Chapter 7: Viral Infections
What family of double stranded DNS viruses includes eight different subtypes for which humans are the only natural reservoir?
human herpesvirus (HHV)
What are HHV-1 and HHV-2 called?
herpes simplex virus (HSV)
What is HHV-3 called?
varicella-zoster virus (VZV)
What is HHV-4 called?
Epstein-Barr virus (EBV)
What is HHV-5 called?
What pattern of symptomatic primary infection is caused by HHV-6 and HHV-7 called?
What is HHV-8 called?
Kaposi sarcoma–associated herpesvirus (KSHV)
The two herpes simplex viruses are similar in structure and disease mechanisms but differ in antigenicity. What accounts for their distinct antigenicity?
Differences in envelope glycoproteins.
Which HSV is adapted best to the oral, facial, and ocular areas (i.e. areas above the waist)?
Which HSV is adapted best to genital zones (i.e. areas below the waist)?
What are the three phases in the natural history of HSV infection?
- primary infection
- recurrent infection
Which phase of HSV infection refers to initial exposure to the virus?
What is the usual incubation period in symptomatic cases of HSV infection?
3 to 9 days
What is the most common site of latency for HSV-1?
Which phase of HSV infection occurs with reactivation of the virus?
HSV-2 infection is associated with at least a twofold increase in risk for what infection?
human immunodeficiency virus (HIV)
What blistering, ulcerative mucocutaneous condition is often preceded by a symptomatic recurrence of HSV?
What is the the most common pattern of symptomatic primary HSV infection?
acute herpetic gingivostomatitis
Which type of HSV is the main cause of acute herpetic gingivostomatitis?
Why is development of acute herpetic gingivostomatitis before 6 months of age rare?
Because of protection by maternal anti-HSV antibodies.
What complication of primary HSV infection in adults causes vesicles develop on the tonsils and posterior pharynx, which rupture to form ulcers with a gray-yellow exudate?
Which type of HSV is the main cause of pharyngotonsillitis?
What is the most common site of recurrence for HSV-1?
What is it called when HSV-1 recurs on the vermilion border?
herpes labialis (“cold sore”)
Besides the lips, where else can recurrent herpetic infection effect?
What is primary or recurrent HSV infection of the fingers is known as?
herpetic whitlow (herpetic paronychia)
What are hepatic lesions caused by contamination of areas of abrasion called?
herpes gladiatorum ("scrumpox")
What are hepatic lesions caused by contamination of injuries created by daily shaving called?
What diffuse life-threatening HSV infection may result in patients with chronic skin diseases, such as eczema?
eczema herpeticum (Kaposi varicelliform eruption)
What should be prompted by HSV infection in a chronic ulcer on the movable oral mucosa?
Thorough evaluation for possible immune dysfunction.
What is the characteristic histopathology pattern of HSV-infected epithelial cells?
Cells exhibit acantholysis, nuclear clearing, and nuclear enlargement (termed ballooning degeneration).
What acantholytic epithelial cells are characteristic of (but not specific to) HSV?
What is the traditional method for diagnosis of HSV?
Viral isolation from tissue culture inoculated with the fluid of intact vesicles.
What are the most commonly used sampling methods for diagnosis of HSV?
- cytologic smear
- tissue biopsy
How soon after initial exposure do antibodies to HSV typically begin to appear?
4 to 8 days
What medication, if administered early, can be beneficial in accelerating clinical resolution of primary herpetic gingivostomatitis?
acyclovir ("rinse-and-swallow" technique)
Why should lidocaine and topical benzocaine should be avoided in pediatric patients with primary herpetic gingivostomatitis?
Because of reports of lidocaine-induced seizures in children and an association between topical benzocaine and methemoglobinemia.
What are three prophylactic antiviral treatment options to reduce recurrences of HSV?
- acyclovir, 400 mg twice daily
- valacyclovir, 1 g daily
- famciclovir, 250 mg twice daily
What condition represents primary infection with the varicella-zoster virus (VZV or HHV-3)?
What is recurrence of latent varicella-zoster virus called?
How is VZV transmitted?
The virus may be spread through air droplets or direct contact with active lesions.
What is the incubation period of VZV?
10 to 21 days (average 15)
Because of increasing varicella vaccination rates, the majority of new varicella cases now represent breakthrough infection. What does this mean?
Infection with wild-type virus in a previously immunized patient.
What is the characteristic symptom of VZV infection in unimmunized individuals?
An intensely pruritic exanthem, beginning on the face and trunk and spreading to the extremities.
The vesicular stage is the classic presentation of VZV infection. How are these vesicles described?
Each vesicle is surrounded by a zone of erythema and has been described as “a dewdrop on a rose petal.”
How long are unimmunized individuals infected by VZV contagious for?
Affected individuals are contagious from 2 days before the exanthem until all the lesions crust.
Perioral and oral manifestations are fairly common in VZV infection. What are the two most common areas involved?
- vermilion border
What bacteria may cause life-threatening secondary skin infections in cases of VZV infection?
group A, β-hemolytic streptococci
Why should aspirin be avoided in children with VZV infection?
It may cause Reye syndrome, a potentially fatal condition characterized by acute encephalopathy, liver failure, and other major organ damage.
The prevalence of VZV complications in adults exceeds that in children. What is the most common complication?
The risk of death from VZV infection is reported to be 15 times greater in adults compared with children. Why is this?
Because of an increased prevalence of encephalitis.
What condition can result from VZV infection during pregnancy?
The cytologic alterations of VZV infection are virtually identical to those described for what other virus?
What is the most definitive method for diagnosis of VZV?
PCR performed on vesicular fluid, cells from the base of a lesion, or a scab from a resolving skin lesion.
What is the preferred antipyretic for childhood cases of VZV infection?
Why should varicella vaccine recipients who develop a rash should avoid contact with those at risk?
Because the varicella virus vaccine is a live, attenuated virus that can be spread to individuals in close contact.
Where does primary infection with VZV (chickenpox) establish latency?
dorsal root ganglia
What condition is caused by reactivation of VZV?
herpes zoster (shingles)
The clinical features of herpes zoster can be grouped into three phases. What are they?
What is the characteristic feature of the prodrome phase of herpes zoster?
During initial viral replication, severe neuralgia develops in the area of epithelium innervated by the affected sensory nerve (dermatome).
What is the characteristic feature of the acute phase of herpes zoster?
The involved skin develops clusters of vesicles set on an erythematous base, which tend to follow the path of the affected nerve and terminate at the midline.
What do oral lesions in herpes zoster indicate?
Oral lesions occur with trigeminal nerve involvement.
What are hepatic lesions on the tip of the nose called?
Hutchinson sign indicates herpetic involvement of the nasociliary branch of the trigeminal nerve. Why is this concerning?
It indicates an increased risk for severe ocular infection, which may lead to permanent blindness.
Reactivation of VZV in the geniculate ganglion may cause (...), which is characterized by cutaneous lesions of the external auditory canal and involvement of the ipsilateral facial and auditory nerves.
Ramsay Hunt syndrome
Approximately 15% of patients progress to the chronic phase of herpes zoster, termed (...), which is characterized by persistent pain after resolution of the rash.
In rare cases, a potentially fatal ischemic stroke syndrome, termed (...), may develop after resolution of a zoster rash involving the trigeminal nerve.
The cytologic alterations of herpes zoster are virtually identical to those described for what other virus?
Herpes zoster often is diagnosed from the clinical presentation. What test can be used to provide confirmation?
What antiviral medications have been found to accelerate healing reduce pain during the acute phase herpes zoster? (3)
Antiviral medications are most effective against herps zoster if initiated within (...) hours after development of the first vesicle.
A herpes zoster vaccine (Zostavax) has been approved by the FDA for use in adults (...) years and older.
Why shouldn't the zoster vaccine generally not be administered to immunocompromised persons?
Because the zoster vaccine contains live, attenuated virus.
What symptomatic disease results from exposure to Epstein-Barr virus (EBV or HHV-4)?
infectious mononucleosis ("kissing disease")
How is infectious mononucleosis usually spread?
Most EBV infections in children are asymptomatic. What are the typically symptoms if they do occur? (4)
- hepatosplenomegaly (less common)
What are three oral manifestations of EBV infection?
- oropharyngeal tonsillar enlargement (80%)
- petechiae (25%)
- necrotizing ulcerative gingivitis (NUG)
The diagnosis of infectious mononucleosis commonly is based upon the clinical presentationand two other findings. What are they?
- 10% atypical lymphocytes
- positive heterophile antibody test
Diagnosis of EBV is be based on a positive heterophile antibody test. What are heterophile antibodies?
IgM antibodies that are directed against viral antigens and cross-react with sheep and horse erythrocytes.
How long does it take for infectious mononucleosis to resolve in most cases?
4 to 6 weeks
Why might patients with infectious mononucleosis be advised to avoid contact sports?
To prevent the rare possibility of splenic rupture.
Why should penicillins should be avoided if possible in patients with infectious mononucleosis?
These antibiotics commonly cause nonallergic morbilliform skin rashes in affected patients.
Where is CMV found in infected patients?
The virus can be found in most bodily fluids, including saliva, blood, urine, tears, respiratory secretions, genital secretions, and breast milk.
At any age, almost 90% of CMV infections in immunocompetent individuals are asymptomatic. What are the two most common manifestations of CMV infection in patients with AIDS?
- gastrointestinal involvement
Neonatal CMV infection can produce developmental tooth defects. What are three tooth defects seen in neonatal CMV?
- enamel hypoplasia
- enamel hypomaturation
- yellow coloration
What is the characteristic histopathological finding in CMV infection?
Swollen, infected cells showing inclusions and prominent nucleoli called “owl eye” cells.
What antiviral medication is used to treat CMV infection in immunocompromised patients?
What group of viruses include echoviruses, coxsackieviruses, and polioviruses?
What population is most affected by symptomatic enterovirus infections?
infants and young children
What are the three main patterns of symptomatic enterovirus infections?
- hand-foot-and-mouth disease
- acute lymphonodular pharyngitis
Which coxsackievirus viruses usually cause herpangina? (9)
A1 to A6, A8, A10, or A22
Which coxsackievirus virus usually causes hand-foot-and-mouth disease?
Which coxsackievirus virus usually causes acute lymphonodular pharyngitis?
What is the major mode of transmission of the enteroviruses?
What is the incubation period of the enteroviruses?
4 to 7 days
Which pattern of enterovirus infection begins with flulike symptoms followed by red macular lesions on the soft palate or tonsillar pillars?
What is the best known presentation of enterovirus infection?
Which pattern of enterovirus infection begins with flulike symptoms followed by oral and hand lesions?
Which pattern of enterovirus infection begins with flulike symptoms followed by yellow or pink nodules on the soft palate or tonsillar pillars?
acute lymphonodular pharyngitis
In most instances, enterovirus infections are self-limiting and without significant complications. What are three sings that indicate increased risk for serious disease?
- fever above 102° F
- severe vomiting
What highly contagious infection is produced by a virus in the family Paramyxoviridae and genus Morbillivirus?
Most cases of measles arise in late winter or spring. How is measles spread?
Most cases of measles are spread through respiratory droplets. What is the incubation period for measles?
The average incubation period for measles is 14 days. When are the affected individuals infectious?
From 4 days before until 4 days after appearance of the associated rash.
What is the major symptom associated with measles infection?
The virus causes significant lymphoid hyperplasia that often involves the lymph nodes, tonsils, adenoids, and Peyer patches.
There are three stages of measles infections. How long is each stage?
3 days (hence the designation "9-day" measles)
There are three stages of measles infections. What are the symptoms of the first stage? (3)
- coryza (runny nose)
- cough (typically brassy)
- conjunctivitis (red, watery, eyes)
What is the most distinctive oral manifestation of the first stage of measles infection?
These lesions of epithelial necrosis called Koplik spots which and appear as white macules (or “grains of salt”) surrounded by erythema.
There are three stages of measles infections. What are the symptoms of the second stage? (3)
- resolution of Koplik spots
- morbilliform rash
There are three stages of measles infections. What are the symptoms of the third stage? (3)
- resolution of fever
- resolution of rash
- brown pigmentation
What serious complication of measles can ccur up to 11 years after the infection?
A degenerative CNS disorder called subacute sclerosing panencephalitis (SSPE), which leads to personality changes, seizures, coma, and death.
What numerous multinucleated giant lymphocytes are found in (but are not specific to) measles infections?
Warthin-Finkeldey giant cells
The diagnosis of measles in an epidemic setting usually is based on the clinical features and history. What test can be used for confirmation?
IgM antibody assay
The measles vaccine is a live, attenuated virus. What two vaccines is it included in?
- MMR (measles, mumps, and rubella)
- MMRV (MMR plus varicella)
The measles vaccine is over 99% effective. What is the recommended vaccination schedule for measles?
The first dose administered between the ages of 12 and 15 months and a second dose between the ages of 4 and 6 years.
What mild illness is caused by a virus in the family Togavirus and genus Rubivirus?
rubella (German measles)
The greatest importance of rubella infection is not in its effects on those who contract the acute illness. What is the significance of this infection?
Its capacity to induce birth defects in the developing fetus.
Rubella infection occurs primarily in late winter and early spring. How is it spread?
Rubella infection is contracted through respiratory droplets. What is its incubation time?
12 to 23 days
The incubation time for rubella is from 12 to 23 days. How long are the patients contagious?
From 1 week before to 1 week after onset of the exanthem.
A large percentage of rubella infections are asymptomatic. Which age groups are more likely to experience symptoms?
adolescents and adults
Prodromal, flu-like symptoms of rubella infection may be seen 1 to 5 days before the exanthem. What is the most common complication?
The most common complication is arthritis, which usually arises subsequent to the rash.
The rash is often the first sign of rubella infection. How long does the rash usually last?
3 days (hence the designation "3-day" measles)
In about 20% of rubella cases, dark-red papules that develop on the soft palate and may extend onto the hard palate. What is this called?
Infection of a pregnant mother with rubella may cause congenital rubella syndrome (CRS). What is the classic triad of CRS?
- deafness (most common, 80%)
- heart disease
What two vaccines are available for rubella?
- MMR (measles, mumps, and rubella)
- MMRV (MMR plus varicella)
What is the routine vaccination schedule for rubella?
The first dose is given at 12 to 15 months of age and the second dose at 4 to 6 years of age.
What infection is caused by a virus in the family Paramyxoviridae and genus Rubulavirus?
mumps (epidemic parotitis)
What is the characteristic feature of mumps?
Diffuse swelling of the exocrine glands; the salivary glands are the best known sites of involvement.
Mumps causes diffuse swelling of the exocrine glands. How is mumps transmitted? (3)
respiratory droplets, saliva, and urine
Mumps is transmitted by respiratory droplets, saliva, and urine. What is its incubation period?
16 to 18 days (range of 2 to 4 weeks)
The incubation period of mumps usually is 16 to 18 days. When are patients contagious?
From 1 day before the clinical appearance of infection to 14 days after its clinical resolution
How doe the efficacy of the mumps component of the MMR vaccine compare to that of measles and rubella?
It is approximately 88% after two doses, lower than that of the measles and rubella components.
Approximately 30% of mumps infections are subclinical. What is the main symptom of mumps?
Discomfort and swelling of the salivary glands, extending to tissues below the mandible.
Mumps causes significant salivary gland changes. Which salivary glands are most often affected?
The main finding in mumps is salivary gland swelling. What is the second most common finding in males?
In about 25% of postpubertal males, epididymo-orchitis causes swelling and pain in the testicles.
What is the most frequently reported oral manifestation of mumps?
Redness and enlargement of Wharton (submandibular) and Stensen (parotid) salivary gland duct openings.
The diagnosis of mumps in an epidemic setting usually can be made easily from the clinical presentation. What is the most frequently used test to confirm the diagnosis?
What two vaccines are available for mumps?
- MMR (measles, mumps, and rubella)
- MMRV (MMR plus varicella)
What vaccines are available for mumps?
- MMR (measles, mumps, rubella)
- MMRV (MMR plus varicella)
What is the recommended vaccination schedule for mumps?
The first dose is administered between 12 and 15 months and the second dose between 4 and 6 years.
What single-stranded RNA virus belonging to the family Retroviridae is the causative agent of AIDS?
human immunodeficiency virus (HIV)
HIV is a single-stranded RNA virus belonging to the family Retroviridae. How many species are there?
There are two species of HIV. Which exhibits a worldwide distribution and is responsible for the majority of cases?
There are two species of HIV. Which predominates in Africa and is associated with lower risk of transmission?
In 1981, the CDC published the first scientific report of AIDS. What was the causative agent of the pneumonia observed in patients that lead to the discovery of HIV?
Where can HIV be found in infected individuals?
In most bodily fluids, including serum, blood, saliva, semen, tears, urine, breast milk, and vaginal secretions.
HIV can be found in most bodily fluids. What are the three most frequent modes of transmission in the US?
- male-to-male sexual contact (66%)
- heterosexual contact
- injection drug use
In the US, the most frequent mode of HIV transmission is male-to-male sexual contact. What race(s) are predominantly affected?
Currently, blacks and Hispanics are the most commonly affected ethnic groups.
What is the primary target cell of HIV?
CD4+ helper T lymphocyte
What are the three clinical stages of HIV?
- acute phase
- chronic phase (or latency period)
During the acute of HIV phase, the patient may be asymptomatic or exhibit a self-limited (...) syndrome.
After HIV infection is established, an immune response is developed, viremia declines, and the patient enters a (...) period.
How long does the acute phase of HIV infection last?
1 to 6 weeks
Are patients in the acute phase of HIV infection infectious?
During this phase, HIV antibodies are not yet detectable, yet patients are extremely viremic and highly infectious.
How long does the clinical latency period of HIV infection last?
It may last several months to more than 15 years, but the median duration is approximately 10 years.
In the chronic phase of HIV infection, there may be a period of chronic fever, weight loss, diarrhea, oral candidiasis, herpes zoster, and/or oral hairy leukoplakia (OHL). This presentation has been termed (...).
AIDS-related complex (ARC)
Over time, the immune system fails to control the HIV. There is a dramatic increase in viremia, and the CD4+ cell count declines, resulting in the development of (...).
acquired immunodeficiency syndrome (AIDS)
In many cases, pneumonia caused by the fungus (...) is the presenting feature leading to AIDS diagnosis.
Clinically significant neurologic dysfunction is present in 30% to 50% of AIDS patients and most commonly manifests as progressive encephalopathy known as (...).
The most widely accepted classification of the oral manifestations of HIV disease was compiled by the EC-Clearinghouse. What are the three groups within this classification?
- strongly associated
- less commonly associated
- seen in HIV infection
(...) is the most common intraoral manifestation of HIV infection and often is the presenting sign that leads to the initial diagnosis.
Although a number of Candida species have been encountered intraorally, the most common organism identified in oral candidiasis is (...).
What is the prognostic significance of finding oral candidiasis in a patient infected with HIV?
It is predictive for subsequent development of full-blown AIDS in untreated patients within 2 years.
More than 90% of patients with AIDS develop oral candidiasis at some time during their disease course. What four clinical patterns are seen?
- pseudomembranous candidiasis
- erythematous candidiasis
- hyperplastic candidiasis
- angular cheilitis
*The first two variants constitute most cases.
What is a distinctive histopathological feature of HIV-associated oral candidiasis?
Biopsy specimens demonstrate candidal organisms embedded in the superficial keratin, but the typical inflammatory reaction may be deficient.
Under what four conditions is systemic antifungal therapy indicated for oral candidiasis in HIV patients?
- if they are not receiving ART
- if there is esophageal involvement
- if their CD4+ count is below 50 cells/mm3
- if they have a high viral load
What is the systemic antifungal of choice for oral candidiasis in HIV patients?
Although EBV is associated with several forms of lymphoma in HIV-infected patients, the most common EBV-related lesion in patients with AIDS is (...).
oral hairy leukoplakia (OHL)
OHL clinically presents as a white mucosal plaque that does not rub off. Where do most cases occur?
Most cases occur on the lateral border of the tongue.
Histopathologically, OHL exhibits thickened parakeratin with surface corrugations or thin projections. What lightly stained cells with abundant cytoplasm are characteristic of OHL?
(...) is a vascular endothelial neoplasm caused by human herpesvirus 8 (HHV-8).
Kaposi sarcoma (KS)
KS mainly manifests as multiple lesions on the skin or oral mucosa. What sites are most commonly affected? (3)
- hard palate
After seroconversion, in the chronic phase, HIV often remains silent except for (...), which is lymphadenopathy present for longer than three months, involving two or more extrainguinal sites.
persistent generalized lymphadenopathy (PGL)
(...) currently represents the most common malignancy among the AIDS population in the United States.
non-Hodgkin lymphoma (NHL)
Three atypical patterns of periodontal disease are associated strongly with HIV infection. What are they?
- linear gingival erythema
- necrotizing ulcerative gingivitis (NUG)
- necrotizing ulcerative periodontitis (NUP)
(...) appears with a distinctive linear band of erythema that involves the free gingival margin and extends 2 to 3 mm apically.
linear gingival erythema
(...) refers to ulceration and necrosis of one or more interdental papillae with no periodontal attachment loss.
necrotizing ulcerative gingivitis (NUG)
(...) is is characterized by gingival ulceration and necrosis associated with rapidly progressing loss of periodontal attachment.
necrotizing ulcerative periodontitis (NUP)
What distinguishes NUP from typical chronic periodontitis?
There is usually no pocketing because extensive gingival necrosis typically coincides with loss of the adjacent alveolar bone.
What four components comprise treatment for NUG and NUP?
- antimicrobial therapy
- pain management
- immediate follow-up care (within 24 hr)
- long-term maintenance (every 3 months)
In patients with gingival necrosis, the process occasionally extends away from the alveolar ridges and creates massive areas of tissue destruction termed (...).
The best known mycobacterial infection is (...), which is caused mainly by Mycobacterium tuberculosis
What is unique about the pattern of TB infection in HIV-infected individuals?
There is an unusual predilection for extrapulmonary involvement among HIV-infected individuals with TB.
Oral lesions are uncommon and occur in less than 5% of all individuals with active TB. What is the most commonly involved oral site?
Hyperpigmentation of the skin, nails, and mucosa has been reported in HIV-infected patients. What are three mechanisms to explain this?
- Medications used to treat AIDS may cause increased melanin pigmentation.
- Opportunistic infections in AIDS may cause adrenocortical destruction.
- There is evidence that HIV infection itself directly causes pigmentation.
HIV-associated salivary gland disease can arise anytime during HIV infection and is considered a localized manifestation of (...) syndrome.
diffuse infiltrative lymphocytosis (DILS)
Thrombocytopenia has been reported in up to 40% of patients with HIV infection. What are four mechanisms to explain this?
- direct infection of platelet progenitor cells
- platelet destruction by anti-HIV antibodies
- platelet destruction by immune complexes
- defective modulation of hematopoiesis
The prevalence of oral recurrent HSV infection among HIV-infected individuals increases significantly once the CD4+ cell count drops below (...) per mm3.
Persistence of active HSV infection for longer than (...) in a patient infected with HIV is one accepted definition of AIDS.
Some patients paradoxically develop herpes zoster shortly after initiating cART, as a result of (...).
immune reconstitution syndrome
Among HIV-infected individuals, most human papillomavirus (HPV) lesions arise in the anogenital region, although oral involvement also is possible. What are the four kinds of "oral warts" caused by HPV?
- oral squamous papilloma
- verruca vulgari
- condyloma acuminatum
- multifocal epithelial hyperplasia
HPV lesions often demonstrate numerous vacuolated epithelial cells with variable in nuclear size called (...).
(...) is the most common endemic respiratory fungal infection in the United States, produced by Histoplasma capsulatum.
What is the most common oral presentation of histoplasmosis?
Although intrabony infection of the jaws has been reported, the most common presentation is a chronic, indurated mucosal ulceration with a raised border.
Lesions that are clinically similar to aphthous ulcerations occur with increased frequency in patients infected with HIV. What are the three types of aphthous ulcerations?
*Two-thirds of affected patients have the usually uncommon herpetiform and major variants .
(...) is an infection caused by the molluscum contagiosum virus (MCV), which is a member of the poxvirus family.
Relative to the general population, HIV-infected individuals have an estimated (...) increased risk of developing oral cavity and pharyngeal cancer.
Confirmation of HIV infection most commonly is obtained by antibody testing. How after the infection does seroconversion normally occur?
3 to 12 weeks
AIDS is diagnosed when a patient has laboratory evidence of HIV infection combined with any one of three other findings. What are these other findings?
- CD4+ count less than 200 per μL
- CD4+ percentage less than 14%
- any AIDS-defining condition
Introduction of cART has resulted in dramatically reduced morbidity and mortality from HIV. What is cART?
combination antiretroviral therapy
Although numerous combinations are possible, cART often consists of three types of drugs. What are they?
Two nucleoside reverse transcriptase inhibitors (NRTIs) plus any one of the following:
- non-nucleoside reverse transcriptase inhibitor
- boosted protease inhibitor
- integrase inhibitor
Some patients who receive antiretroviral therapy during advanced stages of disease develop a paradoxical worsening of their condition termed (...).
immune reconstitution syndrome
Some patients who receive antiretroviral therapy develop immune reconstitution syndrome. What is the mechanism of this condition?
It involves a hyper-inflammatory response to pathogens and pathogenic antigens.