Syphilis related to atypical oral lesions affecting an elderly man. a case report.

OBJECTIVE: To present a case of oral syphilis in an old patient. BACKGROUND: Syphilis seems to be resurging mainly in the young. However, in the last twenty years, the elderly have become more susceptive to infectious diseases due to a more frequent use of sildenafil. CLINICAL REPORT: An 83-year-old man was referred to our clinic complaining of burning mouth. His medical history revealed papular lesions on chest and penis glans, which had been diagnosed and treated as scabiosis 2 months prior to our assessment. The intra-oral examination showed erosive and patch lesions on the bilateral lip commissures, the palate and the border of the tongue. Initially, oral herpes was suspected. However, both the serological test and the cytology were negative. Therefore, syphilis was hypothesised. Non-treponemic (VDRL) and treponemic tests (FTA-ABS) were reagent and secondary syphilis was confirmed. The treatment consisted of penicillin G benzathine 2.4 million IU/IM for 4 weeks. Both oral and skin lesions had complete remission. CONCLUSION: The present case illustrates that syphilis should be suspected in old patients with oral atypical lesions.

C-Reactive protein levels in children with primary herpetic gingivostomatitis.

BACKGROUND: C-reactive protein (CRP) is often used to distinguish bacterial from viral infections. However, the CRP level does have implications, which depend on the clinical scenario and are still under research. OBJECTIVES: To evaluate the distribution of CRP levels in children with primary herpetic gingivostomatitis. METHODS: The electronic database of a tertiary pediatric medical center was searched for all inpatients with a diagnosis of primary herpetic gingivostomatitis without bacterial coinfection. Background and clinical information was collected and CRP levels were analyzed. RESULTS: The study group consisted of 66 patients aged 8 months to 7.1 years who met the study criteria. The average CRP was 7.4 mg/dl (normal 0.5 mg/dl). More than a third of the patients had a level higher than 7 mg/dl. CONCLUSIONS: High values of CRP are prevalent in patients with primary herpetic gingivostomatitis, similar to adenoviral infections and some bacterial infections.

A comparative study between viral isolation and indirect immunofluorescence in the diagnosis of herpes simplex virus.

Fifty patients with oral ulcers were studied clinically and investigated for the detections of Herpes Simplex Virus (HSV) through virus isolation from their lesions (vesicles and ulcers) and detection of the presence of antiviral antibodies (both, IgM and IgG) in their sera using the indirect immunofluorescene (IIF) technique. The results of this study proved that virus isolation is the most reliable method for diagnosis, though the use of antibody serological tests could be a useful adjunct to virus isolation in situations where a rapid laboratory diagnosis is needed. Oral Herpes Simplex virus infection can be viewed, in the main, as a trivial disorder causing patients minor physical discomfort. The prevalence of HSV may be high in innocent infections, as high as 1/3 of the population. However, HSV infection and its complications with troublesome recurrences may make the problem worse. The apparent increase in HSV infection over recent years may be partly due to increased publicity about the disease, the current antiviral treatment, the inclusion of both primary and recurrent cases in clinic follow up and the increased use of viral cultures for diagnosis. The aim of this work is to share in the study of the detection of HSV through virus isolation and detection of antiviral antibodies using IIF technique, as well as the evaluation of the diagnosis by the above mentioned methods.

Levamisole can modulate the serum tumor necrosis factor-alpha level in patients with recurrent aphthous ulcerations.

BACKGROUND: Recurrent aphthous ulcerations (RAU) are common oral inflammatory lesions. Tumor necrosis factor (TNF)-alpha is an important inflammatory mediator and a critical cytokine for adequate host defense. Our previous studies have shown that 14-43% and 59-63% of patients in the ulcerative stage of major, minor or herpetiform RAU have significantly higher than normal serum levels of interleukin (IL)-6 and IL-8, respectively. In this study, we examined whether RAU patients in the ulcerative stage had a significantly higher than normal serum level of TNF-alpha and assessed whether treatment with levamisole can modulate serum TNF-alpha levels in RAU patients. METHODS: This study used a solid phase, two-site sequential chemiluminescent immunometric assay to determine the baseline serum levels of TNF-alpha in 146 patients with RAU, nine patients with traumatic ulcers (TU), and 54 normal control subjects. Fifty-five RAU patients with serum TNF-alpha levels higher than 5.0 pg/ml were treated with levamisole for 0.5-4 months and their serum TNF-alpha levels were measured after treatment. RESULTS: We found that 29% (42 of 146) RAU patients as well as 39% (24 of 61) major type, 20% (14 of 69) minor type, and 25% (four of 16) herpetiform type RAU patients had a serum level of TNF-alpha greater than the upper normal limit of 7.4 pg/ml. The mean serum level of TNF-alpha in patients with RAU (9.1 +/- 1.0 pg/ml, P < 0.001), major type RAU (11.6 +/- 1.9 pg/ml, P < 0.001), minor type RAU (6.9 +/- 0.9 pg/ml, P < 0.005), or herpetiform type RAU (9.6 +/- 2.7 pg/ml, P < 0.001) was higher than that (3.8 +/- 0.2 pg/ml) in normal control subjects. The mean serum TNF-alpha level was significantly higher in patients with major type RAU than in patients with minor type RAU (P < 0.05) and was significantly higher in major type RAU patients in the exacerbation stage than in the post-exacerbation stage (P < 0.05). In 55 RAU patients with serum TNF-alpha levels higher than 5.0 pg/ml, treatment with levamisole for a period of 0.5-4 months could significantly reduce the serum TNF-alpha level from 16.4 +/- 1.9 to 5.8 +/- 0.6 pg/ml (P < 0.001). CONCLUSIONS: We conclude that a significantly higher than normal serum level of TNF-alpha can be detected in 20-39% of patients in the ulcerative stage of major, minor or herpetiform RAU. The serum TNF-alpha level may be associated with the severity and the stage of RAU. Levamisole can modulate serum TNF-alpha levels in RAU patients.

[Effects of immunomodulating therapy on immune status and the disease course in patients with relapsing herpetic stomatitis]. / Vliianie immunomoduliruiushchei terapii na immunnyi status i techenie zabolevaniia u bol'nykh s retsidiviruiushchim gerpeticheskim stomatitom.

Clinical and immunological efficiency of leukinferone in combination with polyoxidonium (immunomodulator) was studied in patients with relapsing herpetic stomatitis (RHS). The levels of alpha- and gamma-IFN were decreased, levels of IgM, IgG, and IgE were increased, active oxygen forms were actively produced, and the count of CD8(+)-cells was increased in patients with RHS. Treatment with polyoxidonium and leukinferone led to an increase of the blood levels of alpha- and gamma-IFN, decrease of IgM, IgG, and IgE levels, normalization of phagocytosis, and decrease of CD8(+)-cell count. The treatment had a pronounced clinical effect in patients with RHS of any severity, which indicates the efficiency of these drugs in combined therapy of patients with RHS.

Presence of viremia in patients with primary herpetic gingivostomatitis.

BACKGROUND: Presence of viremia during primary herpes simplex virus (HSV) infections has been previously investigated, but the findings for immunocompetent individuals have only rarely been reported. METHODS: With use of polymerase chain reaction (PCR), we evaluated blood samples obtained from children with primary herpes simplex virus (HSV) gingivostomatitis for viremia. RESULTS: There were 16 girls and 16 boys, aged 9-44 months (median age, 19 months). Serological test results for HSV type 1 were positive for 3 subjects (10.3%), borderline for 7 (24.1%), and negative for 19 (65.5%). Results of PCR of peripheral blood samples were positive for 11 subjects (34.4%). Time from disease onset to specimen collection was 24-216 h (median, 72 h) and was longer for subjects with positive results of serological tests (P =.014) and shorter for subjects with positive PCR results (P=.42). No cases with positive results of both PCR and serological tests were found. CONCLUSION: PCR detected viremia in 34% of patients with primary herpetic gingivostomatitis. Presence of viremia may play a potential role in viral dissemination, providing a better understanding of the pathogenesis of HSV infections, especially of the central nervous system.

The prevalence of herpes simplex virus shedding and infection in the oral cavity of seropositive patients undergoing head and neck radiation therapy.

OBJECTIVE: Herpes viruses are characterized by their ability to establish and maintain a latent infection that can reactivate. Only 2 preliminary studies have examined herpes simplex virus (HSV) reactivation in patients receiving head and neck radiotherapy. The role of radiation therapy in the reactivation of a latent virus has not been established. The purpose of the present study was to evaluate the incidence of HSV reactivation in patients receiving radiation treatment for head and neck malignancies. METHODS: Twenty patients, 19 of whom were HSV seropositive, undergoing head and neck radiation therapy were assessed weekly before and during radiation therapy, and HSV cultures were completed during cancer treatment. RESULTS: Only 3.6% of the cultures were positive for HSV during radiation therapy. HSV was cultured in 4 men receiving a mean of 6,000 cGy to the head and neck area. Recovery from HSV was seen in patients nearing completion of radiation therapy. CONCLUSIONS: The results of this study suggest that HSV reactivation is not common during radiation therapy. Therefore, this study does not support prophylaxis of HSV in patients undergoing head and neck irradiation.

The natural history of primary herpes simplex type 1 gingivostomatitis in children.

Herpetic gingivostomatitis is the most common specific clinical manifestation of primary herpes simplex infection in childhood. The aim of the present study was to describe the clinical signs, symptoms, viral shedding, serologic findings, and complications in community-acquired gingivostomatitis. We prospectively followed children with herpes simplex type 1 gingivostomatitis lasting less than 72 hours. Clinical examination and viral culture were repeated every 2 to 3 days as long as symptoms or signs persisted. Thirty-six children (ages 12-77 months) were included in the study. Mean duration of oral lesions was 12.0+/-3.4 days; extraoral lesions (in 26 children), 12.0 +/-3.9 days; fever, 4.4+/-2.4 days; and eating/drinking difficulties, 9.1+/-3.0 and 7.1+/-3.1 days, respectively. In all children, viral cultures of the oral lesions were positive for herpes simplex virus (HSV) type 1; viral shedding persisted for a mean of 7.1+/-2.5 days (range 2-12 days). The main complications were dehydration, with three children hospitalized for intravenous rehydration, and one case of secondary bacteremia. Herpetic gingivostomatitis is a relatively severe manifestation of primary HSV type 1 infection in young children.

Immunological investigation of adult patients with primary herpes simplex virus-1 infection.

Peripheral blood mononuclear cell parameters were examined in 17 adult patients with primary herpes simplex virus-1 (HSV-1) infection. Two-color flow cytometry revealed an increase in HLA-DR+ T cell and Leu8+ T cell subsets, and a decrease in CD57+CD16+ subset in the patients. In the symptomatic phase of HSV-1 infection, serum interferon gamma (IFN-gamma) level increased in many patients, and the mean serum level in the patients (0.26 +/- 0.12 U/ml) was significantly higher than the mean control level (0.14 +/- 0.06 U/ml). Soluble intercellular adhesion molecule-1 (sICAM-1) in patients' serum also was increased to a mean level of 398 +/- 130 ng/ml at the first visit. Both the IFN-gamma and sICAM-1 levels fell to near the control levels after the disappearance of oral inflammation. Natural killer (NK) activity was at first increased (mean 46.1 +/- 17.9%), and later decreased to the control level (mean 38.4 +/- 10.6%). In contrast, lymphokine activated killer (LAK) activity at the first visit (mean 53.2 +/- 15.7%) was significantly lower than the control level (mean 69.5 +/- 10.3%). PHA- or ConA-stimulated lymphocytes from the patients incorporated less thymidine than control lymphocytes. These reduced lymphocyte reactivities recovered to the control levels after the disappearance of the acute infection. These results indicate some of the characteristics of lymphocyte pathophysiology in primary HSV-1 infection.

Serum cytokine levels in patients with oral mucous membrane disorders.

Serum cytokine levels were examined in 18 oral squamous cell carcinoma (SCC), 26 lichen planus (OLP), 20 recurrent aphthous stomatitis (RAS), 8 herpetic gingivostomatitis (HGS), 16 pseudomembrane candidiasis (PMC) and 19 acute bacterial infection (ABI) cases. All SCC and most PMC patients possessed clear serum IL-3. No clear increase of IL-4 was observed in most cases though over 20 pg/ml were found in a few OLP, RAS and ABI. ABI exhibited the highest IL-6, and the cytokine level was lower in RAS, PMC, HGS and OLP in this order. Suppressed IL-6 activity was elevated with improvement of HGS lesion. TNF-alpha increased in 9 OLP, but the levels were below 100 pg/ml in all cases. Most SCC possessed higher GM-CSF activity than the controls. Increase of the cytokine corresponding with improvement of the oral lesion was seen in HGS, but not in OLP. From these results, each serum cytokine seems to reflect a characteristic pathophysiology of individual oral disorder.

Clinical and immunological evaluation of oral ribavirin administration in recurrent herpes simplex infections.

A total of 38 out-patients with recurrent oral or genital Herpes simplex virus infections received either oral ribavirin (800-1600 mg/day for 7 days) or placebo following a randomized and balanced protocol. Clinical and laboratory parameters, including haematological, metabolic and immunological tests, were checked in order to estimate tolerance to and efficacy of ribavirin on recurrent Herpes simplex virus infection and on the number of recurrences during the 12 months following treatment. Ribavirin showed definite superiority in the treatment of recurrent Herpes simplex virus 1, when compared to placebo, its efficacy being enhanced if treatment is started as soon as possible after infection has started. No significant modification of the parameters used to assess tolerance was noted; moreover there was no modification of the immunological parameters evaluated.

Absence of viremia in primary herpetic gingivostomatitis.

Using current techniques of viral isolation, whole blood, plasma and buffy coat from 17 children with herpetic gingivostomatitis were cultured. Recovery of herpes simplex virus was inhibited by anticoagulation of blood with heparin and unaffected by anticoagulation with citrate. Herpes virus was not detected in any blood fraction during primary herpes gingivostomatitis.

Acute phase proteins, C9, factor B, and lysozyme in recurrent oral ulceration and Behçet's syndrome.

The concentrations and sequential changes of some acute phase proteins, factor B, and lysozyme have been assayed in recurrent oral ulceration and Behçet's syndrome. C9 was elevated in both groups of patients and was the sensitive index of disease activity; however, it failed to discriminate between the three types of recurrent oral ulcers and four types of Behçet's syndrome. The level of alpha 1 acid glycoprotein and lysozyme were significantly increased predominantly in the ocular type, whereas factor B was significantly increased especially in the neurological type of Behçet's syndrome. It is suggested that the changes in the concentrations of some plasma proteins may help our understanding of tissue involvement in Behçet's syndrome, as well as in the selection of therapeutic agents in this disease.

Serum antibodies to herpes simplex virus type 1 during active oral herpes infection.

Subjects with oral herpes lesions at the time of serum sampling had higher-efficiency antibody (higher proportion of neutralizing antibody as determined by plaque reduction, compared with total antibody as detected by radioimmunoassay) to herpes simplex virus type 1 (HSV-1) than did subjects with no lesions at the time of serum sampling. These higher-efficiency sera also had higher antibody titers to structural components of herpes simplex virus type 1 than did the low-efficiency sera. Absorption of high- and low-efficiency sera with purified herpes simplex virus type 1 particles removed all neutralizing antibody but not all antibody detected by radioimmunoassay. High-efficiency serum was depleted of more antibody to particulate antigen that was the low-efficiency serum, indicating that the high-efficiency serum contained a higher proportion of antibody to the virus particle.