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Gingival disease is common in HIV-infected patients and is thought to be due to an overgrowth of microorganisms It usually responds to professional dental cleaning and chlorhexidine rinses A particularly aggressive gingivitis or periodontitis will develop in some HIV-infected patients; these patients should be given antibiotics that cover anaerobic oral flora (eg, metronidazole, 250 mg four times a day for 4 or 5 days) and referred to oral surgeons with experience with these entities Aphthous ulcers are painful and may interfere with eating They can be treated with fluocinonide (005% ointment mixed 1:1 with plain Orabase and applied six times a day to the ulcer) For lesions that are difficult to reach, patients should use dexamethasone swishes (05 mg in 5 mL elixir three times a day) The pain of the ulcers can be relieved with use of an anesthetic spray (10% lidocaine) For patients with refractory ulcers, thalidomide, starting at a dose of 50 mg orally daily and increasing to 100 200 mg daily, has proved useful Because it is teratogenic; it should be administered only to patients at zero risk of procreation The most common side effects are sedation and peripheral neuropathy Other lesions seen in the mouths of HIV-infected patients include Kaposi s sarcoma (usually on the hard palate) and warts 9 Gastrointestinal manifestations a Candidal esophagitis (See also discussion in 14) Esophageal candidiasis is a common AIDS infection In a patient with characteristic symptoms, empiric antifungal treatment is begun with fluconazole (200 mg daily for 10 14 days) Further evaluation to identify other causes of esophagitis (herpes simplex, CMV) is reserved for patients who do not improve with treatment b Hepatic disease Autopsy studies have demonstrated that the liver is a frequent site of infections and neoplasms in HIV-infected patients However, many of these infections are not clinically symptomatic Clinicians may note elevations of alkaline phosphatase and aminotransferases on routine chemistry panels Mycobacterial disease, CMV, hepatitis B virus, hepatitis C virus, and lymphoma cause liver disease and can present with varying degrees of nausea, vomiting, right upper quadrant abdominal pain, and jaundice Sulfonamides, imidazole drugs, antituberculous medications, pentamidine, clarithromycin, and didanosine have also been associated with hepatitis HIV-infected patients with chronic hepatitis may have more rapid progression of liver disease because of the concomitant immunodeficiency or hepatotoxicity of antiretroviral therapy Percutaneous liver biopsy may be helpful in diagnosing liver disease, but some common causes of liver disease (eg, Mycobacterium avium complex, lymphoma) can be determined by less invasive measures (eg, blood culture, biopsy of a more accessible site) With patients living longer as a result of advances in antiretroviral therapy, advanced liver disease and hepatic failure due to chronic active hepatitis B and or C are increasing causes of morbidity and mortality Treatment of HIV-infected persons with hepatitis B and C with peginterferon has been shown to be efficacious, although less so than in HIV-uninfected persons HIV-infected persons are also more likely to have difficulty tolerating treatment with peginterferon than uninfected persons Liver transplants have.

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it is unclear if the prevalence is greater than in the general population Cases of avascular necrosis of the femoral heads have been reported sporadically, generally in the setting of advanced disease with long-standing infection and in patients receiving long-term antiretroviral therapy The etiology is not clear but is probably multifactorial in nature 6 Myopathy Myopathies are increasingly noted in HIVinfected patients Proximal muscle weakness is typical, and patients may have varying degrees of muscle tenderness The most important clinical distinction is between myopathy due to the primary effect of HIV and that due to zidovudine Patients with symptomatic myopathy, especially with creatine kinase levels greater than 1000 units/L, should have their dose of zidovudine decreased or stopped and should be considered for alternative antiviral therapy A muscle biopsy can distinguish HIV myopathy from zidovudine myopathy and should be considered in patients for whom continuation of zidovudine is essential 7 Retinitis Complaints of visual changes must be evaluated immediately in HIV-infected patients CMV retinitis, characterized by perivascular hemorrhages and white fluffy exudates, is the most common retinal infection in AIDS patients and can be rapidly progressive In contrast, cotton wool spots, which are also common in HIV-infected people, are benign, remit spontaneously, and appear as small indistinct white spots without exudation or hemorrhage This distinction may be difficult at times for the nonspecialist, and patients with visual changes should be seen by an ophthalmologist Other rare retinal processes include other herpesvirus infections or toxoplasmosis 8 Oral lesions The presence of oral candidiasis or hairy leukoplakia is significant for several reasons First, these lesions are highly suggestive of HIV infection in patients who have no other obvious cause of immunodeficiency Second, several studies have indicated that patients with candidiasis have a high rate of progression to AIDS even with statistical adjustment for CD4 count Hairy leukoplakia is caused by the Epstein-Barr virus The lesion is not usually troubling to patients and sometimes regresses spontaneously Hairy leukoplakia is commonly seen as a white lesion on the lateral aspect of the tongue It may be flat or slightly raised, is usually corrugated, and has vertical parallel lines with fine or thick ( hairy ) projections Oral candidiasis can be bothersome to patients, many of whom report an unpleasant taste or mouth dryness There are two major types of oral candidiasis: pseudomembranous (removable white plaques) and erythematous (red friable plaques) Treatment is with topical agents such as clotrimazole 10-mg troches (one troche four or five times a day) Patients with candidiasis who do not respond to topical antifungals can be treated with fluconazole (50 100 mg orally once a day for 3 7 days) Chronic suppression of oral candidiasis with fluconazole has been associated with development of candidiasis resistant to all available azoles and thus should be avoided except in frequently recurring cases Angular cheilitis fissures at the sides of the mouth is usually due to Candida as well and can be treated topically with ketoconazole cream (2%) twice a day.

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