Angular Cheilitis Early Hiv Symptom

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alteration of taste, gingival pain, malaise, fever, and halitosis. As the disease progresses, a whitish pseudomembrane develops along the gingival margins, with ulceration and blunting of the interdental papillae. Acute necrotizing gingivitis, pictured in Figure 12-57, may be an early feature of HIV infection.

On August 6, 2008, the Centers for Disease Control and Prevention (CDC) released a new estimate of the annual number of new HIV infections (HIV incidence) in the United States, revealing that the HIV epidemic is worse than previously thought. That estimate indicated that approximately 56,300 people were newly infected with HIV in the United States in 2006, which is higher than the CDC's previous estimate of 40,000. The new estimate also confirmed that gay and bisexual men of all races, African Americans, and Hispanics/Latinos were most heavily affected by HIV. Although first observed in men having sex with men, HIV is now spreading among the heterosexual population. These cases are related to the use of illegal drugs and contaminated needles, prostitution, and unprotected sex. It has been estimated that more than 90% of patients infected with HIV will have at least one oral manifestation of their disease. It appears that as further immunologic impairment develops, the risk of oral lesions increases. It has also been shown that the oral manifestations can be used as a marker of immune compromise, which is independent of the CD4+ T-lymphocyte count. If left untreated, the oral lesions may interfere with chewing, swallowing, and talking. Many patients have such severe pain that they reduce their oral intake, which results in additional weight loss, malnutrition, and further wasting.

A common oral manifestation of HIV infection is angular cheilitis, also known as perleche. This painful condition is characterized by macerated, fissured, eroded, encrusted, whitish (occasionally erythematous) lesions in the corners of the mouth. Accumulations of saliva gather in the skin folds and are subsequently colonized by yeast organisms such as C. albicans. Angular cheilitis may be associated with intraoral candidiasis. Angular cheilitis may also

Angular CheilitisHiv Simptom Photos
Figure 12-59 Kaposi's sarcoma of the tongue.

develop in patients with normal immunity who wear ill-fitting dentures or wear dentures during the night. An example of angular cheilitis is pictured in Figure 12-58.

Figures 12-26 and 12-33 show patients with oral candidiasis, another extremely common condition associated with HIV infection. Oral candidiasis is characterized by chronic severe pain in the throat that worsens on swallowing or eating. The curdlike white plaques are soft and friable and can easily be wiped off, leaving an area of intensely erythematous mucosa.

Figure 12-27 shows a patient with oral hairy leukoplakia. As mentioned previously, this lesion is seen most frequently either unilaterally or bilaterally on the lateral margins of the tongue. The lesion is white, does not rub off, and occasionally occurs elsewhere in the mouth and oropharynx. Although not correlated with the stage of HIV infection, oral hairy leukopla-kia may be the first sign of infection. It is seen most commonly in gay and bisexual men infected with HIV. It has been suggested that the Epstein-Barr virus may be a cofactor in the development of oral hairy leukoplakia. The finding of oral hairy leukoplakia mandates HIV testing.

As discussed in Chapter 8, The Skin, the oral lesions of Kaposi's sarcoma are common. Figure 8-93 shows some of the typical oral lesions. Lesions of Kaposi's sarcoma of the tongue (Fig. 12-59) and the hard palate (Fig. 12-60) are frequently found in patients with AIDS.

Table 12-1 summarizes the important signs and symptoms of some of the more common oral lesions. Table 12-2 reviews the most common oral lesions seen during the stages of HIV infection. Table 24-5 lists the chronology of dentition.

Stages Infection

Table 12-1 Symptoms and Signs of Oral Lesions


Aphthous ulcer (canker sore; see Fig. 12-45)

Herpetic ulcer (cold sore; fever blister; see Figs. 12-10, 12-55, 12-56)


Squamous cell carcinoma (see Figs. 12-28, 12-50, and 12-52 to 12-54)

Erythema multiforme

Denture hyperplasia

Candidiasis (moniliasis; thrush; see Figs. 12-26, 12-33)


Painful, recurrent white sore with red border on lips, inner side of cheeks, tip and sides of tongue, or palate

Painful, recurrent sores on the lips

Painless sore on lips or tongue lasting

2 weeks to

3 months

Ulcerated sore of the lips, floor of mouth, or tongue

(especially lateral borders); erythroplakia of floor of mouth, soft palate

Sudden onset of multiple painful ulcers in mouth of lips

Painless excess tissue at border of denture

Burning sensation in areas of tongue, inside of cheek, or throat


Single lesion 0.5-2 cm in diameter that is first maculopapular but then ulcerates and has an area of erythema at its border; lesions usually on movable mucosal areas

Multiple vesicles, papules, or ulcers on the mucocutaneous junction, hard palate, or gingivae; as the bullae break, crusting occurs

Single ulcerated lesion with indurated border; lesion without central necrotic material; tender lymphadenitis may be present

Single indurated lesion with indurated and raised border; often in an area of leukoplakia or erythroplakia; absence of necrotic material in crater; base often erythematous; speech alterations may result if lesion is large; painless lymphadenopathy may be present

Hemorrhagic areas of ulceration with erythematous bases, often with pseudomembrane; lesions start as bullae; skin involvement common (target lesions)

Spongy, redundant, often erythematous tissue with impression of edge of denture; frequently seen on anterior maxillary mucosa

Whitish pseudomembrane, resembling milk curd, that can be peeled off, leaving a raw, erythematous area that may bleed; erythematous variant is secondary to broad-spectrum antibiotics

Other Information

Sixty percent of population have periodic canker sores lasting up to 2 weeks; cause is unknown

Primary herpetic infection in children: multiple lesions in clusters on fixed mucous membranes; small, discrete, whitish vesicles before ulceration; ulcers about 1 mm in diameter, which may coalesce; tender lymphadenopathy, fever, and malaise present

Recurrent form, common in adults: lip lesions

Both forms: self-limited illness, 1-2 weeks

Examiner should look for genital lesions (see Figs. 18-13 and 19-33)

Frequently in alcoholic patients or smokers

Many precipitating factors include drug reactions, herpesvirus infections, endocrine changes, and an underlying malignancy; most common in winter and spring in young adults; frequently recurring

Often seen in individuals who are chronically debilitated, patients who are immunosuppressed, or patients receiving long-term antibiotic therapy; commonly seen in persons with AIDS


Table 12-1 Symptoms and Signs of Oral Lesions—cont'd Lesion Symptoms Signs

Erythroplakia (see Figs. 12-20, 12-38)

Lichen planus (see Fig. 12-15)

Traumatic ulcer

Mucocele (see Fig. 12-13)

Black hairy tongue (see Fig. 12-25 B)

Fordyce's spots (see Fig. 12-18)

Painless red area on inside of cheek, tongue, or floor of mouth

Painless white area on inside of cheek, tongue, lower lip, or floor of mouth

Slow-growing, painless mass on inner surface of cheek or tongue

Usually no symptoms; erosive form causes painful, burning sores of inner side of cheek or tongue

Pain in an area of a sore; short duration (1-2 weeks)

Intermittent, painless swelling of the lower lip or inside of cheek; slightly bluish; occasionally ruptures

Gagging sensation associated with ''hairy'' sensation of tongue; large brown or blackish painless lesion on top of tongue


Granular, erythematous papules that bleed

Hyperkeratinized, whitish lesion that cannot be scraped off; looks similar to flaking white paint; often speckled with reddish areas; associated adenopathy may indicate malignant changes of lesion

Yellowish, nontender, soft mass; freely mobile

White lesions on buccal mucosa bilaterally in the form of reticulated papules in lacelike pattern; erosive form appears as hemorrhagic ulcerated lesion with possible white areas or bullae; pseudomembrane may be present over lesion

Single lesion with raised erythema at its border; center often with necrotic debris; occasionally purulent; mild lymphadenitis may be present

Dome-shaped, 1-2 cm in diameter, freely mobile cystic lesion

Elongation of filiform papillae on the dorsum of tongue with a change in their color to almost black or brown

Clusters of small, yellowish, raised lesions best seen on the buccal mucosa opposite the molar teeth

Other Information

High potential for malignancy

Patients are usually men over 40 years of age; linked to smoking, AIDS, alcoholism, and chewing tobacco

Nonerosive form is a common cause of white lesions in the mouth; skin involvement in 10%-35% of affected patients and more frequently seen in patients with emotional stress

Patient frequently know the cause (e.g., biting cheek while eating)

Related to trauma to ductal system of minor labial salivary glands

History of excessive antibiotic use, excessive use of mouthwash, poor oral hygiene, smoking, or alcohol use is common

Common in older individuals; they are normal, hyperplastic sebaceous glands

AIDS, acquired immunodeficiency syndrome.

Table 12-2 Occurrence of Oral Lesions During the Stages of HIV Infection

Oral Lesion

Candidiasis (see Figs. 12-26, 12-33)

Oral hairy leukoplakia (see Fig. 12-27)

Linear gingival erythema

Acute necrotizing gingivitis (see Fig. 12-57)

Necrotizing stomatitis

Herpes simplex-related (see Figs. 12-10, 12-55, 12-56)

Aphthous ulcers (see Fig. 12-45)

Occurrence During Primary HIV Infection


No No

No No

No No


Occurrence During Early HIV





Common Rare

Occasional Occasional

Advanced HIV Disease{

Very common

Very common Very common

Very common Common

Common Common

Very common

HIV, human immunodeficiency virus. *CD4+ count > 500 cells/mm3. {CD4+ count < 200 cells/mm3.

Adapted from Weinert M, Grimes RM, Lynch DP: Oral manifestations of HIV infection. Ann Intern Med 125:485, 1996.

Useful Vocabulary

Listed here are the specific roots that are important to understand the terminology related to diseases of the mouth and pharynx.


Pertaining to




pitcher-shaped structure


Inflammation of the arytenoid cartilage




Pertaining to the cheek and pharynx




Inflammation of the lip




Pertaining to the teeth




Surgical excision of diseased gingiva(e)




Paralysis of the tongue




Pertaining to the nose and lip




White patch on mucous membrane; often premalignant


Useful Vocabulary—cont'd




Painful ulcers around the papillae of the tongue




Red patch on mucous membrane; often premalignant




Excessive salivation


mouth; opening


Inflammation of the mouth

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    Is angular chelitis sign of hiv?
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