Classification of oral diseases of HIV- associated immune suppression (ODHIS)

         Present classification systems for HIV – associated oral lesions developed in the early 1990’s which was named as HAART. Patterns of oral conditions keep on changing very frequently. This highlights the need of new system.

Classification of oral diseases of HIV – associated immune suppression (ODHIS)

System should consider:

·         Changes in epidemiology of oral lesions

·         Therapeutics

·         Development of lesions and immune systems

·         Oral lesions to oral disease

Definition of Oral disease:  abnormality characterized by a defined set of signs and symptoms in the oral cavity, extending from the vermilion border of the lip to the oropharynx, with the exception of salivary gland disease

New Classification- Classification of oral diseases of HIV – associated immune suppression (ODHIS)

Group 1 – ODHIS associated with severe immune suppression (CD4<200 cells/mm³)

Group 2 – ODHIS associated with immune suppression (CD4<500 cells/mm³)

Group 3 – ODHIS assumed associated with immune suppression

A) More commonly observed

B) Rarely reported

Group 4 – Therapeutically-induced oral diseases

Group 5 – Emerging oral diseases

Oral diseases do not belong exclusively to one classification Group

Overlap may exist

Use of the New Classification

·         Identifying undiagnosed individuals

·         Provides additional rationale for HIV testing

·         Affects access and type of HIV-related healthcare

·         Provides clinical markers for therapeutic interventions and efficacy

Group 1. ODHIS associated with severe immune suppression (CD4<200 cells/mm³)

1.      Major recurrent aphthous ulcer

2.      Neutropenia-induced ulcers

3.      Necrotizing ulcerative periodontitis

4.      Necrotizing stomatitis

5.      Cytomegalovirus (CMV)

6.      Chronic HSV

7.      Histoplasmosis

8.      Esophageal, pseudomembranous, and hypertrophic candidiasis

9.      Oral hairy leukoplakia

10.   Kaposi’s sarcoma

11.   Idiopathic Necrotizing Stomatitis    

Hyperplastic candidosis

Oesophageal candidosis

Pseudomembranous Candidosis

Kaposi's Sarcoma

Histoplasmosis

Periodontitis

Neccotizing Sialometaplasia

Chronic HSV

Group 2. ODHIS associated with immune suppression (CD4,500 cells/mm3)

1.       Major recurrent aphthous ulcer

2.       Increased frequency, harder to treat, atypical location

3.       Erythematous candidiasis

4.       Salivary gland disease

5.       Drug induced low salivation

6.       Facial palsy

7.       Neuropathies

8.       Hyposalivation

9.       Human papilloma virus (HPV)

10.   Linear gingival erythema

11.   Non-Hodgkin’s lymphoma

12.   Linear Gingival Erythema

Aptheous Ulcer

HPV

Group 3. ODHIS assumed associated with immune suppression

More commonly observed

1.       Angular candidiasis

2.       Herpes labialis

3.       Intra-oral herpes

4.       Minor aphthous ulcers

Rarely reported

1.       Bacillary epithelioid angiomatosis

2.       Tuberculosis

3.       Deep-seated mycosis (except histoplasmosis)

4.       Molluscum contagiosum

5.       Varicella Zoster Virus (VZV)

6.       HSV Labialis

7.       Intra-oral Herpes

8.       Minor Aphthous Ulcers

Angular Chelitis with candidosis

Group 4. Therapeutically-induced oral diseases

Side-effect

·         Melanotic hyperpigmentation

·         Ulcers

·         Hyposalivation

·         Lichenoid drug reaction

·         Neutropenia-induced ulcers

·         Thrombocytopenia

·         Lypodystrophy-associated oral changes

·         Perioral paresthesia

·         Steven Johnson’s?

·         Exfoliative cheilitis?

Resistance-induced disease

·         Different Candida spp and strains

·         HSV

Antiretrovirals and Adverse Reactions

Antiretroviral Drugs

Indinavir

Saquinavir

Amprenavir

Nevirapine

Delavirdine

Efavirenz

Stavudine

Didanosine

Recurrent HSV

Adverse reactions of antiretroviral drugs

Oral ulcers

Stevens Johnson’s

Taste changes

Dryness

Perioral paresthesia

Thrombocytopenia

Ulcers – Medication Induced

Recurrent HSV

Group 5. Emerging oral diseases

1.       Human papilloma virus, several HPV types (may be associated with immune reconstitution)

2.       Erythema migrans

3.       Variants of Non-Hodgkin’s Lymphoma (NHL B-cell types)

4.       Epithelial neoplasms

5.       Aggressive interproximal dental caries

6.       Condyloma Accuminatum

7.       Squamous Cell Carcinoma

Ebola Virus [Ebola virus disease (EVD) or Ebola hemorrhagic fever (EHF) ]

What is Ebola?

Ebola is a virus which causes rare but deadly disease Ebola virus disease (EVD) or Ebola

hemorrhagic fever (EHF) which is a disease of humans and other primates. Symptoms start two days to three weeks after contact with the virus. Symptoms area fever, sore throat, muscle pain, and headaches. Typically nausea, vomiting, and diarrhea follow, along with decreased functioning of the liver and kidneys. Around this time, affected people may begin to bleed both within the body and externally.

Ebola’s natural reservoir is unknown.Non human primates have been the source of human infections but are not thought to be the reservoirs.

Ebola Taxonomy or Scientific Classification

Order: Mononegavirales

  Family: Filoviridae

  Genus: Ebola like viruses

  Species: Ebola 

Subtypes  

Ebola-Zaire, Ebola-Sudan,Ebola-Ivory Coast-disease in humans

Ebola-Reston-disease in nonhuman primates

Filoviridae or “Filoviruses”

•          Most mysterious virus group

•          Pathogenesis poorly understood

•          Ebola

–        Natural history/reservoirs unknown

–        Exist throughout the world

–        Endemic to Africa

–        Filamentous ssRNA^- (antisense) viruses

History

Named after the Ebola River in the Democratic Republic of the Congo (formerly Zaire), near the first epidemics.

Two species were identified in 1976:

• Zaire ebolavirus (ZEBOV)
• Sudan ebolavirus (SEBOV)

Case fatality rates of 83% and 54% respectively.

A third species, Reston ebolavirus (REBOV), was discovered in November 1989 in a group of monkeys (Macaca fascicularis) imported from the Philippines.

Ivory Coast ebolavirus – Only one case. Unlucky scientist.

Outbreaks of EBOLA

Most Recent Incident

April 25 – June 16 2005 total of 12 cases including 9 deaths were reported in Etoumbi and Mbomo in the Cuvette Quest Region

Ebola Pathogenesis

•          Enters Bloodstream

–         Skin, membranes, Open wounds

•          Cell Level

–         Socks with cell membrane

•          Viral RNA

–        Released into cytoplasm

–        Production new viral proteins/ genetic material

•           New viral genomes

–        Rapidly coated in protein

–        Create cores

•          Viral cores

–        Stack up in cell

–        Migrate to the cell surface

–        Produce trans-membrane proteins

–        Push through cell surface

–        Become enveloped by cell membrane

•          ssRNA^- Genome Mutations

–        Capable of rapid mutation

–        Very adaptable to evade host defenses and environmental change

•          Theory

–         Virus evolved to occupy special niches in the wild

Modes of Transmission

There are 3 modes of infection

1. Unsterilized needles
2. Suboptimal Hospital conditions
3. Personal contact

Symptoms and Diagnostic Tests

•          Early symptoms

–        Muscle aches, fever, vomiting

–        Red eyes, skin rash, diarrhea, stomach pain

–        Acute symptoms

–        Bleeding/hemorrhaging from skin, orifices, internal organs

–        Onset of fever.

–        Intense weakness.

–        Muscle Pain.

–        Headache.

–        Soar Throat.

–        Vommitting, Diarrhoea.

–        Impaired Kidnay and liver function

•          Early Diagnosis

•          Very difficult

•          Signs & symptoms very similar to other infections

•          Laboratory Test for the diagnosis of Ebola Virus

•          PCR detection

•          ELISA (enzyme-linked immuno-absorbant) assay

Is there a cure for Ebola?

•          There are no known curative medications for Ebola.

•          However, there have been very recent developments in preventative medications.

•          No Standard Treatment available

•          Patients receive supportive therapy

•          Treating complicating infections

•          Balancing patient’s fluids and electrolytes

•          Maintaining oxygen status and blood pressure

•          No vaccines!

•          Patients are isolated

•          Medical Staff Training

•          Western sanitation practices

•          Intake

•          Care during stay

•          After patient dies

•          Infection-control Measures

•          complete equipment and area sterilization

Vaccines

•          In June, Jones and his colleagues, Dr. Heinz Feldmann of Winnipeg and Dr. Thomas Geisbert at Fort Detrick, Maryland announced that they had successfully vaccinated monkeys against the deadly Ebola virus

•          The Ebola vaccine is based on the 1976 strain of the Zaire species and protects from the 1995, but not the other 2 species that affect humans.

Risk of Bioterrorism?

Airborne transmission of Ebola Zaire has been demonstrated in monkeys in a controlled laboratory experiment

Plum Island…?

Prevention

After Death

Virus contagious in fluids for days

•          Burial use extreme caution

–        Handling and transport

–        Cultural practices/ religious belief

–        Incinerate all waste!!!!

–        Protective clothing

–        Body sealed in body bag and coffin

–        Sanitation of all equipment before and after

–        Risk for exposure special steps need to be taken to protect the family and community from illness.

–        Family only

–        Why open casket not possible

–        Some practices cannot be done

Conclusion

•          Reservoirs in Nature

–        Largely unknown

–        Possibly infected animals (primates?)

•          Transmission

–        Direct contact blood/secretions of infected person

–        Possible airborne (Reston primate facility)

•          Onset of illness abrupt

–        Incubation period:  2 to 21 days

–        Infections are acute and mostly deadly

Latest Morbidity and Mortality Reports

Ebola-Reston Virus Infection Among Quarantined Nonhuman Primates -- Texas, 1996

Report describes death and blood testing of cynomolgus monkey imported from the Philippines held in a private quarantine facility in Texas

•          Outbreak of Ebola Hemorrhagic Fever ---Uganda, August 2000--January 2001

–        Report describes surveillance and control activities related to the EHF outbreak

–        Presents preliminary clinical and epidemiologic findings

Ebola Information Posters

Ebola Virus

Ebola Virus

Ebola Virus

Ebola Virus

Ebola Virus

Ebola Virus

Ebola Virus