# HIV-Associated Systemic Sclerosis: Literature Review and a Rare Case Report
## 3 Discussion
A \"salt and pepper\" appearance, characterized by utiligo-like depignmentation and perifollicular hyperpigmentation, is a distinguishing skin manifestation. This typical appearance, together with skin sclerosis, is a diagnostic sign of SSc [9]. Terminal phalanges resorption, short and claw-like fingers (due to acro-osteolysis), and fingertip ulcerations are also usually seen [8]. Our patient presented a typical \"salt and pepper\" appearance, predominantly over the forehead and hands. Thick, adherent skin over the extremities, stiffened phalangeal joints on the fingers, reduced dexterity, and mild resorption of terminal phalanges were also observed. Orofacial manifestations may be seen in approximately 80% of SSc cases. Excessive period and periorbital sclerosis result in generalized thickened, non-pinchable skin with smooth, shiny texture, comprising the pathogenic \"expressionless,\" \"mask-like,\" or \"Mona Lisa\" facies or \"wide-eyed\" appearance [36]. \"Mouse facies\" result from atrophied nasal alae, giving a sharp-nosed appearance. Lip and period sclerosis result in limited mouth opening (microstonia) and width (microheilia) and distinctive creases radiating from the mouth, giving a \"purse-string-like\" appearance. Patients often complain of xerosoma, predisposing them to an increased incidence of candidiasis and high caries rates [8;9]. Periodontal features include a low gingival bleeding index, increased periodontal pocket depth, higher periodontal attachment loss, and multiple foci of gingival recession [9;13]. \begin{table}
\begin{tabular}{c c c} \hline
**Author (s) and Year** & **Autoantigen** & **Viral Antigen** \\ \hline [PERSON] et al., 1996 [28] & U1 RNP 70 kD; seen in MCTD and SSc & HIV gp120/41 envelope complex \\ \hline [PERSON] et al., 1987 [29] & U1 RNP 70 kD; seen in MCTD and SSc & Retroviral p30 gag protein \\ \hline [PERSON] et al., 1989 [30] & DNA Topoisomerase I 110 kD; seen in diffuse SSc & Retroviral p30 gag protein \\ \hline \end{tabular}
\end{table} 
Table 3: A summary of the sequence congruity between viral proteins and human autoanti epitopes. Our patient reported typical orofacial manifestations of SSc--thick, shiny facial skin, expressionless appearance, atrophied nasal alae, reduced interincisal and intercommissural distance with pale, fibrotic mucosa, and a depapillated tongue. Gingival recession in the lower anterior teeth and deep pockets were also seen. Periodontal ligament space widening and mandibular erosions are the distinctive radiographic manifestations of SSc [8]. Periodontal ligament space widening is the most frequently occurring radiographic presentation, and SSc should be given a place in the differential diagnosis, where the radiographic features demonstrate widened PDL space with intact lamina dura (particularly in non-mobile posterior teeth with widened PDL space in more than one segment) [36]. Another radiographic manifestation reported in these patients is the presence of bilateral, sharply defined, relatively uniform mandibular erosions at the insertion sites of masticatory muscles (angles, coronoid process, condyles, or digastric region) [36]. The blunting of mandibular angles results in a characteristic \"tail of the whale\" radiographic appearance [9]. The radiographic findings seen in our patient included a widened PDL space (more pronounced in posterior teeth) with intact lamina dura and a slight flattening of the left condylar head. The treatment of SSc necessitates an integrative strategy by incorporating systemic and dental management. The treatment is aimed at inhibiting the production and the accumulation of fibrous proteins, inhibiting vasculature dysfunction, and diminishing the inflammation. Medical management is aimed at preventing tissue ischemia (calcium channel blockers), inhibiting inflammatory-immune processes (immunosuppressive drugs--methotrexate, cyclophosphamide, mycophenolate moetil, cyclosporine A), and inhibiting excess collagen synthesis (D-penicillamine, colchicine) [14].