Editorial Review Human immunodeficiency virus in otolaryngology

The protean manifestations of the human immunodeficiency virus (HIV 1) in the head and neck should be appreciated by all otolaryngologists. Since the infective agent responsible for the acquired immunodeficiency syndrome (AIDS) and related illnesses was discovered in 1983 (Barre-Sinoussi et al.) the spectrum of manifestations has become well denned. The HIV virus attacks the immune system. In the initial stages the virus colonizes helper T lymphocytes and macrophages and replicates unchecked (Nowak and McMichael, 1995). The body then mounts an immune response which limits viral growth, leading usually to a prolonged period of asymptomatic infection. During this second phase the immune system continues to function and the level of free virus in the blood remains low. After a variable period of asymptomatic infection the immune response fails and the virus again replicates with a marked increase in free virus levels. The loss of immune competence in this later stage enables normally benign organisms to cause life-threatening opportunistic infections. The stages of HIV infection have been denned by the 'Centers for Disease Control' in the United States. Stage I refers to 'acute HIV infection' and stage II refers to 'asymptomatic HIV infection'. Stage III indicates persistent generalized lymphadenopathy. Stage IV disease is divided into a number of subgroups, which includes AIDS. Opportunistic infections which define AIDS are: Pneumocystis carinii pneumonia, chronic cryptosporidiosis, toxoplasmosis, extra-intestinal strongyloidiasis, isosporiasis, candidiasis (oesophageal, or broncho-pulmonary), cryptococcosis, histoplasmosis, Mycobacterium avium complex or M. kanasii infection, cytomegalovirus, and chronic mucocutaneous or disseminated herpes simplex infection. Malignancies denning AIDS are Kaposi's sarcoma, nonHodgkin's lymphoma and primary cerebral lymphoma. Antibodies to HIV can be detected in the blood following initial infection. HIV is largely transmitted by blood products and sexual intercourse. In the UK and North America, the infection has mainly been transmitted through homosexual intercourse and iv drug abuse, and there has not been the exponential rise in incidence of HIVrelated disease initially predicted. In Africa and Asia the situation is different, with the virus being endemic in some countries where spread is chiefly through heterosexual intercourse. Various studies have evaluated the manifestations ot HIV in the head and neck (Youngs et al., 1986; Herdman et al., 1989). It appears that up to 84 per cent of infected individuals have either symptoms or signs that may present to otolaryngologists (Barzan et al., 1993). Initial infection may manifest as an 'acute seroconversion illness', with an acute mononucleosis-like illness occurring two to six weeks after HIV infection, usually resolving after one to two weeks, although occasionally lasting longer (Cooper et al., 1985). The symptoms of primary HIV infection which may present to the otolaryngologist are odynophagia, retro-orbital pain, headache, oral ulceration and candidiasis. Identification of acute HIV infection may be important with the possibility of early administration of anti-retroviral drugs, such as zidovudine. It is thought that early chemotherapy may lessen the initial decline in the CD4 lymphocyte count, possibly increasing disease-free interval and life expectancy (Jolles et al., 1996).