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

Upper Limb Anatomy-MCQ

01.Regarding pronator teres which of the following statements is correct?

a)      It forms the lateral border of the cubital fossa

b)      It arises from the coronoid process and lateral epicondyle.

c)      The Median nerve passes deep to both heads

d)     It’s medial border forms the medial boundary of the cubital fossa

e)      It is the most lateral of the superficial flexors of the forearm

02.Regarding the radial nerve which statement is incorrect?

a)      It passes anterior to the lateral epicondyle of the humerus

b)      Injury to the radial nerve from fracture of the shaft of the humerus will result in wrist drop

c)      Injury to the deep radial nerve in the mid forearm will prevent extension only at the MCPJs

d)     Sensory loss from injury to the superficial radial nerve will usually result in loss of sensation over the entire thumb

e)      It is the larger terminal branch of the posterior cord of the brachial plexus

03.Regarding the blood supply of the forearm

a)      The radial artery is the larger of the terminal branches of the brachial artery

b)      The radial artery runs under brachialis as it leaves the cubital fossa

c)      The radial artery has just one named branch proximal to the carpal braches

d)     Ligation of the radial artery at its origin will significantly reduce blood flow through the posterior interosseous artery.

e)      The radial artery has no involvement in the elbow anastomotic network

04The median nerve

a)      Supplies flexor carpi ulnaris and half of flexor digitorum profundis

b)      Gives rise to most of its braches in the upper arm

c)      Gives rise to the common interosseous nerve which divides anterior to the radial head

d)     May be compressed between the two heads of pronator teres

e)      Enters cubital fossa lateral to the brachial artery

Answers

1) E

2) D

3) C

4) D

Anatomy MCQs (Thorax)-12 Questions

1-      Regarding the intercostal nerve all the following are True, EXCEPT:

a-      7^th Intercostal nerve is typical

b-      End by anterior cutanous nerve

c-       2^nd will supply the skin of axilla (lateral branch)

d-      Communicate with sympathetic trunk through rami communication

e-      Located below the arteries

Answer- a

2-      Regarding intercostal arteries:

a-      are superior to veins & nerves

b-      musculophrenic artery will supply 7^th to 9^th intercostals spaces

c-       all the posterior branches are from the aorta

d-      the collateral branch supply the lung

e-      all the anterior branches are from the internal thoracic

Answer- b

3-      All the following are in the Rt atrium, EXCEPT:

a-      azygos vein

b-      anterior cardiac vein

c-       coronary sinus

d-      SVC

e-      IVC

Answer- a

4-      Regarding Rt ventricle all the following are True, EXCEPT:

a-      have three papillary muscle

b-      the  septomarginal trabecula (moderator band) extend from the septum to the base of the anterior papillary muscle

c-       have a pectinate muscle which passes anteriorly

d-      The outflow portion of the champer inferior to the pulmonary  orifice called infandibulum

e-      The infandibulum is smooth and the remainder of the ventricle is rough

Answer- c

5-      X-ray of the Lt border of mediastinum show the following, EXCEPT:

a-      left auricle

b-      aortic arch

c-       pulmonary trunk

d-      left ventricle

e-      right atrium

Answer- e

6-      superior mediastinum shows all the following, EXCEPT:

a-      trachea

b-      ascending aorta

c-       arch of aorta

d-      left brachiocaphalic vein

e-      vagus nerve

Answer- b

7-      Regarding the Arch of the aorta, the incorrect statements is:

a-      Located in superior mediastinum

b-      Located below the brachiocaphalic vein

c-       Connected to the pulmonary trunk by ligamentum arteriosum

d-      It is arches over the Lt main bronchus

e-      The Rt recurrent laryngeal nerves hocks around it

Answer- e

8-      the correct statement about Thoracic duct is:

a-      it is enter to the thorax through caval opening

b-      it lies posterior to the esophagus in the superior mediastinum

c-       it lies in the superior & posterior mediastinum

d-      drain into Rt subclavian vein

e-      it receives the lymph from both lungs

Answer- c

9-      Regarding pericardium:

a-      visceral part supplied by phrenic nerve

b-      Fibrous pericardium consist of visceral & parietal parts

c-       serous pericardium down represent the attachment of central tendon of diaphragm

d-      Located laterally to the esophagus

e-      The oblique sinus is bounded anteriorly by the visceral layer of serous pericardium

Answer- e

10-   All the following are related posteriorly to the heart, EXCEPT:

a-      Oblique sinus

b-      Rt bronchus

c-       Thoracic aorta

d-      Lt vagus

e-      Esophagus

Answer- b

11-   Regarding Rt main bronchus all the following are True, EXCEPT:

a-      wider than the Lt

b-      longer than the Lt

c-       more vertical than the Lt

d-      bacteria pass through it easily

e-      gives off the Rt superior lobe bronchi before entering the hilum

Answer- b

12-   Regarding the pleura the incorrect statement is:

a-      cervical part is above the clavicle

b-      diaphragmatic pleura supplied by intercostal nerves ONLY

c-       cervical pleura is crossed by subclavian vessels

d-      pleural cavity is a potential space

e-      the visceral & parietal pleurae are continuous around the root of the lung

Answer- b

Embolism

Embolus Definition

A detached intravascular solid, liquid  or gaseous mass that is carried by the blood to a site distant from its origin.

Embolism

Occlusion or obstruction of a vessel by an embolus

Causes and Types of emboli

• Thrombi: Thromboembolism
• Microemboli
• Fragments of atheromatous plaques-Atheroemboli
• Bone marrow and bone fragments
• Fat emboli
• Air/nitrogen emboli
• Aminiotic fluid
• Tumour
• Foreign body emboli: IV catheters
• Parasitic emboli

Where emboli lodge depend on their size, their origin, and relevant cardiovascular anatomy.

Those arise in the venous system can travel through the right side of the heart to end up in pulmonary circulation.

Those arise in the left side will block the systemic arteries, and the clinical effect will depend on the organ involved, be it brain, kidneys, spleen, or periphery of the limbs.

Categories of Embolism

• Systemic embolism- Arise in arterial system eg: thromboemboli in arterial system and left heart, atheroemboli, fat, tumor
• Pulonary embolism- Arise in venous system thrombi in right heart and deep venous thrombosis, all except atheroemboli.
• Paradoxical-  By right to left shunt- ASD and VSD
• Retrograde

Pulmonary embolism

Thrombo-emboli often originate in the deep veins and pass in the venous circulation through right side of heart.

The outcome of pulmonary embolism depends on the size of the blood vessel blocked & presence of pre-existing lung diseases.

Massive pulmonary embolism

Massive coiled pulmonary emboli  are impacted in a main pulmonary artery at bifurcation (Saddle embolus).

This leads to acute right heart failure and sudden death. 

Obstruction of medium sized artery

Dual blood supply protects lung from effects of pulmonary arterial embolism.

No infarctions are seen.

There will be local haemorhage but no damage to pulmonary frame work.

Patient may be asymptomatic or breathlessness  or haemoptysis may present

Emboli in small peripheral arteries

Smaller emboli in periphery can lead to infarctions of the lung as there are no collateral supplies to pulmonary arteries in end arteries.

Area affected is often small but may produce symptoms if multiple

Patient has dyspnoea if these are multiple.

If the bronchial blood supply is impaired

Emboli lodging in medium sized arteries can lead to infarctions.

Since the blockage is proximal the infarcted area is large extending as a cone with the base towards the surface and apex at the blocked artery.

Infarcted area is red due to haemorhage  and congestion.

Infarcts are common in lower lobes and are often multiple.

Microscopy

Bloked blood vessel.

Infarcted area shows haemorhage  with loss of nuclear staining.

But still the alveoli can be identified.

The main pulmonary trunk and pulmonary arteries to right and left lungs are seen here opened to reveal a large "saddle" pulmonary thromboembolus. Such an embolus will kill your patient.

Here is another large pulmonary thromboembolus seen in cross section of this lung. The typical source for such thromboemboli is from large veins in the legs and pelvis

This pulmonary thromboembolus is occluding the main pulmonary artery. Persons who are immobilized for weeks are at greatest risk. The patient can experience sudden onset of shortness of breath. Death may occur within minutes.

This pulmonary embolus is adherent to the pulmonary arterial wall. If the patient survives, the thromboembolus will organize and, for the most part, be removed.

A pulmonary infarct is hemorrhagic because of the dual blood supply from the non-occluded bronchial arteries which continue to supply blood, but do not prevent the infarction.

Systemic embolism

Systemic emboli travel in the internal circulation, commonly originating in the left side of the heart.

Arterial emboli, unless very small, nearly always cause infarction. Emboli to the lower limb may produce gangrene of a few toes or of the entire limb.

Sources of emboli

Heart

1. Ischemic heart disease-mural thrombi, aneurisms,, hypokinetic segments
2. Arrhythmias
3. Valvular- Rheumatic hreart
4. Myocardial - Myocarditis
5. Intra cardiac lesions-
6. Myxomas

Arterial System

• Ulcerated atheromatous plaque
• Aortic aneurisma
• Venous shunts in dialysis patients

Sites of lodgement

• Coronary arteries
• Cerebral Arteries
• Renal Arteries
• Splenic Arteries
• Retinal arteries
• Mesentric Arteries
• Limb arteries
• Embolous at the bifurcation of the aorta

Cerebral emboli cause death or infarction unless the embolus lodges in an area that receives adequate collateral supply through the circle of Willis.

A special type of systemic embolus comprises the infected material from vegetations on the heart valves in infective endocarditis. These produce septic infarcts and large abscesses in the affected tissues.

Paradoxical embolus: Venous thrombi that pass through a right–to-left congenital cardiac anomaly

 

Bone marrow emboli

Common in patients who suffered major trauma eg. RTA

Attempted cardiac resuscitation  with rib fractures can lead to this.

Any thing that fractures bones can release bone marrow into venous circulation, resulting in pulmonary emboli.

Clinical significance unclear

Embolism of fragments of atheromatous plaques

Ulcerated atheromatous plaques can cause thrombosis on surface of it or cause embolism of fragments

Cholesterol clefts are seen in the embolus

Fat embolism

Fat from marrow cavities of long bones or from soft tissues can also enter the circulation as a result of severe trauma.

‘Fat embolism syndrome’ characterized by respiratory problems, haemorhagic skin rash, and mental deterioration  24-72 hours after the injury.

The syndrome results from mechanical blockage of vessels, chemical injury to vessels of lung producing pulmonary oedema and activation of coagulative pathway to cause DIC.

Causes of fat embolism

·         Severe trauma with fractures of long bones

·         Damage to fatty tissues

·         Diabetes mellitus

·         Pancreatitis

·         Hyperlipidaemia

Laboratory investigations

·         Urine deposit: fat globules

·         Sputum: fat globules

·         Blood picture :DIC and thrombocytopenia

Air embolism

Large quantities of air within the circulation can act as emboli by forming a frothy mass that can block vessels or become trapped in the right heart chambers to impede pumping.

Over 100 ml of air is needed to produce problems. Lesser amounts dissolve in plasma.

Air can either enter the circulation from

Atmosphere: cut injuries of neck and thorax allowing air to be sucked in.

Air forced into the uterine vessels during badly performed abortions and deliveries,

Produced within circulation: decompression sickness in deep sea divers

Acute decompression sickness

N2 or He will dissolve in blood and tissues at high pressures.

As the diver surfaces, the pressure is reduced and gas begins to come out as minute bubbles.

If rapid this causes air embolism (lodge in brain and skeletal muscle).

Platelets adhere to nitrogen bubbles causing DIC.

Pain around joints, skeletal muscle, respiratory distress coma and death.

Treatment of decompression sickness

·         Early stages, by putting the victim in a decompression chamber pressure will dissolve the bubbles where the high pressure will redissolve the bubbles and allow a slow, controlled decompression.

·         The chronic form, Caisson disease, produces multiple areas of ischaemic necrosis in the long bones

Amniotic fluid embolism

Uncommon but life threatening forms of embolisation.

Amniotic  fluid is forced into the circulation as as a result of traring of the placental membranes and rupture of uterine wall or cervical veins.

Emboli are a mixture of fat, hair, mucous, meconeum and squamous cells from the fetus

Commonly lodge in the alveolar capillaries

Clinically, respiratory failure, cerebral convulsions and coma. Often excessive bleeding due to DIC

Tumour emboli

This is an important mechanism of tumour spread.

Unlikely to have immediate CVS effects