HIV & Oral Infections

Several HIV-related opportunistic infections occur in the mouth. These infections may cause pain during eating or make it difficult to swallow. Oral infections include the following:

  • Oral thrush
  • Oral hairy leukoplakia
  • Oral herpes
  • Apthous ulcers
  • Ulcers in the esophagus

Oral Thrush

Thrush is a fungal infection usually caused by Candida albicans or Candida tropicalis. In this condition, a patchy or solid white coating develops on the tongue, inner cheeks, and roof of the mouth and can extend from the back of the mouth down the esophagus towards the stomach. It may cause discomfort; and if it occurs in the esophagus, it can cause difficulty swallowing.

Thrush is usually treated with oral medicines such as fluconazole (Diflucan) or itraconazole (Sporanox), or with lozenges (e.g., clotrimazole [Mycelex]). The white patches can be brushed off the tongue or the inside of the mouth with a toothbrush, but they come back without medical treatment.

Oral Hairy Leukoplakia

Hairy leukoplakia is a white coating on the tongue that is often confused with thrush. Unlike thrush, it cannot be scraped off with a toothbrush and does not appear on the inner cheeks or roof of the mouth. It gives the tongue a patchy, hairy appearance which is caused by the lengthening of the papillae, the small bumps that cover the surface of the tongue.

The cause of hairy leukoplakia is unknown and it may result from a herpesvirus infection. There is no specific treatment, but it usually resolves on its own after antiretroviral therapy.

Oral Herpes

Herpes simplex, the virus that causes genital herpes, also causes oral herpes. Herpes infections cause small, painful sores (ulcers) that tend to recur and are especially painful when they come in contact with hot, spicy, or salty foods. During the first outbreak, the sores are usually scattered around the inside of the mouth, on the inner cheeks, and possibly on the gums. In subsequent outbreaks, only one or a few sores appear, usually on the outside of the lips.

In each patient, the sores always appear in the same place. For example, in one patient, the sores might always appear on the top left corner of the lower lip, and another patient may develop sores in the middle of the lower lip. Patients who have been infected more than once get recurring sores in more than one place.

In most cases, patients experience burning, tingling, or itching before the sores appear. Patients who have oral herpes should be especially aware of these early symptoms because treatment is much more effective if it is started early.

Treatment for oral herpes may include oral medicines, including famciclovir (Famvir), valacyclovir (Valtrex) and acyclovir (Zovirax), which have proven effective against oral herpes—especially when started at the first sign of an outbreak. Topical creams and ointments also can be used to treat the outbreaks, although they are not usually as effective as pills. Patients who experience frequent recurrences of oral herpes often take continual small doses of famcyclovir, valacyclovir, or acyclovir to prevent recurrences.

Apthous Ulcers

Apthous ulcers are small, shallow ulcers on the inside of the mouth. The ulcers look like herpes ulcers and are sometimes confused with an initial outbreak of oral herpes. Like herpes, Apthous ulcers are painful, especially when they come into contact with hot, spicy, or salty foods. Apthous ulcers always occur on the inside of the mouth and also can develop in the esophagus.

In most cases, apthous ulcers do not require treatment and heal within a week. Rinsing with a mouthwash made from an antacid (e.g., Maalox®) and a local anesthetic (e.g., Viscous Xylocaine) may provide relief for about 30 minutes or so.

Prednisone, which is a corticosteroid, can help shorten the course of severe outbreaks. Some studies have shown that thalidomide may also be effective. Thalidomide can cause severe birth defects and should be used with extreme caution and under the supervision of a qualified health care provider.

Ulcers in the Esophagus

Ulcers in the esophagus cause painful swallowing, which often is described as a sharp, burning, or searing pain. These ulcers are especially painful when eating hot, salty, spicy, or acidic foods. In some cases, the physician looks down into the esophagus with a special instrument (called an endoscope) to identify the ulcer so that it can be treated properly.

Three types of ulcers occur in the esophagus:

  • Herpes ulcers
  • Apthous ulcers
  • Cytomegalovirus (CMV) ulcers

CMV ulcers, which are similar to herpes and apthous ulcers, tend to occur in patients who have extensive thrush in the esophagus. There is no specific treatment for CMV, and most CMV ulcers clear up with thrush treatment.

Lung Infections

Pneumonia is an infection in the lung. Three main pneumonias are associated with HIV infection:

  • Pneumocystis carinii pneumonia (PCP)
  • Bacterial pneumonia
  • Tuberculosis

Pneumocystis carinii pneumonia (PCP) was the first pneumonia to be associated with AIDS. In North America and Western Europe, PCP remains the primary cause for AIDS-related deaths. Preventative treatment (prophylaxis) and antiretroviral therapy have dramatically decreased the number of cases of PCP in the United States in recent years.

HIV-infected patients are at risk for developing PCP when their CD4 counts drop below 200. PCP causes a persistent, dry, hacking cough, and the patient usually feels very ill and feverish. Patients who have PCP generally became very short of breath when walking or engaging in any sort of light activity. Often, they are unable to take a deep breath and hold it without coughing.

PCP usually is treated with one of three medications: trimethoprim sulfamethoxazole (Bactrim®), pentamadine, or atovaquone. Often a steroid (e.g., prednisone) also is prescribed, especially if the blood oxygen level is low. In most cases, PCP can be prevented by combining antiretroviral therapy and one of these medications. In the United States and Western Europe, most patients who develop PCP are not being treated for HIV infection.

Bacterial pneumonias are common HIV-related infections; in fact, these infections are so common that two bacterial pneumonias within 6 months are considered an AIDS-defining condition. Most bacterial pneumonias are caused by the bacterium pneumococcus. These infections can be life-threatening, especially in patients with untreated HIV infection or those who have only recently begun treatment.

Bacterial pneumonia is treated with antibiotics. Many types can be prevented by receiving pneumoccal vaccination, taking antiretroviral therapy, and by not smoking. Smoking weakens the lungs and makes the body more susceptible to pneumonia. Patients who are HIV positive and smoke should speak with a physician or other health care provider about quitting.

Tuberculosis (TB) is one of the oldest and deadliest infections. About one-third of the world's population is infected with Mycobacterium tuberculosis, the bacterium that causes TB. Tuberculosis is the number one cause of death by infectious disease worldwide. It is also the most common infection risk for HIV-infected people with normal T-cell counts. TB is the leading cause of death among HIV-infected patients, accounting for about one-third of all AIDS-related deaths worldwide.

In the industrialized world, TB is no longer a great public health problem because of dramatic improvements in living conditions and sanitation, and the development and use of effective anti-TB drugs since the 1940s. In the developing world, however, TB remains a serious public health problem.

Not everyone who is infected with M. tuberculosis develops "active tuberculosis." In fact, only about 10% of people who are infected and are otherwise healthy develop TB symptoms during their lifetime. Patients with HIV are much more susceptible to developing active tuberculosis. In the United States, people who are infected with HIV and TB are 100 times more likely to develop active tuberculosis than people who are infected with TB but not HIV, according to the American Association for World Health.

The annual rate of TB cases in the United States is 40 times greater among people who are infected with HIV than in the general population. Therefore, all patients who are HIV positive should have a screening PPD (purified protein derivative) skin test and chest x-ray. The PPD skin test is used to detect M. tuberculosis infection.

Patients with HIV who also are PPD positive should receive prophylactic therapy—treatment to prevent the onset of active TB. Most patients are treated for 9 months with a medicine called isoniazid (INH), which is effective against active TB in patients who are HIV-positive, as well as those who are HIV-negative. Like antiretrovirals, INH must be taken every day for 9 months so that the TB bacteria do not become resistant to the drug. INH can cause liver problems, especially in African American and Latina women, a factor that is considered before prescribing the drug.

Active TB is characterized by fever, sweats, fatigue, cough, and bloody phlegm. Patients who have active TB are very contagious and must be isolated during early treatment to prevent the spread of infection.

Treatment for active TB involves 3 or 4 antibiotic medications taken for 6 to 12 months. Like antiretroviral therapy, the medication must be taken every day. If the drugs are not taken correctly, the tuberculosis bacteria can develop resistance, which is a huge global public health problem and one of the reasons so many people die from TB.

Because incorrect therapy can lead to resistance which, in turn, can lead to treatment failure and death, patients who have active TB should see a physician or other health care provider who has expert, up-to-date knowledge of TB and HIV treatment.

Gastrointestinal (GI) Tract Infections

At some point, diarrhea affects at least 50 percent of all patients with HIV/AIDS. It remains an important and common problem, although not nearly as great a problem as it was before the advent of antiretroviral therapy in the mid-1990s. Antiretroviral drugs prevent most of the infections and illnesses that cause diarrhea. Before antiretrovirals, diarrhea affected nearly all HIV/AIDS patients at some point and was very difficult to treat.

Diarrhea can be either acute (severe and short term) or chronic (constant and long term). Patients with severely suppressed immune systems (i.e., those who have greater viral loads and lower CD4+ counts) tend to experience diarrhea more frequently and for longer periods of time.

HIV patients who have diarrhea for more than 2 days should see a physician or other health care provider. If left untreated, diarrhea can lead to vitamin and mineral loss, weight loss, and wasting. Patients with HIV/AIDS who experience diarrhea should have their weight and body composition (e.g., electrolyte balance) monitored on a regular basis to avoid dehydration and death.

Some of the more common causes of diarrhea in patients with HIV/AIDS include the following:

  • Antiretroviral drugs (especially protease inhibitors)—Diarrhea caused by protease inhibitors is usually treatable. Rarely, patients must discontinue taking the drug to stop the diarrhea.
  • Antibiotics—used to treat HIV-related infections and illnesses
  • Digestive tract infections—Many foods and sources of drinking water contain parasitic microorganisms that don't affect people with healthy immune systems. In people with HIV/AIDS, infection with these parasites can lead to sickness and sometimes death.
  • Lactose intolerance—Dairy product(s) can lead to diarrhea, if a person is lactose intolerant.

Bacterial Gastroenteritis
Bacterial gastroenteritis is a bacterial infection (e.g., salmonella) in the intestines that causes nausea, vomiting, cramps, and diarrhea. It is the most common infectious cause of diarrhea in North America and Western Europe and usually results from contaminated food or water.

Patients with bacterial gastroenteritis are treated with an antibiotic and a clear-liquid or bland diet until symptoms improve. Interestingly, AZT is effective against salmonella and may be used as a preventative treatment.

Clostridium difficile
C. difficile is a bacterium that causes diarrhea in people following treatment with antibiotics. Because many patients with HIV are treated with antibiotics, they are at increased risk for developing C. difficile diarrhea, which is often profuse, watery, and foul-smelling, and may contain mucus or blood. This condition usually is treated with metronidazole, vancomycin, or neomycin. If left untreated, it can lead to serious illness.

Parasitic Infections

Microscopic, parasitic amoeba can cause severe diarrhea. Patients usually become infected by drinking contaminated, unpurified water. Amoeba can also be transmitted sexually if there is oral contact with feces.

An amoebic infection requires treatment with two antibiotics, metronidazole and iodoquinol, to destroy and remove the adult amoeba and amoebic cysts.

Giardia is a water-borne parasite that inhabits streams and wells and can be found in unpurified drinking water. Like amoeba, giardia can be transmitted sexually if there is oral contact with feces.

Giardia can cause severe, often foamy diarrhea, and many patients with giardia have foul-smelling "sulfur burps." Treatment usually involves metronidazole.

Cryptosporidiosis is caused by a microorganism known as Cryptosporidium parvum. Like amoeba and giardia, C. parvum lives in feces. People can become infected by eating contaminated food or water, and it can be transmitted sexually, if there is oral contact with feces.

Before the use of antiretroviral therapy, many HIV patients had cryptosporidiosis, and it was very difficult to treat. Now, the condition is rare in patients who are taking antiretrovirals. Treatment includes paromomycin, either alone or combined with azithromycin.

Preventing Parasitic Infections

Preventing the spread of parasitic infection involves practicing safe oral-anal sex, which involves the following:

  • Using a protective barrier to avoid oral contact with feces
  • Adequately cleaning sex toys or disposing of non-reusable sex toys after anal contact
  • Washing hands and fingers adequately after anal or fecal contact

Publication Review By: Stanley J. Swierzewski, III, M.D.

Published: 30 Nov 2000

Last Modified: 23 Jul 2015