Factors associated with increased frequency of HIV-related oral candidiasis

Gillian M. McCarthy\ lain D, Mackie^ John Koval^ Harinder S, Sandhu'' and Thomas D, Daley^ 'Division of Oral Biology. DepBrtinent of Medicine. Department of Epidemiology und Biostatistics. ^Division of Periodontics and 'Division ol Oral Pathology. The University of Western Ontario. London. Ontario. Canada

VIc( ;irth\ (iVI. Maekie II). Kovul J, Sandhu HS, Daley 11): f a e t o r s associated witli increased frequeiie> ot IllV-related or;il eandidiasis. J Oral Pathol Med I ' W l ; 2(1: 332 Ci.

1 l l \ - r e l a t e d or;il eamlidmsis was investigated in 71 HI V-seropositive patictits VVIK) reeciveel mletvicws, oral examinations anil lieni;itologic investigation. Diagnosi\ of candidiasis was 24 71 (34"'ci). 'fhe elinieal presentations vsere p\eiii.U>membranous K ( n " r i ) , erylheniatous 14 (2()"'ii), ;ingular eheilitis ,3 (4"ii). lwent>-six patients (37"o) h;i(l candidi;isis or were receiving anlilungal ireatmeiit lor reeurrent pseiidoniembranous type. Twelve of 13 (92"'i)) p;itients wilh .AIDS and 14 58 (24".,) without .AIDS were affeetcd. Bivariate analyses showed sigiiilieant ;issoeiations with A I D S , the use ot /ichtvudine, low 14-eotiiit, Kerostoniia; marital st;itiis (soinetiine married), restricted pcrtornianee st;ittis and ;ice of •3."i yr. Multi\'ariate logistic regression analysis showed that the presenee of xerosttimia was an independent and statistieally sigiiitleaiit predictor of I l l V related oral eandidiasis. 14-couiil and restricted performance status were the secoml anil third most miptirtant predictors.

Oral eandidiasis is an earK mamtestation of IllV-disease and has been reeenll\ reviewed hy S.A\|.\RA\..\'>\.\KI- & HOI vtsiRi c (1). fhere is a need to idenlit\ p;i!ieiHs vsho h a \ e a greater risk o\ developing onil c;indidiasis, so that interventions ean be designed to redtiee ihe Irequciiev of this iiiteetion. This is p;irtieularl\ important as there is evidence thai eaiididal intcetion may induce ininuinosuppression (2 6) and this may inOueiiee the prognosis of fllVmfecteiJ iiiclividiials. I'uetors whieh may predispose to incre;ised carriage of (anduhi spp. ;ind or the oeeurrcnee ot eandidiasis tiave been reviewed (4, 7 ')), howx'vcr, little is kiiowai about the eliology ;IIKI pathogenesis of H IV-associatcil candidiasis. This s t t a h investigated oral caniiuliasis in patienis with IIIV iiiteetion. I h e specific ob[eetives were (1) to measure the freqtieneics of HIV-rchited oral eandidiasis and (2) to identity faetors ;issoeiateii with increased trequency of oral eandidiasis m a population of p;itients inteeled by IIIV.

Material and methods Ihe studv populalion included patients who were seropositive tor antibody to

HIV when tested with 1.1.ISA and Western Bhit. Patients were excluded it they were minors, ineonipeteiit or if inlorined consent was not obt;iinccl. I h e patients were interviewed and given ;in orul examination. Bkiod was taken for hematologie examination and aiklitional intorniation w;is obtained trom thc elinieal records. The criteria for clinical diagnosis of 1IIV-relatetl oral eandidiasis were cltnicitl ;tppcar;inee, as ilescribed by (iRi i:NSt','\N et al. (ID) and thc identillcation of candidal hyplKie on PAS stained smears. Deseriptive statistics were calculated and the assoeiations between the predictor variables and the otiteome variable, eandidiasis, were investigated by means of Pearson's ehi-sqtiare test with Yates continuity correction ( I I ) . I he variables lound to be significant iti this bivariate analysis were entered into a multivariate logistic regression in order to stuily thc elTcet of each predictor on candidiasis 111 the presence of the other pixxlietors. A backward stepping algorithm was a p pheil to see whieh ol the selected predictors were supertltiotis and cotild be removed from the regression model. /'values ol ()():< lO'/L). I h c Wald .statistic, formed (in the case ol a siimie

///l -relafed oral eandidiasi.'i 333 parameter) by thc square of the ratio ot the estimated regression eoellleicnt dividcil by its estimated statidatxl error, and its signillcaiice arc given, ;is well ;ts the degrees of freedom of thc i"e\stiliant chi-sqtiarc statistic. Otily the presence absence of xerostiMiiia is clearly signitleant (/'^^0.0166) in the presence of the other fotir variables, aithotigh T4-eotint is almost significant (/' = O.O872). When the backward stepping algorithm was used to remove variables trom the regression model in order of the smallness of their test statistic, thc statistical siunilahlc 1. Hiarae teristies of the sltidy poptilalion (/( 71) Paticiils Variable

Catceorv

Aue

•. .vS vr > 3 s >r

37 52.1 34 47.')

Sex

Mcn Wonu'n

67 94.4 4 5.6

Marital Slafus

Sometime married 26 36.6 Never m,irried 45 63.4

I'.ilueation

< 1 2 vr > 12 vr

.18

f.flinic group

(.;.B, and Iielaiut Other l:ur Other

46 64.8

•Sincikiiig

Present Ahsent

36 ,s0.7 3,s 49.3

Aleohol

>H.5 L vr •• 8.5 I. yr

52 73.2 1') 26.8

Plaque liulcx

0

33 46.5

21 29.6 4

s

5.6

li.3

1

.^2 45.1

3 fdcnUilous

20 28.2 7 9.9 4 5.6

Kegular denial eare

Present Absent

35 49.3 36 .so.7

Xerostomia

Present .•\hseiit

10 14.1 61 85.9

Aitiibiolies

I'rcsciil .Absent

7 9.9 64 90.1

Anlilungal a,iJ:ciits

Present Absent

14 19.7 57 80..3

Perkirniaiiec slaius

No resliielioii Some restriction

53 74.6 IS 25.4

liiiic sinec diagnosis

:,= 2(1 Months ••2fl Months

41 57.7 30 42.3

Risk group

l . l l . Male 2. B. Male ^. IV Drug 4. 1 leniophiliae 5. Other

47 66,2

32 45.1 17 2}.^) 22 31.0

(DC

< .i()() mm' .?()(! 5(K) > 500 2

elassifiealion

}

T4 fouiU

AIDS

,x ! 1.,! 1

1.4

1(1 14.1 s 7.0

4

4."! 60.6 Ill 14.i 18 25.4

I'reseiil AbsenI

.SS 81.3

13 18.7

llcancc oi the remaining variables increased, sei that, at the last step, pertbrtnancc stattts was removed althcutgh It had a /'-valtic of t),0956, and the remaining model contained onlv r4-cotmt aiul xerostomia, with regression coefficients and test statistics as shown in lable ,5. Both xerostomia aiul T 4 eotiiit had very sigiiitlcant regression slopes (/'=. 0.0106 and 0.017,5, respectively). File order in which predietors were removed from the equation were marital status, age group, and tlnally pertbrmancc stattts.

fable 2. Fhe trequenev i>f HlX'-assoeialed orai eaiididiasis. One patieiif had nu^ie than I lesion Patienis alTeelcd elinieal piesenlalioii

»i

l*rv iheinatous Pseudoinembraiioiis An,i!ular eheilitis I Iv perplastie

14

0

20 I I 4 0

Total

24

34

tients who had vcrostomia. This resuli agrees with other reports that xerosloinia predisposes !o eandidiasis (7 9, 18 21). Xerostomia was ciinsidered to Discussion be present if there was stibjcctive comThe trcqtieney of patients alTcctcd by plaint of drv tnouth, reduced pooling of clinical signs of 1 llV-related oral eandi- saliva and thc oral mucosa appeared drv diasis (34%) is similar to the weighted on elinieal exatnination, Xenistomia mean reported frequeney (3t)"o), demav enhance stiseeptibility to eandidiascribed by SAMAR..\\..\X ..\Kt & HoMsis by redtteing the llushmg aetion ot siRi^f, (1) and the recently published saliva and the lubrication of thc oral (reqtiencics oi} I "„ tbtiiui by B.VROM et mucosa, laciiitating traumatic iiijurv al. (12) and 36"« hy PORII;R et ul. (13). and by a redtietion in the salivarv coii7\vcnt\ petrent of patienis |14 71) siituents which enlnince local immunewere takmg antifungal agetits. Two paftmetion. Poor oral hygiene mav be astients, who were taking antifungal soeiated with candidiasis (7) and inagents for recurrent pseudomcmbra- creasing frequency of eandidiasis vvith iKHis type, were itiekided in the croup mcrcasmg values of the plaque index alTcctcd by candidiasis, although no were fotmd, hcivvcvcr these dilferciiees clinical lesions were apparent. The tVc- were not signitlcant beeause of the samqueiicy of HIV-related eandidiasis has ple si/e. Plaque index and xeriisttimia been recently reviewed, (1) but intbrmawere not associated. tion regarding the use of antifungal Stipertleuil eandidiasis occurs when agents and thc stibseqtient impact on cell-mediated immtmc defects are presestimates of thc prevalence of IllV-re- ent t2, 4. 18, 23). The principle effecl latcd candidiasis is lackitig. The prevof HIV on the itntnune system is the alence ot oral candidiasis may be underdepletion of T4-lymphoev1cs with adestimated and the clinical presentations vancing disease. .'\s a result of this, there may be intlueticed bv coticurretit ttcatIS a drop in the r4-eiHiiU and a reversal ment. In patients with HIV, this includes of thc T4 T8 ratio (24), In this studv, self-tnedication, as well as prescribed there was a notable mcreasc in the tretreatment with defined tbllovv-up. quency of candidiasis with deelimng 14coutit, and this was particular!) marked The multivariate logistic regression vvlieti thc T4-eotint was '-30(1 mm \ analysis shows that the presenee abThis agrees with ht.\xt et al.. who found sence of xerostotnia is a statistically that i>ral pscudomenihranoiis earuiidiasignitlcant predictor of tlie presence absis occtu'rcd when the r4-coimi was sence ot candidiasis whether other pre< 300 mm' and that esophageal eaiulidictors are tiscd or not; it is essentially independent of the other variables. T4- diasis occtirred when the T4-eount was •-. 100 mm' (2,5). Oral cindidiasis and count is the second most important premcreased earriage oi Camiida .\pp. have dictor, but Us statisttcal signillcance bebeen noted in I II\-inleeted patients comes enhanced as other predietors are with low T4 cotmts bv others {l(y 30). removed frotn the regression equation, showing that I 4-eount is related to the Oral caiididiasis has also been deseribed in a patient with low 14 eouiit who did three predietors, age, marital status and not have HIN' (31). A reversed T4 18 performance status. Of thc three remaining variables, performance status cell ratio has also been found to be assoeiated vvith inereased frequeney of canseems to be thc most important and it didiasis (32 3,s). is closely telated to thc other two. Candidiasis was touiid approximatePerformanee status was assessetl acly three times more trcqtieiitly in pa- cordina to the elassitlcation bv Mil 11 R

334

VICCARUIV' ei al.

ct al. (22) and provides an assessment ol the "'weilness" ot each patient, (andi(iiasis IS known as a disease of the diseased, and it is not surprising that pa-

JabI,

tients with restrietions on their abilities to function were more likely to have eandiduisis. All study participants were outpatients and most had no restriction.

assoeiated «ith inereased frcqueney ot

IV ax-la lei.1 oral e;indidiasis Pafient s wifh eaiulu liasis in 71)

\ariable

('aleuorv

.Ace Marital

/'value

1!

Married Wid"0: 2' 1112 4.

24. CiAllo RC. The .AIf)S virus. .Sci 4in 198~: 256: 4~ 56 25. IMAVI N , C V R I ' I M I R (X J, M VM R KH,

I-'|SHI R .X. SiiiN M. DvMoRiH SB. llier.irehieiil pvitlerii of mueosai eaiutkla tn leelions m H I \ "Seropt>sui\e women, .ini .1 Md 1990: 89' 142 d. 26. Ksoni 1 R RM. Human immunodetieieiiev Virus inieetion. l\'rniuio! Ciui 19S'*:7: 36'* 85. :".

KAI'I V\ M I L SAHKK N , M ( N I it NS,

Mil I/tR KL SARNdVOHARAN NK i. P VVIvv.v S. Dermalologie liiitlings and matiifesiafions of aequired iinmutiodefieieiiev svtKlroiiie t.\II)S). ,/ Am Acml Dcrnuiioi 1987; 16: 485 506. 28. PlIIIlMHRl. .A, RlISIMUR R, LiN/lK 11, liRNsr M, KiR\ P, MiH.ii W. Oral eandidiasts deteriiiined b\ a quantitative nielluHi eorrelalion to marker of' the minuinologie svsteni 5th ltitcrn:nknial t'otil'ereiiee on .AIDS Montreal U'S'». Abslrael riiBP329. 29. FoRssAMirK J. MoRii 1 orA1 vxsos I . BiniRiil I n Ci, R VRI ssox A. t'l rKONi \ PO. WASSFRVIAN J. Oral i\in,litiu uiivcdiis in l l l \ ' mfeelion. S