實習醫師病例報告

(1)

實習醫師病例報告

報告者: Intern L組呂維仁、趙珮吟、劉冠宏、

劉芳如、楊超捷

指導者: 王文岑醫師暨口腔病理科全體醫師

(2)

General Data

Name: 王x平

Gender: ^male

Age: 46

Native: 高雄市

Marital Status: 已婚 Occupation: 自由業 Attending V.S.: 王文岑

First visit: 93.07.12

(3)

Chief Complaints

White patches over left buccal mucosa and both lips about 2 months

(4)

Present Illness

White patches over L＇t buccal mucosa and both lips since 2 months ago.

Painless

Removable but appeared soon

(5)

Past History

‧Denied any systemic disease

‧Denied any drug or food allergy

Personal Medical History:

‧OD

‧Extraction

‧Prosthesis

‧Attitude toward dental treatment : cooperative

Personal Dental History:

(6)

Personal Habits

‧Alcohol: ( - )

‧Betel nuts: (+) 3y/ 1package/ day, quitted

‧Cigarette: (+) 20 years/ 1 package/ day

Risk factors related to malignancy :

‧Denied

Other special habits:

(7)

Oral Examination

Creamy-white patches covered whole L＇t BM and posterior R＇t BM

Removable by scraping

(8)

Oral Examination(cont~)

White patches covered palate extending from hard palate to soft palate, measuring approximately 5cm x 3cm.

The patches could be removed by scraping it and the surface covered by the white patches was reddish.

Upper dentition:

malocclusion

(9)

White plaques covered the dorsal tongue ranging along the lateral border. The plaques could be removed by scraping it, too.

Oral Examination(cont~)

(10)

White patches covered the lower lip extending from the L＇t mouth angle to the middle. The patches could be removed.

Several small vesicles with some crusts around the

L＇t mouth angle.

Gingival inflammation and cervical abrasion

Oral Examination(cont~)

(11)

Physical Examination

• (‐) Pain

• (‐) Swelling

• (‐) Bleeding tendency:

• (‐) Induration:

• (‐) Fever or local

heat:

• (‐) Lymphadenopathy:

Radiography Examination

Nil

(12)

Summary of Clinical Features

Removable white patches covered whole buccal mucosa, palate, and tongue,

asymptomatic.

Small vesicles with some crusts around the L＇t mouth angle.

(13)

Small vesicles

Fever (-)

Local heat (-) Edema (-)

Pain(-)

Pus discharge (-)

Separated white patches Reddish(+) after scraping

it

(14)

Working Diagnosis of the White Lesion

Lichen Planus

Leukoplakia

Psudomembranous

candidiasis

(15)

Lichen planus (

reticular form)

Our case Site Buccal mucosa, tongue,

palate, gingival, lip

Buccal mucosa, tongue,palate

Age middle age 46

Gender ♀ ♂

Frequency 0.1%~2.2% Unknown

Appearance Lace‐like network of white lines (Wickham’s striae)

Creamy‐white patches

Symptom Asymptomatic Asymptomatic

Other

clinical feature

Non‐ removable Removable

(16)

Our Case

Lichen Planus

(17)

Leukoplakia Our case

Site Buccal mucosa,

tongue, palate

Buccal mucosa, tongue, palate

Age >40 46

Gender ♂ ♂

Frequency Unknown Unknown

Appearance White Creamy‐white

patches Mucosal

surface White Reddish

Symptom Asymptomatic Asymptomatic Other clinical

feature Non‐ removable Removable

(18)

Our Case

Leukoplakia

(19)

Pseudomembrane candidiasis Our case Site Buccal mucosa, dorsal

tongue, palate

Buccal mucosa, tongue,palate

Age > 40 46

Gender ♀ ♂

Frequency Common Unknown

Appearance Creamy‐white to yellow plaques

Creamy‐white patches

Mucosal surface

Reddish Reddish

Symptom Asymptomatic or foul taste, burning mouth sensation

Asymptomatic Other

clinical feature

Removable Removable

(20)

Pseudomembrane candidiasis

Our Case

(21)

‧Candidiasis, buccal, tongue, palate, smear cytology

Pathological report:

(22)

Clinical Impression

Oral

candidiasis

^over

BM, palate, tongue

Herpes simplex virus

infection

over L’t mouth

angle

Underline

disease

(23)

Pathogenesis Our case Drugs/Medications:

multiple

antibiotic, corticosteroids…

No medications

Endocrinopathies:

DM, Hypoadrenalism,

Hypothyroidism…

No history

Hematologic Disorders :

Lymphoma, Leukemia…

No history

Immunodeficiency: HIV,

Thymic alymphoplasia…

No history

Leukocyte Disorders:

Myeloperoxidase deficiency…

No history

Î examination

(24)

Pathogenesis Our case Malignancy :

Leukemia, Thymoma…

No history

Î examination Nutritional Deficiencies :

Iron deficiency, Vitamin B deficiency…

Balanced taking food Î examination

Other : Radiation therapy, xerostomia, old age, denture use…

No radiation therapy;

Middle age;

No denture

R/O other pathogenesis

Doubt of candidiasis with other disorders

Arrange patient to Lab survey

(25)

Treatment Planning

Antifungal treatment

Further Lab survey to R/O possibility

of other disorders or infections

(26)

Treatment Course

OE • Multiple removable white patches over whole oral cavity, including mouth floor

Imp • Candidiasis of mouth

• Herpes simplex infection L’t mouth angle

Tx • Take smear slides for buccal, palate and tongue dorsal

• Lab survey

• CBC-I ; Herpes simplex virus serol

• HIV 1+2 (ELISA)

• TP ; Bil ; GOT ; GPT ; Alk-p ; UN ; CRTN ; GGT

< 93-07-12 > First Visit (Tx 1)

Î Rx: Diflucant

(27)

CBC : WNL

P＇t data normal unit

WBC 8.00 4.0-10.0 X1000/ul

RBC 4.84 4.5-6.0 X10^6/ul

Hgb 14.7 13-17 g/dl

Hct 45.2 40-53 %

MCV 93.4 79.0-101.0 Fl

MCH 30.4 26.0-35.0 Pg

MCHC 32.5 31.0-37.0 g/dl

PLT 212 130.0-500.0 X1000/ul

RDW-CV 13.2 11.5-14.5 %

RDW-SD 45.1 36.0-46.0 fl

< 93-07-19 > See Report 93-7-12

(Tx 2)

(28)

P＇t data normal unit

Protein 7.37 6.0-8.3 gm/dl

Albumin 3.68 3.5-5.0 gm/dl

A/G 1.00 1.50-2.01

Bil(Total) 0.50 0.2-1.0 mg/dl

Bil(Direct) 0.07 0-0.2 mg/dl

Bil(Ind.) 0.40 0.0-0.8 mg/dl

GOT(AST) 30 10-42 IU/L

GPT(ALT) 29 10-40 IU/L

ALP 84 32-92 IU/L

UN 15.9 7.0-18.0 mg/dl

Creatinine 0.86 0.6-1.3 mg/dl

GGT 52 7-64 IU/L

(29)

Lab data

Herpes simplex virus ＜ 1:4 Æ Negative

（positive ≧ 1:4）

ELISA of HIV :

^Positive

Treatment Course ^cont~

(30)

OE

‧Multiple removable white patches

disappeared 2 days after last visit post medication

Imp

‧Oral candidiasis , suspect HIV infection

Tx

‧Western blot test

‧Anti HIV-I

‧Anti HIV-II

Treatment Course ^cont~

< 93-07-19 >

Cont~

(31)

• White patches disappeared OE

• Oral candidiasis

• Human immunodeficiency virus（HIV）

infection Final Impreesion

• Referred p’t to Infection Dept.

Tx

Treatment Course ^cont~

< 93-07-26 > See Report 93-07-19 (Tx 3)

HIV WB (+)

(32)

Treatment Courses (Infection Dept)

Tx1 < 93‐08‐11 > HIV Tx

Tx2~ < 93‐09‐01 >

• Diflucan (50mg) 2# QD x 21days Rx :

• CBC, Chest X-ray ( CXR ), Urine test Examination:

Anti-HCV:

(+)

VL:146000 copies/ml

(>50 copies/ml)

CD4:157

(<200) HBsAG: (-) STS: (-)

CXR : Consider pneumonia

in ant.

segment of right upper

lobe

• Diflucan (50mg) 2# QD x 7days

• Combivir 1# BID x 7days

• Kaletra 3# BID x 7days

Rx :

• CXR, CBC Examination:

Start HAART

(33)

Treatment Courses (Infection Dept) (cont~)

Tx3~4 < 93‐09‐08 > ~ < 93‐09‐15 >1

^st

month of HAART

BW : 48-50 kg

E.S.R : 31 mm/h (>10

mm/h)

CRP : 5.26 ug/ml (>5

ug/ml)

CXR : Interval revolution of bronchopneu

monia at ant.

segment of right upper

lobe (compared

with 8/12)

Abd. echo report(on 9/13) : Hepatic

nodule (0.82cm)

• Diflucan (50mg) 2# QD x 7days x 28days

• Combivir 1# BID x 7days x 28days

• Viracept (250mg) 5# BID x 7days x28days Rx :

< 93-09-08 > < 93-09-15 >

(34)

Tx5~6 < 93‐10‐13 > ~ < 93‐10‐27 >2

^nd

month of HAART

Tx7 < 93‐11‐24 > 3

^rd

month of HAART

• Aggravated diarrhea, palpitation , anxiety, suicidal O idea

• Suggest combivir plus viramune, and continue diflucan

Tx

• Diflucan (50mg) 2# QD x 14days

• Xanax(0.25mg) 1# TID x 28days

• Combivir 1# BID x 14days

• Viramune(200mg ) 1# BID x 14days Rx

• Aggravated diarrhea, palpitation, anxiety improved

O

(35)

Tx8~9 < 93‐12‐22 > ~ < 93‐12‐27 >4

^th

month of HAART

• No diarrhea, no palpitation after switching to combivir plus

• Viramune, mild nausea sensation, headache no rash

O

Examination ( 93-12-22 )

CBC:

WNL

VL <50

copies/ml CD4 :417

Back to normal range

(36)

Tx10~15 < 94‐04‐13 > ~ < 95‐04‐19 >8^th~20^th month of HAART

• Skin itching, eczema, suicide idea O

• Ichderm Cream(15gm) 1#BID x 28days

• ClariTYNE(10mg) 1# QD x 28days

• Esperson(5gm) 1# BID x 7days Rx

CBC, CXR, Abd.

Echo

VL<50

copies/ml CD4:220

Abd.

Echo:

Hepatic nodule(0.6

cm)

CBC, CXR, AFP

VL<50

AFP:5.3 ng/ml (<

20 ng/ml)

Examination (95-01-15 )

Examination ( 94-07-13 )

(37)

Treatment Courses (Infection Dept) (cont~) Tx16 < 96‐03‐21 > Lost f/u for about 1 year since 95/04/19

(於95年7月底自行停藥)

• Skin papules, carbuncle, insomnia, P’t refused psychiatric Tx

O

• Elomet Cream(5gm) 1 tube BID x 7days

• Fusotex(5gm) 1# BID x 7days

• Estazolam(2mg) 1# QD x 28days

• Xanax(0.25mg) 1# TID x 28days

• Viramune(200mg) 1# BID x 28days

• Combivir 1# BID x 28days Rx

CBC, CXR, Abd. Echo,

AFP

VL=2450

AFP : 6.9 ng/ml ( < 20

ng/ml)

Examination

(38)

• Occupation improve, skin papules, carbuncle O

• Cloxacillin(250mg) 2# QID x 14days

• Septon(5gm) 1# BID x 30days

• Fusotex(5gm) 1# TID x 7days Rx

CBC, CXR, Abd. Echo,

AFP

VL<50

AFP : 6.9 ng/ml ( < 20

ng/ml)

Examination(96-06-29)

Tx18~20 < 96-05-02 > ~ < 96-06-29 > Continue HAART Tx17 < 96‐04‐04 > Continue HAART

• Carbuncle and insomnia improve O

• Ditto Rx

(39)

CBC:

WNL

VL<50

Examination(96-10-19)

Tx21~25 < 96-07-27 > ~ < 97-02-15 > Continue HAART

• Skin lesion improve, carbuncle recover, muscle cramping,

• Eye itching O

• Ditto Rx

(40)

93/8/11 94/7/13 95/4/19 96/3/21 96/6/29 96/11/16

WBC 5.94 4.25 5.11 3.34 3.53 5.03

RBC 5.06 3.4 3.34 4.58 3.05 3.32

Hgb 15.3 14.3 14.5 14 12 13.8

Hct 46.5 42.1 41.1 42.4 34.8 40.6

HCV 91.9 123.8 123.1 92.6 114.1 122.3

HCH 30.2 42.1 43.4 30.6 39.3 41.6

HCHC 32.9 34 35.3 33.9 34.5 34

PLT 193 213 197 209 309 206

RDW-CV 12.6 12.3 12 12.6 20.6 12.8

RDW-SD 42.0 55.6 54 42.4 81.3 57.5

NEUT 54.1 59.8 65 66.1 65.6 57

Lab data summary

(41)

93/8/11 94/7/13 95/4/19 96/3/21 96/6/29 96/11/16

EOSIN 1 3.3 2.7 4.5 1.1 2.2

BASO 0 0.4 0.2 0 0.2 0.4

LYMPH 35 31.6 27 24.9 24.9 35.2

MONO 16 4.9 5.1 4.5 8.2 5.2

HDL-C 75.5 36 51 65

LDL-C 74.4 69 50 52

GPT(ALT) 24 23 28 28 17 22

CHOL 111 134 164 143 130 151

TG 128 98 57 145 62 55

Creatinie 0.81 0.99 1.02 1.1 0.9 0.93

Sugar 80 83 84 84 93 98

TC/HDL 2.2 4 2.5 2.3

LDL/HDL 1 1.9 1 0.8

(42)

93/8/11 93/12/22 94/7/13 95/4/19 96/3/21 96/6/29 96/11/16 CD4 9.36% 11.45% 15.37% 22.24% 8.41% 12.70% 16.10%

CD8 80.86% 76.54% 71.69% 68.66% 70.62% 78.60% 73.90%

CD4:CD8

ratio 0.12 0.15 0.21 0.32 0.12 0.16 0.22

HIV-VL 146000 <50 <50 <50 2450 <50 <50 Total T-

cell 89.52% 88.69% 85.95% 84.54% 81% 88.80%

Active T-

cell 67.39% 43.64% 43.60% 41.31% 42.32%

Total B-

cell 7.53% 6.98% 10.12% 12.20% 13.57% 4.80%

27-51%

14-44%

CD4:CD8

ratio 0.12 0.15 0.21 0.32 0.12 0.16 0.22

1.4~2.0

(43)

Another Two Cases:

Case II ^{(96‐10‐01)}

A 46 y/o male complained of pain at lateral tongue, lips and palate for 2 years.

Smoking, betel nut chewing, alcohol consumption for 20~25years.

Denied heart disease, arrhythmia, TB , Thyroid disease, sex transmitted diseases, drug allergy….et al.

Herpes zoster over right back in one year

(44)

Case I (cont~)

• Removable white patches over bilateral BM, upper lip, and tongue dorsum.

Oral Examination

Smear cytology: Oral candidiasis over lateral tongue, lips and palate Lab survey : HIV infection

Refer to Infection Department for

further treatment on 96-10-17

(45)

Another Two Cases:

Case III ^{(96‐11‐05)}

A 31 male comes with multiple white spots over full mouth for 2 months.

Denided any habbits and any systemic diseases.

A syphilis history about 4 years ago was found from his

previous medical charts. (92-10-07) BUT!!!

(46)

Case II (cont~)

• Removable white patches over bilateral BM, palate, and tongue dorsum.

• Cough, pueumonia for 2months

Oral Examination

Smear cytology: Oral candidiasis over BM, palate and tongue

Lab survey : HIV infection

Refer to Infection Department for further treatment on 96-11-22

Homosexual and one-night stand experience

was told in the later treatment courses

(47)

Our Case Case I Case II Normal range

WBC 8 3.28 2.39 4.0-10.0 x1000/ul

RBC 4.84 4.79 3.6 4.5-6.0 x10*6/ul

Hgb 14.7 13.6 10.6 13-17 g/dl

Hct 45.2 41.8 31.5 40-53 %

CRP 5.26 1.41 11.9 <5 ug/ml

HDL-C - 27 24 29.0-85.0 mg/dl

LDL-C - 94 151 0.0-130 mg/dl

HIV 1+2(ELISA) + + +

HIV 1,2 (WB) HIV 1(+) HIV 1(+) HIV 1(+)

HIV-VL 146000 184000 813000 <50 copy/mL

HAslgG - - -

HBsAg - - -

HBsAb + + +

HCVAb + - -

CD4 9.36 6.21 10.7 27-51 %

CD8 80.86 67.4 51.2 14-44 %

HLA-DR positive 74.92 78.4 - 28.36-46.1 %

STS - - +

Amoebiasis test - - -

Chlamydia(Sero) - + +

Toxoplasmosis - - -

IgM - - -

Cryptococci - - -

neoformans(S) - - -

CMV(sero) - - -

CMV IgG(B) - - +

CMV IgM(B) - - -

AFB - - -

(48)

Discussion

‧Introduction

‧Oral clinical features

‧Other clinical features

‧The relationship between the oral pathosis and HIV

HIV

HIV P＇t in dental treatment

(49)

HIV ( Human Immunodeficiency Virus )

Identified in 1983(AIDS) Previous names

¾

Immune Deficiency-Associated Virus(IDAV)

¾

Human T-lymphotropic virus-III (HTLV-III)

Desinated in 1986

(50)

‧Initially discovered and termed LAV

‧More virulent, relatively easily transmitted

‧Cause of the majority of HIV infections globally

HIV-1（Chimpanzee)

‧Less transmittable than HIV-1

‧Largely confined to West Africa

HIV-2 (Sooty Mangabey)

(51)

‧The majority of HIV infections

‧Contact with the genital, oral, or rectal mucous membranes of another

Sexual route

‧Intravenous drug users

‧Recipients of blood transfusion

‧Reuse of needles

‧Health care workers

Blood or blood product route

‧Pregnancy

‧Intrapartum at childbirth

Mother-to-child transmission

(MTCT)

Blood or blood product route

Sexual route

(52)

Stage I:

‧Asymptomatic, not categorized as AIDS

Stage II:

‧Minor mucocutaneous manifestations, recurrent upper respiratory tract infections

Stage III:

‧Unexplained chronic diarrhea for longer

than a month, severe bacterial infections, pulmonary tuberculosis

Stage IV:

‧Toxoplasmosis of the brain, candidiasis of the esophagus, trachea, bronchi or lungs and Kaposi's sarcoma.

(53)

Stage I:

‧Asymptomatic, not categorized as AIDS

Stage II:

‧Minor mucocutaneous manifestations, recurrent upper respiratory tract infections

Stage III:

‧Unexplained chronic diarrhea for longer

than a month, severe bacterial infections, pulmonary tuberculosis

Stage IV:

‧Toxoplasmosis of the brain, candidiasis of the esophagus, trachea, bronchi or lungs and Kaposi's sarcoma.

(54)

Systemic Symptoms of AIDS

Fevers

Sweats (particularly at night)

Chills

Swollen lymph nodes Sore throat

Weakness

Weight loss Diarrhea

Joint and muscle aches

(55)

Oral candidiasis

Periodontal disease Gingival bleeding Aphthous stomatitis Herpetic stomatitis

(56)

Cervical lymphadenopathy Deep neck space infections

Otitis media Otomycosis

Sensory neural hearing loss

(57)

Pneumocystis pneumonia

Tuberculosis

(58)

Esophagitis

Chronic diarrhea

(59)

Toxoplasmosis

Progressive multifocal leukoencephalopathy

(PML)

(60)

Kaposi＇s sarcoma Burkitt＇s lymphoma Hodgkin＇s disease Anal and rectal carcinomas

Kaposi’s sarcoma

(61)

Oral Features of HIV/AIDS

(62)

Oral Lesion of HIV Positive Patients

Oral lesions in

symptomatic stage

or

pre- AIDS stage

when CD4+ lymphocyte counts

are reduce and range from 200~800 per μl

Hairy leukoplakia

Pseudomembranous candidiasis Diffuse herpes simplex

gingivostomatitis

Gingivitis/periodontitis Acute nonspecific ulcers

Diffuse varicella-zoster lesion

(63)

Pseudomembranous candidiasis Hairy

leukoplakia

Acute nonspecific

ulcer

(64)

Necrotizing ulcerative gingivitis

Herpes simplex virus infection

Varicella zoster virus

infection

(65)

Oral Lesions of AIDS Stage

‧Candidiasis – intra oral , esophageal

‧Diffuse herpes simplex gingivostomatitis

‧Diffuse varicella-zoster lesion

‧Cryptococcosis

‧Histoplamosis

‧Herpes simplex infection

‧Cytomegalovirus ulcer

‧HIV gingivitis/periodontitis

Infection

(66)

Kaposi＇s sarcoma

Neoplasm

Kaposi＇s sarcoma

Non-Hodgkin＇s lymphoma

Non-Hodgkin＇s lymphoma Non-Hodgkin＇s lymphoma

Oral Lesion of AIDS Stage

(67)

The onset of OC and/or OHL is heralded by the

sequence of a sustained reduction of CD4+, with an associated sharp increase of VL.

After adjustment for clinical stage and antiretroviral use, the main factor associated with the

development of either oral lesion and OC was CD4+

count

Adv Dent Res 19:122-129, April, 2006 E. Blignaut1*, L.L. Patton2, W. Nittayananta3,V.

Ramirez-Amador4, K. Ranganathan5, A. Chattopadhyay6

Are oral candidiasis and hairy leukoplakia

related to the CD4 and viral load kinetics

during HIV infection?

(68)

OC predicted CD4

⁺

counts, changes in CD4

⁺

counts, and AIDS-defining disease occurrences after adjustment for VL.

OHL predicted CD4

⁺

counts but not a change in CD4

⁺

count .

Number of OC episodes was the most significant predictor for change in CD4

⁺

count after adjustment for antiretroviral medications.

Adv Dent Res 19:130-138, April, 2006 M.M. Coogan1*, P.L. Fidel, Jr.2, M.C. Komesu3, N. Maeda4, L.P. Samaranayake5

Oral Candidiasis or oral hairy

leukoplakia can predicted CD4

⁺

(69)

The relationship of smoking and CD4 counts, OC, OHL, or HIV-OD

Amit Chattopadhyay, PhD, MPH, MDS, BDS(Hons), Dip Journ, DcFM,

MSASMS(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;99:39-47)

OD

OC

OHL

(70)

What is more important in the development of oral

candidiasis in HIV-infected patients, low CD4 counts or high viral load?

CD4 hallmark predictor：200 cells/L.

VL < 36000 copies/ml Æ no confounding effects of CD4

VL > 36000 copies/ml

• CD4 Æ < 45 cells/L -- 100% OPC+

• 45 ~ 150 cells/L -- 20% OPC+

• 150 ~ 500 cells/L -- 100% OPC+

Viral load was more important than CD4 cell number as a predictor of OPC

Adv Dent Res 19:130-138, April, 2006 M.M. Coogan1*, P.L. Fidel, Jr.2, M.C. Komesu3, N. Maeda4, L.P. Samaranayake5

(71)

Oral Care and Treatment

Protocols in HIV

(72)

Consent:

‧Based on a patient＇s voluntary authorization

Confidentiality:

‧Not absolute

Dental duty of care:

‧Unethical to refuse

Does an oral health care worker have a professional

obligation to disclose their own HIV ?

(73)

‧

“ It was both safe and desirable to make regular dental care available to HIV-positive patients.＂

ADA 1994:

(74)

Circumstances when routine dental treatment may need to modified:

Low CD4 lymphocyte levels predispose to oral lesions requiring specific treatment

Reduced platelet levels below 60,000 cells mm^3- (normal 150,000~400,000) effect clotting time Reduced neutrophil levels below 500 cells mm^3- (normal 2500~7500) may require antibiotic

prophylaxis

Patients with late stage AIDS may require a rolling treatment plan with regular reviews of ability to attend and withstand treatment

(75)

‧Screen for HIV-related oral lesions and treat if necessary

‧Screen for xerostomia as a possible symptom of HIV or as side-effect of HAART

Consensus guidelines:

‧Prevent further disease

Blood analysis~ assist in planning treatment

‧Patients with HAART medications (breakdown in liver function)

Local anesthetic :

(76)

No evidence-based data support the need for routine antibiotic to prevent

bacteremia and septicemia

Indications:

‧CD4+ ≤200 per μl

‧PMNL ≤ 500 per μl , before oral

sugery (antibacterial mouthrinse and scaling)

‧Patients infected HIV via IV drug use

Æ at risk for developing endocarditis

(77)

Conclusion

Oral candidiasis can be the first manifestation of HIV infection.

OC present Æ VL

Aggressive dental procedure could be delayed if oral candidiasis present

Consent was not absolutely right

(78)

References

Á http://en.wikipedia.org/wiki/HIV

Á http://hiv.buffalo.edu/hivlifecycle.shtml

Á http://www.nyu.edu/socialwork/ip/grey_lit/archives/2007/04/

Á HIV manifestations in otolaryngology/Received 2 May 2005/H.K.C. Prasad 180 et al.

Á Incidence of oral candidiasis and oral hairy leukoplakia in HIV-infected adults in North Carolina/ Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;99:39-47

Á Markers of Immunodeficiency and Mechanisms of HAART Therapy on Oral Lesions/S.R. Flint1*, A. Tappuni2, J. Leigh3,A.-M.

Schmidt-Westhausen4, L. MacPhail5/Adv Dent Res 19:146-151, April, 2006

Á Candida-Host Interactions in HIV Disease:Relationships in Oropharyngeal Candidiasis/P.L. Fidel, Jr./Adv Dent Res 19:80-84, April, 2006

Á HIV Phenotypes, Oral Lesions, and Management of HIV-related Disease/E. Blignaut1*, L.L. Patton2, W. Nittayananta3,

Á V. Ramirez-Amador4, K. Ranganathan5, A. Chattopadhyay6/Adv Dent Res 19:122-129, April, 2006

(79)

Á Perspective Oral Manifestations of HIV

Disease/Perspective – Oral Manifestations Volume 13 Issue 5 December 2005/January 2006

Á Candida and Mycotic Infections/M.M. Coogan1*, P.L. Fidel, Jr.2, M.C. Komesu3,N. Maeda4, L.P. Samaranayake5/Adv Dent Res 19:130-138, April, 2006

Á HIV manifestations in otolaryngology/H. Kishore Chandra

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/ American Journal of Otolaryngology–Head and Neck Medicine and Surgery 27 (2006) 179– 185

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實習醫師病例報告