral Dis 1997;3 Suppl 1:S36-40.  Back to cited text no. 3
    
4.Arendorf TM, Bredekamp B, Cloete CA, Sauer G. Oral manifestations of HIV infection in 600 South African patients. J Oral Pathol Med 1998;27:176-9.  Back to cited text no. 4
    
5.Ranganathan K, Reddy BV, Kumarasamy N, Solomon S, Viswanathan R, Johnson NW. Oral lesions and conditions associated with human immunodeficiency virus infection in 300 south Indian patients. Oral Dis 2000;6:152-7.  Back to cited text no. 5
    
6.Reznik DA. Oral manifestations of HIV disease. Top HIV Med 2005;13:143-8.  Back to cited text no. 6
    
7.Fabian FM, Kahabuka FK, Petersen PE, Shubi FM, Jürgensen N. Oral manifestations among people living with HIV/AIDS in Tanzania. Int Dent J 2009;59:187-91.  Back to cited text no. 7
    
8.Sontakke SA, Umarji HR, Karjodkar F. Comparison of oral manifestations with CD4 count in HIV-infected patients. Indian J Dent Res 2011;22:732.  Back to cited text no. 8
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9.Gilquin J, Weiss L, Kazatchkine MD. Genital and oral erosions induced by foscarnet. Lancet 1990;335:287.  Back to cited text no. 9
    
10.MacPhail LA, Greenspan D, Greenspan JS. Recurrent aphthous ulcers in association with HIV infection. Oral Surg Oral Med Oral Pathol 1992;73:283-8.  Back to cited text no. 10
    
11.Zhang X, Langford A, Gelderblom H, Reichart P. Ultrastructural findings in oral hyperpigmentation of HIV-infected patients. J Oral Pathol Med 1989;18:471-4.  Back to cited text no. 11
    
12.Burkit′s Oral Medicine Diagnosis and Treatment, Infectious Diseases. 10 th ed. New Delhi: BC Decker Inc, Elsevier; 2003. p. 542.  Back to cited text no. 12
    
13.Ranganathan K, Umadevi M, Saraswathi TR, Kumaraswamy N, Solomon S, Johnson N. Oral lesions and conditions associated with human immunodeficiency virus infection in 1000 south Indian patients. Ann Acad Med Singapore 2004;33:37-42.  Back to cited text no. 13
    
14.Sharma G, Pai KM, Suhas S, Ramapuram JT, Doshi D, Anup N. Oral manifestations in HIV/AIDS infected patients from India. Oral Dis 2006;12:537-42.  Back to cited text no. 14
    
15.Taiwo OO, Hassan Z. HIV-related oral lesions as markers of immunosuppression in HIV sero-positive Nigerian patients. J Med Sci 2010;1:166-70.  Back to cited text no. 15
    
16.Bodhade AS, Ganvir SM, Hazarey VK. Oral manifestations of HIV infection and their correlation with CD4 count. J Oral Sci 2011;53:203-11.  Back to cited text no. 16
    
17.Naidu SG, Thakur R, Singh AK, Rajbhandary S, Mishra RK, Sagtani A. Oral lesions and immune status of HIV infected adults from eastern Nepal. Exp Dent 2013;5:e1-7.  Back to cited text no. 17
    
18.Silverman S Jr, Migliorati CA, Lozada-Nur F, Greenspan D, Conant MA. Oral findings in people with or at high risk of AIDS: A study of 375 homosexual males. J Am Dent Assoc 1986;112:187-92.  Back to cited text no. 18
    
19.Palmer GD, Robinson PG, Challacombe SJ, Birnbaum W, Croser D, Erridge PL, et al. Aetiological factors for oral manifestations of HIV. Oral Dis 1996;2:193-7.  Back to cited text no. 19
    
20.Delgado WA, Almeida OP, Vargas PA, Leon JE. Oral ulcers in HIV-positive Peruvian patients: An immunohistochemical and in situ hybridization study. J Oral Pathol Med 2009;38:120-5.  Back to cited text no. 20
    

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Correspondence Address:
Mayur Chaudhary
Department of Oral Pathology and Microbiology, Bharati Vidyapeeth Deemed University Dental College and Hospital, Pune - 411 043, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1755-6783.140250

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