Open Journal of Stomatology, 2011, 1, 168-171
doi:10.4236/ojst.2011.14025 Published Online December 2011 (http://www.SciRP.org/journal/ojst/ OJST ).
Published Online December 2011 in SciRes. http://www.scirp.org/journal/OJST
Necrotising stomatitis as a presenting symptom of HIV
Gbemisola A. Agbelusi, Olutola M. Eweka
Department of Preventive Dentistry, College of Medicine, University of Lagos, Lagos, Nigeria.
Received 23 August 2011; revised 30 September 2011; accepted 17 October 2011.
ABSTRACT
Background: Necrotising Stomatitis is an uncommon
oral infection associated with diminished systemic
resistance (immunocompromised state) including HIV
infection. Significant predisposing factors include poor
oral hygiene, unusual life stress, recent illness (e.g.
Measles), malnutrition, smoking and even inadequate
sleep. It occurs commonly in developing nations with
poor living conditions. Objective: To present a case o f
severe Necrotising Stomatitis in a previously undiag-
nosed HIV Seropositive patient. Patient and Method:
This case report describes severe, rapidly spreading
necrotising stomatitis in a 35 years old lady, the con-
dition which led to her being diagnosed with HIV.
The treatment modalities, challenges of management
and the differential diagnosis were discussed. Result:
During the course of her management, patient’s oral
condition improved. However, later recurrence was
seen due to severe anaemia caused by malnutrition
and aggravated by Zidovudine antiretroviral drug.
Conclusions: There is need for interdisciplinary in-
teractions between the dentists and the physicians
managing HIV patients, to allow effective manage-
ment and afford patient the best treatment.
Keywords: Necrotizing Stomatitis, HIV, Anaemia, Zido-
vudine
1. INTRODUCTION
Necrotising Stomatitis (NS) is an inflammatory disease
of the mouth characterised by the destruction of epithet-
lium, connective tissue and papillae. The disease may
cause a loss of periodontal attachment and the destruct-
tion of bone, in advanced stages it may lead to cancrum
oris [1]. It is an uncommon oral infection associated with
diminished systemic resistance, immunocompromised s t at e
including HIV infection.
Necrotising Stomatitis (NS) also called Necro tising Ul-
cerative Stomatitis is very difficult to differentiate from
Necrotising Ulcerative Periodontitis (NUP). NS is gen-
erally localised, very rapidly destructive disease of the
oral mucosa, alveolar bone and overlying gingivae, al-
though considered less severe deep pain. NS may also
involve the palatal mucosa [2]. Significant predisposing
factors include poor oral hygiene, unusual life stress,
recent illness (e.g. Measles), malnutrition, smoking and
even inadequate sleep has been implicated. It occurs
commonly in develop ing nations with poor livin g condi-
tion [3].
NS is rarely seen in HIV seronegative patients espe-
cially where there is no underlying medical conditions.
However, it is more commonly seen in HIV seropositive
patients and could be a pointer to the diagnosis of HIV
in undiagnosed patients as is described in this case re-
port.
Signs and symptoms include, painful ulcers with ne-
crotic base, foul taste, halitosis, fever, associated infla-
med and painful gingivae/oral mucosa, sequestrum for-
mation and cervical lymphadenopathy. Patient experien-
ces difficulty in eating and swallowing.
Treatment is generally highly effective and life-saving,
if early diagnosis is made. Th i s reduces subsequent disabi-
lity or even death. The treatment of NS is identical to
that utilised to treat NUP. Treatment protocol includes
irrigation and debridement of necrotic areas, oral hygi-
ene instructions and use of mouthwashes, metronidazole
antibiotics and analgesics for pain [4]. As these diseases
are often associated with systemic medical conditions,
proper management of the systemic disorders is appro-
priate as highlighted in this report.
Recall visits are very important to monitor progress of
treatment and institute rehabilitation where necessary.
2. CASE REPORT
A 35 years old female patient, Miss P, presented at the
Oral Medicine Clinic of the Lagos University Teaching
Hospital on 13/11/2006 with a 2 week h istory of sor es in
her mouth.
She noticed the whitish ulcers in her mouth which she
claimed was getting bigger and deeper, there was associ-
ated severe pain, fever, malaise and painful throat, but

G. A. Agbelusi et al. / Open Journal of Stomatology 1 (2011) 168-171 169
there was no pus dischar ge nor bleeding.
It was her first visit to the dental clinic. She had no re-
levant past medical history, she was single, a caterer who
neither drank alcohol nor smoked cigarette.
On examination, patient was markedly pale with swol-
len lower lip which was diffuse and tender to touch. Sub-
mandibular lymph nodes were enlarged and tender. In-
tra-orally, the oral hygiene was poor with marked halito-
sis and generalised marginal gingivitis. A large irregular
ulcer measuring about 15 mm in diameter was seen on the
left side of the lower lip. Ulcer was tender with a ne-
crotic base and erythematous border. A smaller ulcer was
also seen on the buccal mucosa of the right cheek about
12 mm in diameter, oval in shape and also covered with
necrotic tissue. (Figures 1 and 2). There was a whitish
hair-like corrugated patch on the lateral borders of the
tongue which did not wipe off.
An impression of Necrotising Stomatitis and Hairy
Leukoplakia was made.
Differential diagnosis: Major Aphthous ulcer.
Investigations: The following investigations were or-
dered:
1) Haematological profile (full blood count and
differentials).
2) HIV screening for HIV I & II with pre and post.
Figure 1. Lesion on the labial mucosa at presentation.
Figure 2. Lesion seen on the right buccal mucosa test coun-
selling.
3) Histological examination was not carried out sin ce
the clinical presentation was adequate for diag-
nosis.
Treatment:
1) Counselling and reassurance.
2) Local treatment:
 0.2% Chlorhexidine mouth wash (clear
Breath) 8 hrly × 1/52 to alternate with Hy-
drogen peroxide mouth rinse.
 Xylocaine gel fo r top i cal a pplication.
3) Systemic treatment:
 Tabs. Ciprofloxacin 500 mg bd × 1/52.
 Tabs Metronidazole 400 mg tds × 1/52.
 Tabs Vit C 300 mg tds × 1/52.
 Tabs folic acid i daily × 1/52.
 Tabs fergon i tds × 1/52.
 Tabs paracetamol ii tds × 3/7.
Patient was given one week appointment for review.
Result of investigations after on e week:
 HIV screening was PO SITIVE for HIV I.
HB—9.4 g/dl, MCV—79.8, MCH—25.3, Neu-
trophils—49.3, Platelets—170 × 103, WBC—
2.7 × 103. (Hypochromic Microcytic anaemia).
 CD4 count was 33 cells/mm3 (22/1 1/06).
3. FOLLOW UP VISITS
Subsequent visits, the oral ulcers were reducing in size
and healing satisfactorily. Pallor and hairy leukoplakia
had cleared. Patient was feeling much better and was re-
ferred to HIV Clinic where she commenced Highly Ac-
tive Antiretroviral Therapy (H AART) in December 2006.
Antibiotics were discontinued but she continued with the
supportive therap y (haematinics and mouth rinses).
Two months later (January, 2007), she presented with
fresh lesions on the upper left labial mucosa of about 5
cm which was increasing in size. Her CD4 had risen to
37 cells/mm3, oral hairy leukoplakia was again present
on the lateral border of the tongue. She commenced anti-
biotics and supportive therapy.
On further review (22/01/2007), she was extremely
pale, left side of the lip was swollen with large necrotic
ulcers on the buccal mucosa, extending from the angle of
the mouth to the area of the second upper molar. There
was also spread of the necrotic lesio n to the gingivae on
the same side and also on the palate.
A clinical impression of recurrent necrotizing stomati-
tis was made.
The oral lesions were treated and she was referred
back to the HIV Clinic for possible admission and blood
transfusion for the anaemia. On further investigation, it
was noted that she had been on Zidovudine (one of the
combination ARV drugs) which is not compatible with
presence of anaemia. This was therefore responsible for
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her worsening anaemia and subsequent recurrent necro-
tising stomatitis.
The medication was changed and she has since im-
proved with no other episode of the lesion. Her CD4 co-
unt as at 22/9/08 was 448 cells/mm3 and she has had no
further recurrence. She had about 15 follow-up visits
after the first presentation.
4. DISCUSSION
Necrotising Stomatitis is a rare condition, which is seen
in immunocompromised patients e.g. in HIV infection.
Compared to other ulcerative and necrotising lesions
seen in HIV infected patients, NS is the most uncommon
seen in our environment.
A study carried out by Wright and Agbelusi, 2005 [5]
citing groups II and III lesions in 100 HIV positive Nige-
rians had no record of the lesion, other studies carried
out in Lagos by Agbelusi and Wright [6] among routine
dental patients presenting with oral lesions suggestive of
HIV/AIDS did not reveal any manifestation of NS. Also
in Jos, in Northern Nigeria no case of NS was seen as a
manifestation of HIV infection [7]. Benin City in Edo
state also had no record of NS in studies carried out
among HIV positive patients seen [8]. This is to show
that NS is a very uncommon lesion, even in HIV posi-
tive patients in Nigeria.
Though patient was unaware of her HIV status at the
time of presentation , the nature o f the lesion with the wi-
de spread presentation and the presence of Oral hairy
leukoplakia gave a pointer that she could be HIV posi-
tive, this was confirmed with the test result and the CD4
count of 32 cells/mm3 which also revealed that patient
was in full blown AIDS. This fact underscores the fact
that oral lesions may be the first presentation of HIV in-
fection and may lead to a diagno s is of HIV.
The aetiology of this condition had been seen to be
multifactorial. Anaerobic bacteria as the causative agent,
coupled with the underlying HIV infection, malnutrition
due to pain from the ulcer in the mouth resulting in an-
aemia, which is further complicated by side effects of
Zidovudine were all factors that predisposed her to the
condition.
The diagnosis of the lesion was based on its clinical
presentation and response to therapy. Correct diagnosis
is of utmost importance as an incorrect diagnosis and
treatment would have worsened the condition and may
result in fatality. For example, if the lesion had been
misdiagnosed as apthous major ulcer or erythema multi-
forme, administration of steroids would have worsened
the condition as the patient was already severely immu-
nocompromised.
Histologic features of NS are generally reported to be
non-specific and usually include surface ulceration cov-
ered by a fibro-purulent membrane with an acute or mix-
ed inflammatory cell infilterate and extensive hyperae-
mia of underlying lamina propria [9]. Since the histo-
logic feature of NS is not pathognomic, a biopsy is usu-
ally not indicated [10].
The use of oxidizing mouthwash and anaerobic anti-
microbial is paramount to the successful management of
the condition. Hydrogen peroxide helped in debriding
the lesion and hastened the healing.
Side effects of Zidovudine worsened her condition as
the patient had a recurrence of the lesion and a worsen-
ing of the anaemia. Also the CD4 count did not improve
initially as expected with the use of HAART. Vigilance
on the part of the dentist and due consultation with the
haematologist revealed the problem which was promptly
rectified with dramatic improvement in the patient’s
condition. This demonstrates the need for interdiscipli-
nary management of patients so that the patient can get
the best care.
Patient had worked as a caterer in a reputable hotel for
6 years, but had to take some time off when the illness
started. The severity and recurrence of the lesions led to
prolonged absenteeism at work which eventually caused
her her job and she was faced with financial difficulties
in keeping up her daily needs and more importantly main-
taining her health.
5. CONCLUSIONS
This presentation highlights this uncommon oral mani-
festation of HIV in a previously undiagnosed HIV pa-
tient, the role of multi-factorial aetiology in the appear-
ance of the condition, interdisciplinary management by
the oral physician and the haematologist resulting in
proper diagnosis and ulti mately i mpro ving her co nditio n.
The consequences of wrong diagnosis and improper ma-
nagement could have led to further spread of the lesion
with fatal consequences.
We cannot underestimate the role of detailed history,
proper clinical examination and correct diagnosis, which
ultimately determined the management protocol.
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