FIGURE 16 Oral hairy leukoplakia associated with EBV Source From

(PCR) for CMV viral load in serum can be used, but the clinical utility of the test is not yet clear.

Whether treatment is beneficial for oral ulcers caused by CMV is not clear. Ulcerative esophagitis-causing symptoms can be treated with IV antivirals such as ganciclovir, foscarnet, or cidofovir, followed by oral maintenance, usually with oral valganciclovir.

Epstein-Barr Virus and Oral Hairy Leukoplakia. OHL has been encountered since the early epidemic and has been strongly linked to Epstein-Barr virus (EBV) (3). It has a typical appearance of whitish thickening of the lateral tongue (Fig. 16), more specifically of the foliate papillae on either or both sides, appearing corrugated or "hairy" (Fig. 17); it is rarely found in other areas of the oral cavity. In contrast to pseudomembranous oral candidiasis, the lesions cannot be scraped away with a tongue blade.

It is the most common oral lesion in HIV-infected persons, encountered in 20% of asymptomatic patients and becoming more frequent with disease progression, with pseudomembranous candidiasis the second most common, encountered in about 6%. It does not, however, signify the presence of HIV infection, being infrequently found in solid organ or bone marrow transplant recipients or patients undergoing chemotherapy. Presence of OHL, regardless of the size of the lesion, signifies a more rapid progression to AIDS even after adjusting for CD4 counts at a similar degree with oral candidiasis. Pathogenesis is debated, but it seems the total EBV genome is invariably present in OHL lesions; multiple strains or defective replication cycle have been speculated.

The diagnosis is usually made clinically, but can be confirmed only by biopsy, since the involved epithelium shows characteristic changes and the presence of EBV can be demonstrated by immunohistochemistry, in situ hybridization, or electron microscopy. This can be useful for the differential diagnosis, which could include friction keratosis, smokers' leukoplakia, leukoplakia associated with dysplasia and oral squamous cell carcinoma in situ,

FIGURE 18 Oral warts. Source: Courtesy of the International AIDS Society-U.S.A. From Refs. 3, 4, 11.

lichen planus, hyperplastic candidiasis, geographic tongue, and certain genodermatoses. Of note, OHL is not associated with progression to malignancy, despite the well-known oncogenic association of EBV with other malignancies (Burkitt's lymphoma, nasopharyngeal carcinoma, and others).

Treatment is indicated for aesthetic or functional reasons; superinfection with Candida should be treated with fluconazole and the OHL lesion responds to high-dose acyclovir, but recurrence is the rule. Other agents, such as ganciclovir, foscarnet zidovudine, or topical podophyllum toxin, have been used with some success.

Human Papilloma Virus. Lesions of human papilloma virus (HPV) in the oral cavity take the form of cauliflower-like, flat, or papilliferous warts (Fig. 18) and are usually caused by different HPV types from those causing genital lesions.

Flat oral warts are identical to the lesions of focal epithelial hyperplasia (Heck' s disease). Rarely, dysplasia has been found in association with HPV lesions of the oral cavity. Large bulky lesions may be found in the larynx or tracheobronchial tree (respiratory papillo-matosis), which can cause severe symptoms from hoarseness, dysphonia, or hemoptysis.

Diagnosis is made by the characteristic clinical appearance on physical examination or endoscopy.

Treatment for oral warts is usually by surgical or laser excision, fulguration, cryo-surgery, or trichloroacetic acid application. Intralesional cidofovir injection has been used with varying degrees of success. Screening for other sites of infection (e.g., the genitourinary tract) and treatment of those areas are advised. Recurrence, however, is common.

Molluscum Contagiosum (Molluscipoxvirus). The etiologic agent of molluscum contagiosum is a poxvirus of the family Poxviridae, which is encountered with increased frequency in HIV disease. Lesions are typically papular and umbilicated with a keratinized core that can be readily expressed. Lesions appear on the face and neck, sometimes in large numbers, and become aesthetically problematic. Treatment options include curettage, cryosurgery, and local trichloroacetic acid application. Immune restoration in cases of decreased CD4 count is helpful in controlling the extent of the lesions. Cidofovir has been used in recalcitrant cases, either topically or systemically.

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