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Opportunistic Infections: Oral Hairy Leukoplakia (Ohl)

Basic Information

The mouth is important both for diagnosis and prognostic staging of HIV and oral manifestations of HIV occur in 40% of patients with HIV infection. In patients diagnosed with AIDS, oral lesions have been reported in over 90% at some point in the course of the disease, increasing in incidence with advanced HIV disease.

Oral hairy leukoplakia (OHL) is a viral infection of the oral cavity. Other HIV-related viral infections that can infect the area of the mouth include CMV, herpes simplex, varicella-zoster and papillomavirus. HIV-related infections of the mouth can also be fungal (i.e. candidiasis which, like OHL, is often one of the first opportunistic infections to appear -- and indeed it can be confused with OHL) or bacterial (which includes HIV gingivitis and HIV-related periodontal disease).

Often OHL is one of the first indicators of HIV disease -- in patients who have not been tested for HIV the presence of OHL is diagnostic -- suggesting a seriously compromised immune system indicative of HIV infection, although OHL has also been seen:

  • in immunosuppressed organ transplant recipients (heart, bone marrow, kidney)
  • in other immunosuppressed persons
  • during some chemotherapy cancer treatments
  • even on rare occasions in persons who are not immunosuppressed

Nonetheless it is not only an indicator of HIV infection but an indicator of a person's lessening or weakening immunity, predictive (without HIV treatment) for a progression to AIDS -- in other words, a progression from asymptomatic HIV infection to an AIDS-defining disease within three years of OHL diagnosis. There may be additional or co-factors that also contribute to fairly rapid progression to AIDS (such as CD4 count) but other possible factors have not been conclusively identified.

It is a fairly harmless illness on its own -- a benign infection occurring in about one-fifth of HIV-infected persons whose CD4 lymphocyte count is above 500 cells per mm. It fluctuates or waxes and wanes and sometimes resolves spontaneously, causing little trouble for most patients.

OHL is caused by the Epstein-Barr virus (EBV) and while EBV may be passed through kissing, there is no indication or reason to believe that OHL is. There are no preventive measures to take to avoid getting this infection, except for treatment for HIV itself.

The cause of the infection is unknown, however the outer cell layers of the oral mucosa membrane undergo a thickening process due to the cells in the mucosa membrane that are infected by Epstein-Barr virus.

Symptoms

  • The OHL lesion or lesions are white (sometimes referred to as white plaques) and appear most frequently on the sides and surface of the tongue.
  • The lesion or lesions are often raised and have a thick or corrugated (hence "hairy") surface and rough texture.
  • The lesion or lesions may be flat but coat the tongue.
  • Usually no symptoms are felt but sometimes there is discomfort or pain and some patients complain that OHL's presence interferes with taste.
  • OHL can also be seen in other parts of the mouth (besides the sides and surface of the tongue) including:
  • the bottom or floor of the mouth
  • lining of the throat
  • the soft palette
  • lining of the cheeks
  • Size varies greatly from a fraction of an inch to covering the entire surface of the tongue.

Diagnosis/Treatment

Diagnosis is usually made by electron microscopic examination of affected tissue in which Epstein-Barr virus may be found.

It resembles thrush (oral candidiasis) -- and has been diagnosed when treatments for thrush prove ineffective.

Many patients decide not to treat OHL. However, some elect to do so for cosmetic reasons or because in some cases discomfort and even pain occurs. But the white plaques or lesions cannot be scraped away.

Treatment consists of taking oral acyclovir or gancyclovir and this treatment has provided some beneficial results although once a patient stops the medication lesions usually return.

Topical agents or solutions such as topical retinoid and podophyllin resin can be applied directly to the lesion or lesions and may heal within a week. If healing does not occur within a week, repeat the applications. As with oral acyclovir, the use of these medications are rarely effective beyond the period of usage and recurrences are more the rule than the exception.

We at Always Your Choice have had experience diagnosing and treating OHL and if you are diagnosed with OHL at our medical offices or elsewhere -- and you have not yet had an HIV test -- one is indicated. It is important to find out your HIV status as there is drug therapy now available that in most cases can dramatically slow the progression of HIV disease. If you feel you have OHL we at Always Your Choice would be pleased to see you.