Necrotizing Stomatitis as First Sign of HIV Infection

In an in-press article in the Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology, Scott M. Peters, DDS, from Columbia University College of Dental Medicine, New York, New York, and colleagues report a case of a 20-year-old homosexual Caucasian man with undiagnosed HIV that first presented as necrotizing ulcerative stomatitis (NUS).

According to the authors, periodontal disease associated with HIV infection usually presents as linear gingival erythema (LGE), necrotizing ulcerative gingivitis (NUG), or necrotizing ulcerative periodontitis (NUP). However, they explain that these are not distinct entities; instead, they reflect a spectrum of disease severity.

In addition, the term “NUS” describes progression of this inflammatory process from an initial infection of the marginal gingivae to massive tissue destruction within the oral cavity, including underlying bone.

Periodontal disease is a common problem in patients with HIV infection, just as it is in individuals without HIV infection. However, LGE, NUG, NUP, and NUS are atypical presentations of periodontal disease that are strongly associated with HIV infection.

“Our case adds an additional report of NUS in an HIV-positive individual,” the authors write.

The patient was referred to an oral surgeon because of pain and a burning sensation on his palate. He described having initially felt “a bubble” at the top of his mouth. As this lesion grew in size, he also developed burning pain, chills, and night fevers.

The man had no medical conditions, and no history of previous surgeries. Apart from taking ibuprofen for pain relief, he was not using prescription medications, nor was he using illicit drugs or smoking. However, he reported multiple sexual encounters with multiple male partners, and had not been recently tested for HIV.

The gingiva of his anterior maxilla was swollen and reddened, and a large necrotic ulcerative lesion of the anterior hard palate had resulted in exposure of underlying bone. Several teeth in this region were also mobile, and the oral cavity was foul-smelling. White plaques were seen on the oral mucosa, consistent with oral candidiasis which was confirmed by fungal culture. Radiography confirmed the presence of alveolar bone absorption of the anterior hard palate.

Histopathology was also performed on biopsy samples of the hard palate lesion, demonstrating ulceration with bacterial overgrowth, and connective tissue necrosis, vasculitis, and inflammation.

The patient consented to HIV testing; his CD4 count was reduced and HIV was detected on rapid exam. A positive western blot subsequently confirmed HIV infection in the patient, and his HIV viral load was 271,779 copies/mm³.

Based on these findings, clinicians made a diagnosis of HIV-associated NUS of the maxilla, and prescribed combination antiretroviral therapy (cART).

After one month of treatment, the patient’s viral load decreased to less than 20 copies/mm³. Although his CD4 count had not yet normalized, it had markedly improved.

Clinicians also debrided the necrotic maxillary tissue and splinted the mobile teeth. A computed tomography scan also showed extensive destruction of bone within the oral cavity, including in the anterior maxilla, buccal, and palatal cortices, as well as the anterior nasal floor. Consequently, the patient underwent anterior maxillary debridement, extraction of involved teeth, and obturator delivery.

The patient remained on cART at 1-year followup. At this time, he had an undetectable HIV viral load and his CD4 count had further increased, but still had not normalized.

The incidence and prevalence of these atypical oral lesions seem to be declining in HIV patients, Dr. Peters and colleagues note, in part because of antiretroviral therapy.

However, they emphasize that this case “serves as a reminder that clinicians must remain cognizant of the oral manifestations of HIV, as they can help guide proper diagnosis and treatment of systemic diseases.”

Feature Picture Source: CDC / Minnesota Department of Health, RN Barr Library; Librarians Melissa Rethelefsen & Marie Jones

Dr. Parry graduated from the University of Liverpool, England in 1997 and is a board-certified veterinary pathologist. After 13 years working in academia, she founded Midwest Veterinary Pathology, LLC where she now works as a private consultant. She is passionate about veterinary education and serves on the Indiana Veterinary Medical Association’s Continuing Education Committee. She regularly writes continuing education articles for veterinary organizations and journals, and has also served on the American College of Veterinary Pathologists’ Examination Committee and Education Committee.