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   Abstract
   Introduction
   Case Report
   Acknowledgement
   References
   Article Figures

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CASE REPORT
Year : 1992  |  Volume : 58  |  Issue : 1  |  Page : 33-35

Oral hairy leukoplakia of the lips with CMV retinitis in a woman with AIDS


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Correspondence Address:
R Ganesh


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  Abstract 

A female prostitute, seropositive for HIV by ELISA and Western blot, presenting with mucous lesions of tongue and lower lip and also with unilateral loss of vision of the right eye is discussed. The tongue and lip lesions were confirmed by histopathological examination to be hairy leukoplakia, and the loss of vision was found to be due to retinitis-probably due to cytomegalovirus infection. The patient also had candidiasis, both oral and genital and lymphopaenia.


Keywords: Oral Hairy Leukoplakia, CMV retinitis, AIDS


How to cite this article:
Ganesh R, Williams J, Krishnaram A S, Sethur. Oral hairy leukoplakia of the lips with CMV retinitis in a woman with AIDS. Indian J Dermatol Venereol Leprol 1992;58:33-5

How to cite this URL:
Ganesh R, Williams J, Krishnaram A S, Sethur. Oral hairy leukoplakia of the lips with CMV retinitis in a woman with AIDS. Indian J Dermatol Venereol Leprol [serial online] 1992 [cited 2014 Dec 20];58:33-5. Available from: http://www.ijdvl.com/text.asp?1992/58/1/33/3738



  Introduction Top


The entire spectrum of HIV infection is ever changing as more and more clinical entities are getting added to it. In 1984, certain oral lesions suggestive of leukoplakia were noticed over the tongue of immunosuppressed individuals and subsequently were found to be associated with HIV disease. [1] They were first attributed to HPV virus but later works confirmed them to be caused by Epstein Barr virus. [2] The condition was termed Oral hairy leukoplakia.

Among the various ocular manifestations of AIDS, CMV retinitis is the most common presentation. This condition is unilateral mostly and progresses to cause blindness. [3] For the first time, since surveillance and follow up of HIV patients commenced in this Institute, a case of HIV seropositive female prostitute has presented with oral hairy leukoplakia and CMV retinitis. Considering the rarity of these cases in India, the same is reported.


  Case Report Top


A 35-year old female prostitute attended the Institute of Venereology, Government Rajaji Hospital, Madurai on 30-11-1990 with the complaints of general weakness with progressive diminution of vision in the right eye for 1 month and recurrent genital ulcerations of 6 months duration. She was a known seropositive for HIV antibody by both ELISA and Western blot during the surveillance 6 months earlier but was asymptomatic then. She was undernourished, anaemic, not jaundiced and there was no generalised lymphadenopathy. Her tongue and lower lip were covered by white plaques with ribbed surfaces [Figure - 1]. Ophthalmoscopic examination of right eye revealed retinitis examination revealed multiple, tender, superficial necrotic ulcers with polycyclic margins over both labia majora and minora. Vulvovaginitis with thick curdy-white vaginal discharge was also noticed. Pelvic examination was painful with positive chandlier's sign. Inguinal glands were enlarged, discrete, nontender and firm on both sides. Other systems were clinically normal. Her contacts could not be traced except one who turned out to be seronegative for HIV.

Haemogram showed total leukocyte count to be 2600 cells/cumm and absolute lymphocyte count of 1144 cells/cumm. Haemoglobin was 8 gm percent. Blood sugar, urea and ESR were within normal limits. Investigations for syphilis and gonorrhoea were negative. Smear and culture from both tongue and vagina were positive for candida albicans.

Radiological and scan examination of head and abdomen were normal. Chest X-ray was suggestive of pulmonary tuberculosis but the sputum was repeatedly negative for AFB. Histopathological examination of lip and tongue plaques showed squamous epithelium thrown into hair like projections with evidence of hyperkeratosis and acanthosis. There was, evidence of vacuolation and ballooning in a few foci in stratum spinosum. Subepidermal structure did not show any evidence of inflammation. Findings were suggestive of hairy leukoplakia.

Based on the clinical, serological and histopathological evidences, a diagnosis of AIDS with oral hairy leukoplakia, candidiasis and CMV retinitis was made.

Treatment commenced with clotrimazole mouth paint for tongue and vaginal pessaries and ointment for vaginal candidiasis besides oral acyclovir for genital herpes. The associated PID was treated with erythromycin and metronidazole. Later cotrimoxazole 2 tablets bid and dapsone 100 mgs once a day were added as chemoprophylaxis for PCP besides antitubercular treatment.

This case was the first case in our department with the presentation of oral hairy leukoplakia of the lips, CMV retinitis and candidiasis of oral and genital regions in an AIDS patient.

Oral hairy leukoplakia occurs almost exclusively in human immunodeficiency virus infected patients and is predictive for the subsequent development of AIDS. It presents as a white plaque with a rough surface, most commonly on the sides of the tongue. [2] In our case, the white plaques were present not only on the tongue but also on the lower lips which is not described so far in the literature. Candidiasis and Oral hairy leukoplakia are known to coexist in a majority of these patients. [4] In our case, ophthalmic examination by direct and indirect ophthalmoscopy was strongly suggestive of retinitis with the characteristic appearance.

As serological confirmation for CMV was not possible at our Institute, the same was not carried out. Due to non availability, both azidothymidine and Gancyclovir were not considered an this case.


  Acknowledgement Top


Our thanks are due to the following :

1. Dr. Prabakaran, Assistant professor of Ophthalmology, Government Rajaji Hospital, for carrying out the ophthalmoscopic examination.

2. The Professor of Pathology, Madurai Medical College, Madurai for carrying out the HPE.

3. The Institute of Virology, Madurai Medical College, Madurai for carrying out the serological investigations.

4. The Dean, Government Rajaji Hospital, Madurai for permitting this publication[5].

 
  References Top

1.Greenspan D, Greenspan J S, Conant M, et al. Oral 'Hairy' leukoplakia in male homosexuals : Evidence of associatiion with both papillomavirus and a herpes group virus. Lancet 1984; 2: 831 -4.  Back to cited text no. 1    
2.Resnick L, Herbst JS, Raab-Traub N. Oral hairy leukoplakia. J Am Acad Dermatol 1990; 22 : 1278 - 82.  Back to cited text no. 2    
3.Youle M, Clarbour J, Wade P, et al. AIDS therapeutics in HIV Disease, in : Nervous System. Edinburgh : Churchill Livingstone, 1988; 32.  Back to cited text no. 3    
4.Randle HW. White lesions of the mouth, Disorders of mucous membrane. Dermatol Clin 1987; 5 : 641 - 8.  Back to cited text no. 4    
5.Adler MW. AIDS : an introduction, Medicine International. 1988; 2350 - 1.  Back to cited text no. 5    


    Figures

[Figure - 1], [Figure - 2]



 

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