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Oral Manifestations of Pediatric HIV Infection: Clinical Characteristics, Diagnosis, Treatment Recommendations and Disease Significance Clinical Characteristics,

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Presentation on theme: "Oral Manifestations of Pediatric HIV Infection: Clinical Characteristics, Diagnosis, Treatment Recommendations and Disease Significance Clinical Characteristics,"— Presentation transcript:

1 Oral Manifestations of Pediatric HIV Infection: Clinical Characteristics, Diagnosis, Treatment Recommendations and Disease Significance Clinical Characteristics, Diagnosis, Treatment Recommendations and Disease Significance

2 Disease Pattern Differences in Pediatric and Adult HIV Infection Narrower spectrum of infectious diseases in childrenNarrower spectrum of infectious diseases in children More vulnerable to recurrent bacterial infectionsMore vulnerable to recurrent bacterial infections More susceptible to central nervous system disordersMore susceptible to central nervous system disorders Increased risk for HIV-lymphoproliferationIncreased risk for HIV-lymphoproliferation Decreased risk for malignanciesDecreased risk for malignancies Endocrine and metabolic impact on growth and developmentEndocrine and metabolic impact on growth and development Behavioral and emotional problems due to chronic illnessBehavioral and emotional problems due to chronic illness

3 Diagnosis of Pediatric HIV Oral Lesions Clinical examination is important because history is often unknown or incompleteClinical examination is important because history is often unknown or incomplete Rely on noninvasive procedures for initial diagnosis and treatmentRely on noninvasive procedures for initial diagnosis and treatment Treatment often requires modification and individual customizationTreatment often requires modification and individual customization Successful management necessitates care giver involvement and understandingSuccessful management necessitates care giver involvement and understanding Diagnosis should be re-evaluated, if treatment is not effectiveDiagnosis should be re-evaluated, if treatment is not effective

4 Oral Manifestations of Pediatric HIV Infection Most children will have at least one oral lesionMost children will have at least one oral lesion Infectious diseases: bacterial, viral and fungalInfectious diseases: bacterial, viral and fungal Most neoplasms are EBV driven: lymphoma, leiomyoma and leiomyosarcomaMost neoplasms are EBV driven: lymphoma, leiomyoma and leiomyosarcoma Immunologic disorders: aphthous ulcers, parotitis, lymphadenopathy, thrombocytopenia and allergic reactionsImmunologic disorders: aphthous ulcers, parotitis, lymphadenopathy, thrombocytopenia and allergic reactions Iatrogenic diseases are caused by drug side effectsIatrogenic diseases are caused by drug side effects Dental diseases: Dental caries, enamel hypoplasia, over-retained teeth, delayed eruption of teethDental diseases: Dental caries, enamel hypoplasia, over-retained teeth, delayed eruption of teeth

5 Oral Candidiasis in Children Common opportunistic fungal infection, affecting up to 72% of HIV infected childrenCommon opportunistic fungal infection, affecting up to 72% of HIV infected children Cause: Candida species, usually Candida albicansCause: Candida species, usually Candida albicans Contributing factors: Immune suppression, xerostomia medications, oral appliances, poor oral hygieneContributing factors: Immune suppression, xerostomia medications, oral appliances, poor oral hygiene Forms: Pseudomembranous, erythematous & hyperplastic candidiasis, angular cheilitis, median rhomboid glossitis, cheilocandidiasisForms: Pseudomembranous, erythematous & hyperplastic candidiasis, angular cheilitis, median rhomboid glossitis, cheilocandidiasis Site: Lips and oropharyngeal mucosaSite: Lips and oropharyngeal mucosa Signs & Symptoms: Red or white patches, erosions, burning sensation, sore throat, taste alterationsSigns & Symptoms: Red or white patches, erosions, burning sensation, sore throat, taste alterations Diagnosis: Clinical findings, culture, cytology, biopsyDiagnosis: Clinical findings, culture, cytology, biopsy

6 Oral Candidiasis in Children

7 Rx: Oropharyngeal Candidiasis Nystatin susp: 100, ,000 U 4 times daily for daysNystatin susp: 100, ,000 U 4 times daily for days Clotrimazole susp, troche: 10 mg 4-5 times daily for daysClotrimazole susp, troche: 10 mg 4-5 times daily for days Fluconazole susp, tab: 3-6 mg/kg daily for daysFluconazole susp, tab: 3-6 mg/kg daily for days Ketoconazole susp, tab: 5-10 mg/kg in 1 or 2 doses for daysKetoconazole susp, tab: 5-10 mg/kg in 1 or 2 doses for days Itraconazole susp: 2-5 mg/kg daily for daysItraconazole susp: 2-5 mg/kg daily for days Amphotericin IV: mg/kg/dAmphotericin IV: mg/kg/d Antifungal ointment or cream for lips, if neededAntifungal ointment or cream for lips, if needed

8 Parotitis in Children Lymphocyte-mediated salivary gland disease observed observed in about 30% of childrenLymphocyte-mediated salivary gland disease observed observed in about 30% of children Cause: CD8+ infiltrate; HIV, EBV; genetic predispositionCause: CD8+ infiltrate; HIV, EBV; genetic predisposition Median age of onset: 5.4 yearsMedian age of onset: 5.4 years Site: Parotid and submandibular glands; may affect lungs and other organsSite: Parotid and submandibular glands; may affect lungs and other organs Signs & Symptoms: Diffuse facial swelling, may be tender, xerostomia, cervical lymphadenopathy, enlarged palatine tonsilsSigns & Symptoms: Diffuse facial swelling, may be tender, xerostomia, cervical lymphadenopathy, enlarged palatine tonsils Diagnosis: Clinical findings, advanced imaging, aspiration or labial lip biopsyDiagnosis: Clinical findings, advanced imaging, aspiration or labial lip biopsy Complication: Bacterial sialadenitis, lymphomaComplication: Bacterial sialadenitis, lymphoma

9 Parotitis in Children

10 Treatment of Parotitis Caries and gingivitis prevention: Topical fluorides, clorhexidine gluconate oral rinseCaries and gingivitis prevention: Topical fluorides, clorhexidine gluconate oral rinse Pain management: Nonsteroidal anti-inflammatory drugs (NSAIDS)Pain management: Nonsteroidal anti-inflammatory drugs (NSAIDS)  Ibuprofen: 5-10 mg/kg q 4-6 h (max = 40 mg/kg/d)  Naproxen: 5-10 mg/kg q 8 h (max = 1500 mg/d) Saliva stimulants: Pilocarpine, cevimeline hydrochlorideSaliva stimulants: Pilocarpine, cevimeline hydrochloride Severe facial swelling: Prednisone; surgery, if large cystic lesions are presentSevere facial swelling: Prednisone; surgery, if large cystic lesions are present Bacterial sialadenitis: Antibiotics - clindamycinBacterial sialadenitis: Antibiotics - clindamycin

11 Herpes Simplex Infection in Children Common viral infection affecting up to 24% of childrenCommon viral infection affecting up to 24% of children Transmission: Direct contact, asymptomatic viral shedding in genital fluids and salivaTransmission: Direct contact, asymptomatic viral shedding in genital fluids and saliva Median age of onset: 5 yearsMedian age of onset: 5 years Site: Orofacial, nasal and esophageal regionSite: Orofacial, nasal and esophageal region Signs & Symptoms: Painful gingivitis, recurrent persistent ulcers intraorally; vesicles and crusted ulcers on lips and skinSigns & Symptoms: Painful gingivitis, recurrent persistent ulcers intraorally; vesicles and crusted ulcers on lips and skin Non-nutritive sucking habits increase risk for ocular and digital infectionNon-nutritive sucking habits increase risk for ocular and digital infection Diagnosis: Clinical, culture, PCR, cytology, biopsyDiagnosis: Clinical, culture, PCR, cytology, biopsy

12 Herpes Simplex Infection in Children

13 Treatment of HSV Infection Systemic Antiviral MedicationsSystemic Antiviral Medications  Zovirax, generic (acyclovir): 15 mg/kg, 5 times/day  Famvir (famciclovir): Not approved for pediatric use  Valtrex (valacyclovir): Not approved for pediatric use  Foscavir (foscarnet), if resistant (6.4% HIV) - IV Topical Antiviral Agents: Not usually recommendedTopical Antiviral Agents: Not usually recommended  Denavir (penciclovir) 1% cream  Zovirax (acyclovir) 5% ointment  Abreva (docosanol) 10% cream (OTC)

14 Cytomegalovirus Infection in Children Congenital Infection: % of HIV-exposed infantsCongenital Infection: % of HIV-exposed infants Transmission: Viral shedding in genital fluids, breast milk, urine and saliva; blood, organsTransmission: Viral shedding in genital fluids, breast milk, urine and saliva; blood, organs CMV disease: 8-18%; retinitis, pneumonitis, colitis, mucocutaneous ulcers, neuropathy, encephalopathyCMV disease: 8-18%; retinitis, pneumonitis, colitis, mucocutaneous ulcers, neuropathy, encephalopathy Site: Oral and esophageal regions, salivary glandsSite: Oral and esophageal regions, salivary glands Oral S/S: Persistent ulcers, gingivitis, pyogenic granuloma; enamel hypoplasia - congenital diseaseOral S/S: Persistent ulcers, gingivitis, pyogenic granuloma; enamel hypoplasia - congenital disease Diagnosis: Culture, PCR, biopsyDiagnosis: Culture, PCR, biopsy Treatment: Ganciclovir, foscarnet, cidofovirTreatment: Ganciclovir, foscarnet, cidofovir

15 Cytomegalovirus Infection in Children

16 Herpes Zoster in Children Prevalence: 2-6% HIV infected childrenPrevalence: 2-6% HIV infected children Cause: Reactivation of varicella-zoster virusCause: Reactivation of varicella-zoster virus Median age: 7.6 yrs but common under 5 yrsMedian age: 7.6 yrs but common under 5 yrs Site: 5% in the head & neck region; CN5 & CN7Site: 5% in the head & neck region; CN5 & CN7 Signs & Symptoms: Vesicles, coalescing ulcers, thick crust on skin, follow dermatome and stop at midline; pain, fever and headache; 4% are bilateralSigns & Symptoms: Vesicles, coalescing ulcers, thick crust on skin, follow dermatome and stop at midline; pain, fever and headache; 4% are bilateral Diagnosis: Clinical, culture, cytologyDiagnosis: Clinical, culture, cytology TX: Acyclovir, valacyclovir, famciclovir, foscarnetTX: Acyclovir, valacyclovir, famciclovir, foscarnet Complication: Scarring, blindness, secondary infection, disseminated diseaseComplication: Scarring, blindness, secondary infection, disseminated disease

17 Herpes Zoster in Children WRONG PICTURE !

18 Aphthous Stomatitis in Children Pediatric prevalence: Up to 16%; common oral lesionPediatric prevalence: Up to 16%; common oral lesion Cause: Localized immune dysfunctionCause: Localized immune dysfunction Predisposing factors: Trauma, hematologic disorders, nutritional deficiencies, allergies, oral appliancesPredisposing factors: Trauma, hematologic disorders, nutritional deficiencies, allergies, oral appliances Variants: Minor, major and herpetiformVariants: Minor, major and herpetiform Site: Primarily affects nonkeratinized oropharyngeal mucosa, esophagusSite: Primarily affects nonkeratinized oropharyngeal mucosa, esophagus S/S: Painful recurrent ulcers, multifocal pattern, increase in the major variant, may result in scarringS/S: Painful recurrent ulcers, multifocal pattern, increase in the major variant, may result in scarring Diagnosis: Clinical; culture and biopsy, if persistentDiagnosis: Clinical; culture and biopsy, if persistent

19 Aphthous Stomatitis in Children

20 Treatment of Aphthous Ulcers Pain management: Topical anesthetics and coating agents, systemic analgesicsPain management: Topical anesthetics and coating agents, systemic analgesics Ulcer management:Ulcer management:  Kenalog (triamcinolone) in Orabase 0.1%  Fluocinonide gel or ointment 0.05%  Clobetasol gel or ointment 0.05%  Dexamethasone elixir 0.5 mg/5 mL  Beclomethasone dipropionate:1-2 puffs/3X/d  Prednisone (2mg/kg/d or mg): 5-7 d  Thalidomide ( mg/d)

21 Molluscum Contagiosum in Children Common skin infection caused by the poxvirusCommon skin infection caused by the poxvirus Associated with low CD4+ countsAssociated with low CD4+ counts Predisposing factors: Trauma and dermatitisPredisposing factors: Trauma and dermatitis Transmission: Direct contactTransmission: Direct contact Site: Facial skin and genital regionSite: Facial skin and genital region Signs & Symptoms: Multiple, pearly-white nodules with umbilicated center and erythematous borderSigns & Symptoms: Multiple, pearly-white nodules with umbilicated center and erythematous border Diagnosis: Clinical, cytology, biopsyDiagnosis: Clinical, cytology, biopsy TX: Surgical - curettage, cryotherapy, excision Topical – cantharidin, cidofovir, imiquimodTX: Surgical - curettage, cryotherapy, excision Topical – cantharidin, cidofovir, imiquimod

22 Molluscum Contagiosum in Children

23 Periodontal Diseases in Children Disease Classification and Prevalence Linear gingival erythema (LGE): %Linear gingival erythema (LGE): % Necrotizing ulcerative gingivitis (NUG): 0 - 5%Necrotizing ulcerative gingivitis (NUG): 0 - 5% Necrotizing ulcerative periodontitis (NUP): 0 - 5% (most common oral lesion in Africa)Necrotizing ulcerative periodontitis (NUP): 0 - 5% (most common oral lesion in Africa) Necrotizing stomatitis (NS): UnknownNecrotizing stomatitis (NS): Unknown Conventional gingivitis: %Conventional gingivitis: % Periodontitis modified by systemic disease: UnknownPeriodontitis modified by systemic disease: Unknown

24 Linear Gingival Erythema in Children Pediatric prevalence: Up to 38%; common oral lesionPediatric prevalence: Up to 38%; common oral lesion Cause: Unknown but Candida sp, especially C. albicans, C. dublinienesis has been implicatedCause: Unknown but Candida sp, especially C. albicans, C. dublinienesis has been implicated Site: Usually multiple teeth but may be localizedSite: Usually multiple teeth but may be localized Signs & Symptoms: Fiery red band 2-3 mm wide on marginal gingiva; petechiae or diffuse erythema on adjacent mucosa; bleeding is uncommon; pain is rareSigns & Symptoms: Fiery red band 2-3 mm wide on marginal gingiva; petechiae or diffuse erythema on adjacent mucosa; bleeding is uncommon; pain is rare Note: Erythema is disproportional to amount of plaqueNote: Erythema is disproportional to amount of plaque Diagnosis: Clinical; nonresponsive to oral hygieneDiagnosis: Clinical; nonresponsive to oral hygiene TX: Plaque and caries control; antifungal medicationsTX: Plaque and caries control; antifungal medications

25 Linear Gingival Erythema in Children

26 Necrotizing Ulcerative Gingivitis Pediatric prevalence: 0 - 5%; uncommon oral lesionPediatric prevalence: 0 - 5%; uncommon oral lesion Cause: Fusiform-spirochete bacteria; Gram-negativeCause: Fusiform-spirochete bacteria; Gram-negative Predisposing factors: Stress, immune suppression, smoking, malnutrition, pre-existing gingivitisPredisposing factors: Stress, immune suppression, smoking, malnutrition, pre-existing gingivitis Age: Adolescents in US; young children in developing countries, especially AfricaAge: Adolescents in US; young children in developing countries, especially Africa Site: Anterior gingiva to widespreadSite: Anterior gingiva to widespread Signs & Symptoms: Punched out, ulcerated papillae, bleeding, pain, lymphadenopathy, fetid odor, feverSigns & Symptoms: Punched out, ulcerated papillae, bleeding, pain, lymphadenopathy, fetid odor, fever Diagnosis: Clinical, biopsy of persistent lesionsDiagnosis: Clinical, biopsy of persistent lesions

27 Necrotizing Ulcerative Gingivitis

28 Necrotizing Ulcerative Periodontitis Pediatric prevalence: 0 - 5%; uncommon oral lesionPediatric prevalence: 0 - 5%; uncommon oral lesion Cause: Fusiform-spirochete bacteria; Gram-negativeCause: Fusiform-spirochete bacteria; Gram-negative Predisposing factors: Immune suppression, smoking, malnutrition, stress, pre-existing periodontitisPredisposing factors: Immune suppression, smoking, malnutrition, stress, pre-existing periodontitis Age: Usually adolescentsAge: Usually adolescents Site: Lower anterior gingiva to widespreadSite: Lower anterior gingiva to widespread S/S: Features of NUG, rapid bone loss, necrosis and sequestration, tooth lossS/S: Features of NUG, rapid bone loss, necrosis and sequestration, tooth loss Diagnosis: Clinical and radiographic, biopsy, if persistent lesionsDiagnosis: Clinical and radiographic, biopsy, if persistent lesions

29 Necrotizing Ulcerative Periodontitis

30 Necrotizing Stomatitis in Children Pediatric prevalence: Uncommon oral diseasePediatric prevalence: Uncommon oral disease Cause: Multifactorial including bacterial, fungal, viralCause: Multifactorial including bacterial, fungal, viral Predisposing factors: Severe immune suppression, neutropenia, malnutritionPredisposing factors: Severe immune suppression, neutropenia, malnutrition Site: Often contiguous with gingival lesions but may occur at any mucosal siteSite: Often contiguous with gingival lesions but may occur at any mucosal site Signs & Symptoms: Persistent, destructive ulcers with thick, tenacious pseudomembrane; single or multiple; very painfulSigns & Symptoms: Persistent, destructive ulcers with thick, tenacious pseudomembrane; single or multiple; very painful Diagnosis: Clinical, culture, biopsy, if persistentDiagnosis: Clinical, culture, biopsy, if persistent Complication: Weight loss and wasting diseaseComplication: Weight loss and wasting disease

31 Necrotizing Stomatitis in Children

32 Necrotizing Periodontal Diseases Management Management NUG/NUP: Debridement, 10% povidone-iodine, extraction of involved primary teeth, chlorhexidine oral rinse, antifungal and antibiotic therapyNUG/NUP: Debridement, 10% povidone-iodine, extraction of involved primary teeth, chlorhexidine oral rinse, antifungal and antibiotic therapy Antibiotics: Clindamycin mg/kg/d or penicillin VK mg/kg/d plus metronidazole 30 mg/kg/d or amoxicillin + clavulanate 40 mg/kgAntibiotics: Clindamycin mg/kg/d or penicillin VK mg/kg/d plus metronidazole 30 mg/kg/d or amoxicillin + clavulanate 40 mg/kg Systemic analgesics for painSystemic analgesics for pain Periodic dental visits: Every 3-4 monthsPeriodic dental visits: Every 3-4 months

33 Conventional Gingivitis in Children Conventional gingivitis mimics LGEConventional gingivitis mimics LGE Decreased gingival health is associated with advanced HIV disease and decreased CD4 percentagesDecreased gingival health is associated with advanced HIV disease and decreased CD4 percentages Higher plaque and gingival indices associated with candidiasisHigher plaque and gingival indices associated with candidiasis Leukopenia and anemia mask the clinical signs of erythemaLeukopenia and anemia mask the clinical signs of erythema

34 Lymphadenopathy in Children Prevalence: Cervical lymphadenopathy > 50%Prevalence: Cervical lymphadenopathy > 50% Cause: HIV and EBV lymphoid replicationCause: HIV and EBV lymphoid replication Site: Generalized; submandibular, cervical and pharyngeal tonsilsSite: Generalized; submandibular, cervical and pharyngeal tonsils S/S: Bilateral, persistent, diffuse enlargement; nontender; no erythema of the skin; > 0.5 cm at more than one siteS/S: Bilateral, persistent, diffuse enlargement; nontender; no erythema of the skin; > 0.5 cm at more than one site Significance: Positive predictor of HIV survivalSignificance: Positive predictor of HIV survival Mimics viral, bacterial infection, lymphomaMimics viral, bacterial infection, lymphoma Treatment: None required; aspiration biopsy and advanced imaging with significant enlargementTreatment: None required; aspiration biopsy and advanced imaging with significant enlargement

35 Lymphadenopathy in Children

36 Hairy Leukoplakia in Children Pediatric prevalence: 2 - 3%; uncommon oral lesionPediatric prevalence: 2 - 3%; uncommon oral lesion Cause: Replicating and latent EBV, multiple strains and recombinant variantsCause: Replicating and latent EBV, multiple strains and recombinant variants Site: Primarily lateral border of the tongueSite: Primarily lateral border of the tongue Signs & Symptoms: Filmy to shaggy adherent white plaques, asymptomatic, taste abnormalities, burning sensation; lesion waxes and wanesSigns & Symptoms: Filmy to shaggy adherent white plaques, asymptomatic, taste abnormalities, burning sensation; lesion waxes and wanes Concurrent disease: CandidiasisConcurrent disease: Candidiasis Diagnosis: Clinical, cytology, biopsy, PCR or in situ hybridizationDiagnosis: Clinical, cytology, biopsy, PCR or in situ hybridization

37 Hairy Leukoplakia in Children

38 Oral Warts in Children Skin lesions are common but oral warts are rare (<1%)Skin lesions are common but oral warts are rare (<1%) Cause: Human papillomavirus (HPV)Cause: Human papillomavirus (HPV) Transmission: Direct contact, vertical infectionTransmission: Direct contact, vertical infection Predisposing factor: Inflammatory skin disordersPredisposing factor: Inflammatory skin disorders Site: Perioral skin, vermilion, oral and nasal mucosaSite: Perioral skin, vermilion, oral and nasal mucosa S/S: Spiky or flat, papillary or stippled, white papules and nodules; usually multiple or florid in numberS/S: Spiky or flat, papillary or stippled, white papules and nodules; usually multiple or florid in number Diagnosis: Clinical, biopsy, HPV-typingDiagnosis: Clinical, biopsy, HPV-typing TX: Excision, laser ablation, cryotherapy when localizedTX: Excision, laser ablation, cryotherapy when localized

39 Oral Warts in Children

40 Thrombocytopenia in Children Pediatric prevalence: Up to 18% during disease coursePediatric prevalence: Up to 18% during disease course Cause: Antibody-mediated, bone marrow failureCause: Antibody-mediated, bone marrow failure Site: Oropharyngeal and nasal mucosa, skinSite: Oropharyngeal and nasal mucosa, skin S/S: Gingival bleeding, petechiae, purpura, hematoma; nosebleedS/S: Gingival bleeding, petechiae, purpura, hematoma; nosebleed Diagnosis: Complete blood count, including platelet count, thrombopoietinDiagnosis: Complete blood count, including platelet count, thrombopoietin TX: HAART regimens, interferon- , steroids, IVIG, transfusionTX: HAART regimens, interferon- , steroids, IVIG, transfusion

41 Thrombocytopenia in Children

42 Cancer in Children Prevalence: 2% of HIV infected childrenPrevalence: 2% of HIV infected children Cause: Viral-associated, EBV, HHV-8, HPVCause: Viral-associated, EBV, HHV-8, HPV Median age: 4.3 years - vertical; 13.4 years - bloodMedian age: 4.3 years - vertical; 13.4 years - blood Types from Children’s Cancer Group ( ):Types from Children’s Cancer Group ( ):  Non-Hodgkin’s lymphoma (65%)  Leiomyosarcomas, leiomyomas (17%)  Leukemia, lymphoblastic and myeloid (8%)  Kaposi’s sarcoma (5%)  Hodgkin’s lymphoma (3%)  Vaginal carcinoma, tracheal neuroendocrine (2%)

43 Lymphoma in Children Prevalence: < 2%; most common malignancyPrevalence: < 2%; most common malignancy Type: Most are high-grade non-Hodgkin’s lymphomaType: Most are high-grade non-Hodgkin’s lymphoma Cause: EBV, HHV-8 and immunosuppressionCause: EBV, HHV-8 and immunosuppression Median age: 5.5 years ( yrs)Median age: 5.5 years ( yrs) Site: 80% are extranodal; GI and CNSSite: 80% are extranodal; GI and CNS Oral site: Tonsils, palate and gingivaOral site: Tonsils, palate and gingiva S/S: Rapid growth, diffuse pink to red mass, ulceration; pain & paresthesia; tooth mobility and displacement; bone lossS/S: Rapid growth, diffuse pink to red mass, ulceration; pain & paresthesia; tooth mobility and displacement; bone loss Diagnosis: Biopsy, advanced imaging, tumor stagingDiagnosis: Biopsy, advanced imaging, tumor staging TX: Multiagent chemotherapy +/- radiationTX: Multiagent chemotherapy +/- radiation

44 Lymphoma in Children

45 Kaposi’s Sarcoma in Children Pediatric prevalence: Rare except for AfricaPediatric prevalence: Rare except for Africa Cause: HHV-8 and immune suppressionCause: HHV-8 and immune suppression Rare vertical transmission, except AfricaRare vertical transmission, except Africa Form: Lymphadenopathic type with or without diffuse skin lesions; rare oral involvementForm: Lymphadenopathic type with or without diffuse skin lesions; rare oral involvement Oral site: Palate and gingivaOral site: Palate and gingiva S/S: Red to purple macule or nodule; single or multiple, usually asymptomaticS/S: Red to purple macule or nodule; single or multiple, usually asymptomatic Diagnosis: Biopsy and tumor stagingDiagnosis: Biopsy and tumor staging TX: HAART regimens, chemotherapyTX: HAART regimens, chemotherapy

46 Kaposi’s Sarcoma in Children

47 Cutaneous Lesions in Children Prevalence: > 80% of HIV infected children will have at least one mucocutaneous lesionPrevalence: > 80% of HIV infected children will have at least one mucocutaneous lesion  Infectious diseases account for 66%  Inflammatory disorders account for 33% Similar prevalence as oral lesions in these childrenSimilar prevalence as oral lesions in these children Besides herpetic infections, several lesions are potentially contagious to the health care providerBesides herpetic infections, several lesions are potentially contagious to the health care provider  Impetigo  Tinea corporis  Scabies

48 Impetigo in Children Type: Contagious, superficial bacterial infectionType: Contagious, superficial bacterial infection Cause: Staphylococcus aureus, streptococciCause: Staphylococcus aureus, streptococci Transmission: Direct contactTransmission: Direct contact Site: Usually the face but any body surfaceSite: Usually the face but any body surface Signs & Symptoms: Vesicles, pustules or bullae with a red base and covered by honey-colored sticky crust; lymphadenopathy; may become hyperpigmentedSigns & Symptoms: Vesicles, pustules or bullae with a red base and covered by honey-colored sticky crust; lymphadenopathy; may become hyperpigmented Diagnosis: Clinical, cultureDiagnosis: Clinical, culture TX: Mupirocin (Bactroban) ointment for isolated lesions; systemic antibiotics if widespreadTX: Mupirocin (Bactroban) ointment for isolated lesions; systemic antibiotics if widespread

49 Impetigo in Children

50 Tinea Infections in Children Type: Superficial fungal infection (ringworm)Type: Superficial fungal infection (ringworm) Cause: Dermatophytes and immune defectCause: Dermatophytes and immune defect Distribution: Tinea pedis (feet); tinea corporis (face, body, limbs); tinea capitus (scalp); tinea cruris (groin)Distribution: Tinea pedis (feet); tinea corporis (face, body, limbs); tinea capitus (scalp); tinea cruris (groin) Signs & Symptoms: Annular lesions with red, scaly, advancing front; alopecia when scalp is involvedSigns & Symptoms: Annular lesions with red, scaly, advancing front; alopecia when scalp is involved Diagnosis: Clinical, cytologyDiagnosis: Clinical, cytology Significance: Severe and persistent infectionSignificance: Severe and persistent infection TX: Topical or systemic antifungal medications; refer to pediatrician or dermatologistTX: Topical or systemic antifungal medications; refer to pediatrician or dermatologist

51 Tinea Infections in Children

52 Antiretroviral Regimens in Children HAART: 2 nucleoside analogue reverse transcriptase inhibitors (NRTI) protease inhibitor (PI) or 1non- nucleoside reverse transcriptase inhibitor (NNRTI)HAART: 2 nucleoside analogue reverse transcriptase inhibitors (NRTI) protease inhibitor (PI) or 1non- nucleoside reverse transcriptase inhibitor (NNRTI) NRTI oral side effects: Oral ulcers (ddC), sore throat (ABC), xerostomia (ddI), anemia, neutropenia (AZT)NRTI oral side effects: Oral ulcers (ddC), sore throat (ABC), xerostomia (ddI), anemia, neutropenia (AZT) PI oral side effects: Taste perversions, xerostomia, exfoliative cheilitis, circumoral paresthesia, thrombocytopeniaPI oral side effects: Taste perversions, xerostomia, exfoliative cheilitis, circumoral paresthesia, thrombocytopenia NNRTI oral side effects: Lichenoid reaction, erythema multiforme majorNNRTI oral side effects: Lichenoid reaction, erythema multiforme major Drug Interactions and dentistry: Midazolam, triazolam, metronidazole, meperidineDrug Interactions and dentistry: Midazolam, triazolam, metronidazole, meperidine

53 Antiretroviral Regimens in Children

54 Dental Considerations in Children Poor compliance with therapiesPoor compliance with therapies Oral effects of medications: dry mouth, vomiting, taste alterations, sucrose and alcohol contentOral effects of medications: dry mouth, vomiting, taste alterations, sucrose and alcohol content Symptomatic orofacial lesionsSymptomatic orofacial lesions Referred pain: Sinusitis, otitis media, neuropathiesReferred pain: Sinusitis, otitis media, neuropathies Compromised airway and pulmonary functionCompromised airway and pulmonary function Poor motor skills: neuropathy, encephalopathyPoor motor skills: neuropathy, encephalopathy Hematologic disorders: CytopeniasHematologic disorders: Cytopenias HAART regimens & potential drug interactionsHAART regimens & potential drug interactions Exposure to a variety of infectious diseasesExposure to a variety of infectious diseases


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