Dysphagia

, Volume 7, Issue 3, pp 126–137 | Cite as

Oral diseases in HIV-1 infection

  • Charles E. Barr
Article

Abstract

HIV-associated oral lesions have been reported since the beginning of the AIDS epidemic, be they fungal, viral, bacterial, neoplastic, or non-specific in origin. The most common lesions are oral candidiasis (OC; noted in several forms) and oral hairy leukoplakia (OHL). OC appears to be directly related to levels of immunosuppression while OHL, a newly described lesion, is associated with the Epstein-Barr virus. Although prevalance data for all types of oral lesions are scarce, this review identifies and describes those reported most often. Lesions associated with HIV may appear on most oral mucosal surfaces and may differ from those seen on other body areas. The role of saliva in reducing the potential for transmission of the HIV virus appears to be significant. Physicians and dentists should cooperate in the management of the HIV patient who has oral disease.

Key words

HIV-1 AIDS Oral mucosa Lesions Prevalence Saliva Deglutition Deglutition disorders 
This is a preview of subscription content, log in to check access.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Gottlieb MS, Schroff R, Schanker HM, et al.:Pneumocystis carinii pneumonia and mucosal candidiasis in previously healthy homosexual men: evidence of a new acquired cellular immunodeficiency.N Engl J Med 305:1425–1431, 1981PubMedCrossRefGoogle Scholar
  2. 2.
    Masur H, Michelis MA, Green JB, et al.: An outbreak of community-acquiredPneumocystis carinii [neumonia: initial manifestation of cellular immune dysfunction.N Engl J Med 305:1431–1438, 1981PubMedCrossRefGoogle Scholar
  3. 3.
    Siegel FP, Lopez C, Hammer GS, et al.: Severe acquired immunodeficiency in male homosexuals manifested by chronic perianal ulcerated herpes simplex lesions.N Engl J Med 305:1439–1444, 1981CrossRefGoogle Scholar
  4. 4.
    Barré-Sinousi F, Chermann JC, Rey F, et al.: Isolation of a T-lymphotropic retrovirus from a patient at risk for acquired immune deficiency syndrome (AIDS).Science 220: 868–870, 1983Google Scholar
  5. 5.
    Gallo RC, Salahuddin SZ, Popovic M, et al.: Frequent detection of isolation of cytopathic retorviruses (HTLV-III) from patients with AIDS and at risk for AIDS.Science 224: 500–503, 1984PubMedGoogle Scholar
  6. 6.
    Popovic M, Sarngadharan MG, Read E, Gallo RC: Detection, isolation and continuous production of cytopathic retroviruses (HTLV-III) from patients with AIDS and pre-AIDS:Science 224:506–508, 1984PubMedGoogle Scholar
  7. 7.
    Lozada-Nur F, Silverman S Jr, Migliorati CA, et al.: The diagnosis of AIDS and AIDS related complex in the dental office: findigns in 171 homosexual males.Calif Dent J (June): 21–25, 1984Google Scholar
  8. 8.
    Klein RS, Harris CA, Small CB, et al.: Oral candidiasis in high-risk patients as the initial manifestion of the acquired immunodeficiency syndrome.N Engl J Med 311:354–358, 1984PubMedCrossRefGoogle Scholar
  9. 9.
    Lozada-Nur F, Silverman S Jr, Conant M: New outbreak of oral tumors, malignancies, and infectious diseases strikes young male homosexuals.J Calif Dent Assoc 10:39–42, 1982Google Scholar
  10. 10.
    Silverman S Jr, Migliorati CA, Lozada-Nur F, et al.: Oral findings in people with or at high risk for AIDS: a study of 375 homosexual males.J Am Dent Assoc 112:187–192, 1986PubMedGoogle Scholar
  11. 11.
    Greenspan D, Greenspan JS, Conant M, et al.: Oral hairy leukoplakia in male homosexuals: evidence of association with papillomavirus and a herpes group virus.Lancet 2: 831–836, 1984PubMedCrossRefGoogle Scholar
  12. 12.
    Hollander H, Greenspan D, Strongari S, et al.: Hairy leukoplakia and the acquired immunodeficiency syndrome.Ann Intern Med 104:892, 1986PubMedGoogle Scholar
  13. 13.
    Barr CE, Torosian JP: Oral manifestations in patients with AIDS or AIDS related complex.Lancet 2:288, 1986PubMedCrossRefGoogle Scholar
  14. 14.
    Schiodt M, Pindborg JJ: AIDS and the oral cavity. Epidemiology and clinical oral manifestations of human immune deficiency virus infection: a review.Int J Oral Maxillofac Surg 16:1–14, 1987PubMedCrossRefGoogle Scholar
  15. 15.
    Pindborg JJ: Classification of oral lesions associated with HIV infection.Oral Surg 67:292–295, 1989PubMedCrossRefGoogle Scholar
  16. 16.
    Romanowski B, Weber J: Oral candidiasis and the acquired immunodeficiency syndrome.Ann Intern Med 101:400–401, 1984PubMedGoogle Scholar
  17. 17.
    Chandrasekar PH, Molinari JA: Oral candidiasis: forerunner of acquired immunodeficiency syndrome (AIDS)?Oral Surg 60:532–534, 1985PubMedCrossRefGoogle Scholar
  18. 18.
    Phelan JA, Saltzman BR, Friedland GH, Klein RS: Oral findings in patients with acquired immunodeficiency syndrome.Oral Surg 64:50–56, 1987PubMedGoogle Scholar
  19. 19.
    Pindborg JJ: Oral candidiasis in HIV infection. In Robertson PB, Greenspan JS (eds):Perspectives on Oral Manifestations of AIDS. Littleton, MA: PSG Publishing, 1988, pp 28–37Google Scholar
  20. 20.
    Barr CE, Croxson TS, Andersson M, Turgeon L: HIV associated oral lesions: immunologic, virolic and salivary parameters.J Oral Pathol Med (in press)Google Scholar
  21. 21.
    Kaslow RA, Phair JP, Friedman HB, Lyter P, et al.: Infection with the human immunodeficiency virus. Clinical manifestations and their relationships to immune deficiency: a report from the multi-center AIDS cohort study.Ann Intern Med 103:474–480, 1987Google Scholar
  22. 22.
    Korting HC, Markis O, Georgii A, Froschl M: In vitro susceptibilities and biotypes ofCandida albicans isolates from the oral cavities of patients infected with human immunodeficiency virus.J Clin Microbiol 26:2626–2631, 1988PubMedGoogle Scholar
  23. 23.
    Phair J, Munoz A, Detels R, Kaslow R, et al.: The risks ofPneumocystis carinii pneumonia among men infected with human immunodeficiency virus type 1.N Engl J Med 322: 161–165, 1990PubMedCrossRefGoogle Scholar
  24. 24.
    Tavitian A, Raufman JP, Rosenthal LE: Oral candidiasis as a marker for esophageal candidiasis in the acquired immunodeficiency syndrome.Ann Intern Med 104:54–55, 1986PubMedGoogle Scholar
  25. 25.
    Barr C: Dental management of HIV-associated oral mucosal lesions: current and experimental techniques. In Robertson PB, Greenspan JS (eds):Perspectives on Oral Manifestations of AIDS. Littleton, MA: PSG Publishing, 1988, pp 77–95Google Scholar
  26. 26.
    DeWit S, Weerts D, Goosens H, Cluemck N: Comparison of fluconazole and ketoconazole for oropharyngeal candidiasis in AIDS.Lancet 1:746–747, 1989CrossRefGoogle Scholar
  27. 27.
    Lynch DP, Naftolin LZ: OralCryptococcus neoformans infection in AIDS.Oral Surg 64:449–453, 1987PubMedCrossRefGoogle Scholar
  28. 28.
    Glick M, Cohen SG, Cheney RT, et al.: Oral manifestations of disseminatedCryptococcus neoformans in a patient with acquired immunodeficiency syndrome.Oral Surg 64:454–459, 1987PubMedCrossRefGoogle Scholar
  29. 29.
    Greenspan D, Greenspan JS: Oral mucosal manifestations of AIDS.Dermatol Clin 5:733–737, 1987PubMedGoogle Scholar
  30. 30.
    Rindum JL, Schiodt M, Pindborg JJ, Scheibel E: Oral hairy leukoplakia in three hemophiliacs with human immunodeficiency virus infection.Oral Surg 63:437–446, 1987PubMedCrossRefGoogle Scholar
  31. 31.
    Ficarra G, Barone R, Gagliotti D, et al.: Oral hairy leukoplakia among HIV-positive intravenous drug abusers: a clinicopathologic and ultrastructural study.Oral Surg 65: 421–426, 1988PubMedCrossRefGoogle Scholar
  32. 32.
    Syrjanen S, Laine P, Niemela M, Happonen RP: Oral hairy leukoplakia is not a specific sign of HIV-infection but related to immunosuppression in general.J Oral Pathol Med 18:28–31, 1989PubMedCrossRefGoogle Scholar
  33. 33.
    Greenspan D, Conant M, Silverman S Jr, Greenspan JS, Petersen V, DeSoaza Y: Oral “hairy” leukoplakia in male homosexuals. Evidence of association with both papillomavirus and herpes group virus.Lancet 2:831–836, 1984PubMedCrossRefGoogle Scholar
  34. 34.
    Greenspan JS, Greenspan D, Lenette ET, Abrams DI, et al.: Replication of Epstein-Barr virus within the epithelial cells of oral “hairy” leukoplakia an AIDS associated lesion.N Engl J Med 313:1564–1571, 1985PubMedCrossRefGoogle Scholar
  35. 35.
    Greenspan D, Greenspan JS, Hearst NG, Pan L-Z: Relation of oral hairy leukoplakia to infection with the human immunodeficiency virus and the risk of developing AIDS.J Infect Dis 155:475–481, 1987PubMedGoogle Scholar
  36. 36.
    Greenspan D: Oral manifestations of HIV infection. In Robertson PB, Greenspan JS (eds):Perspectives on Oral Manifestations of AIDS. Littleton, MA: PSG Publishing, 1988, pp 38–48Google Scholar
  37. 37.
    Fung JC, Shanley J, Tilton RC: Comparison of the detection of herpes simplex virus in direct clinical specimens with herpes simplex virus—specific DNA probes and monoclonal antibodies.J Clin Microbiol 22:748–753, 1985PubMedGoogle Scholar
  38. 38.
    Melbye M, Grossman RJ, Goedert JJ, Eyster ME, Biggar RJ: Risk of AIDS after herpes zoster.Lancet 1:728–731, 1987PubMedCrossRefGoogle Scholar
  39. 39.
    Schiodt M, Rindum J, Bygbjert I: Chickenpox with oral manifestations in an AIDS patient.Can Dent J 91:316–319, 1987Google Scholar
  40. 40.
    Scully C, Prime S, Martland N: Papillomaviruses: their possible role in oral diseases.Oral Surg 60:166–174, 1985PubMedGoogle Scholar
  41. 41.
    Kutcher M, Naghashfar Z, Sawoda E, et al.: Papilloma virus lesions of the mouth: genotypes and malignant potential.J Dent Res 66:183 (abstract no. 615), 1987Google Scholar
  42. 42.
    Owen WF Jr: Sexually transmitted disease and traumatic problems in homosexual men.ann Intern Med 92:805–808, 1980PubMedGoogle Scholar
  43. 43.
    Kanas RJ, Jensen JL, Abrams AM, et al.: Oral mucosal cytomegalovirus as a manifestation of the acquired immunodeficiency syndrome.Oral Surg 64:183–189, 1987PubMedCrossRefGoogle Scholar
  44. 44.
    Marder MZ, Barr CE, Mandel ID: Cytomegalovirus presence and salivary composition in acquired immunodeficiency syndrome.Oral Surg 60:372–376, 1985PubMedGoogle Scholar
  45. 45.
    Murray PA, Winkler JR, Sadkowski L, et al.: Microbiology of HIV associated gingivitis and periodontitis. In Robertson PB, Greenspan JS (eds):Perspectives on Oral Manifestations of AIDS. Littleton, MA: PSG Publishing, 1988, pp 105–118Google Scholar
  46. 46.
    Murray PA, Grassi M, Winkler JR: The microbiology of HIV-associated periodontal lesions.J Clin Periodontol 16: 635–642, 1989CrossRefGoogle Scholar
  47. 47.
    Zambon JJ, Reynolds HS, Genco RJ: Studies of the subgingival microflora in patients with acquired immunodeficiency syndrome.J Periodontal 61:699–704, 1990Google Scholar
  48. 48.
    Rams TE, Andriolo J Jr, Flik D, Abal SN, McGivern TM, Slots J: Microbiological study of HIV-related periodontitis.J Periodontal 62:74–81, 1991Google Scholar
  49. 49.
    Winkler JR, Murray PA: Periodontal disease—a potential intraoral expression of AIDS may be a rapidly progressive periodontitis.Calif Dent Assoc J 15:20–24, 1987Google Scholar
  50. 50.
    Winkler JR, Grassi M, Murray PA: Clinical description and etiology of HIV-associated periodontal diseases. In Robertson PB, Greenspan JS (eds):Perspectives on Oral Manifestations of AIDS. Littleton, MA: PSG Publishing, 1988, pp 49–70Google Scholar
  51. 51.
    Grassi M, Williams CA, Winkler JR, Murray PA: Management of HIV-associated periodontal diseases. In Robertson PB, Greenspan JS (eds):Perspectives on Oral Manifestations of AIDS. Littleton, MA, PSG Publishing, 1988, pp 119–130Google Scholar
  52. 52.
    Winkler JR, Murray PA, Greenspan JS: Periodontal disease of male homosexuals as related to AIDS virus infection.J Dent Res 66:256 (abstract no. 1197), 1987Google Scholar
  53. 53.
    Pindborg JJ, Holmstrup P: Necrotizing gingivitis related to human immunodeficiency virus (HIV) infection.Afr Dent J 1:5–8, 1987Google Scholar
  54. 54.
    Barr CE, Rua-Dobles A, Andersson M, Croxson TS: Periodontal disease: immunologic profile and HIV status.J Dent Res 69:186 (abstract no. 624), 1990Google Scholar
  55. 55.
    Barr CE, Rua-Dobles A, Andersson M: Periodontal disease by HIV serostatus in a gay male cohort.J Dent Res 70:415 (abstract no. 1196), 1991Google Scholar
  56. 56.
    Volpe F, Schwimmer AS, Barr CE: Oral manifestations ofMycobacterium avium intracellulare in a patient with AIDS.Oral Surg 60:560–570, 1985CrossRefGoogle Scholar
  57. 57.
    Lozada F, Silverman S Jr, Conant MA, Volberding PA: Oral manifestations of tumor and opportunistic infections in the acquired immunodeficiency syndrome (AIDS): findings in 53 homosexual men with Kaposi's sarcoma.Oral Surg 56:491–494, 1983PubMedCrossRefGoogle Scholar
  58. 58.
    Eversole L, Leides A, Jacobson P, Shafer E: Oral Kaposi's sarcoma associated with acquired immunodeficiency syndrome among homosexual males.J Am Dent Assoc 107: 248–253, 1983PubMedGoogle Scholar
  59. 59.
    Lummerman H, Freedman PD, Kerpel SM, Phelan JA: Oral Kaposi's sarcoma: a clinicopathologic study of 23 homosexual and bisexual men from the New York metropolitan area.Oral Surg 65:711–716, 1988CrossRefGoogle Scholar
  60. 60.
    Ficarra G, Berson AM, Silverman J Jr, et al.: Kaposi's sarcoma of the oral cavity: a study of 134 patients with a review of the pathogenesis, epidemiology, clinical aspects and treatment.Oral Surg 66:534–550, 1988CrossRefGoogle Scholar
  61. 61.
    Epstein JB, Lozada-Nur F, McLead A, Spinelli J: Oral Kaposi's sarcoma in acquired immunodeficiency syndrome (AIDS).Cancer 64:2424–2430, 1989PubMedCrossRefGoogle Scholar
  62. 62.
    Epstein JB, Scully C: HIV infection: clinical features and treatment of thirty-three homosexual men with Kaposi's sarcoma.Oral Surg 71:38–41, 1991PubMedCrossRefGoogle Scholar
  63. 63.
    Phelan JA, Essig S, Freedman PD, et al.: Major aphthouslike ulcers in patients with AIDS.Oral Surg 71:68–72, 1991PubMedCrossRefGoogle Scholar
  64. 64.
    Barr CE, Croxson TS, Dobles A, et al.: HIV-associated oral lesions: immunologic and salivary parameters.J Dent Res 69:289, 1990Google Scholar
  65. 65.
    Langford A, Groth A, Kumze R, et al.: Oral hyperpigmentation associated with HIV infection.J Dent Res 68:189 (abstract no. 64), 1989Google Scholar
  66. 66.
    Anonymous: Education and foster care of children infected with HTLV-III/LAV.MMWR 34:517–521, 1985Google Scholar
  67. 67.
    Sande MA: Transmission of AIDS. A case against casual contagion.N Engl J Med 314:380–382, 1986PubMedCrossRefGoogle Scholar
  68. 68.
    Freidland GH, Saltzman BR, Rogers MF, et al.: Lack of transmission of HTLV-III/LAV infection to household contacts of patients with AIDS or AIDS related complex with oral candidiasis.N Engl J Med 314:344–349, 1986CrossRefGoogle Scholar
  69. 69.
    Friedland G, Kahl P, Saltzman B, et al.: Additional evidence of lack of transmission of HIV infection by close interpersonal (casual) contact.AIDS 4:639–644, 1990PubMedGoogle Scholar
  70. 70.
    Groopman JE, Salahuddin SZ, Sarngadharan MG, et al.: HTLV-III in saliva of people with AIDS related complex.Science 226:447–449, 1984PubMedGoogle Scholar
  71. 71.
    Ho D, Byington R, Schooley R, Flynn T, et al.: Infrequency of isolation of HTLV-III virus from saliva in AIDS.N Engl J Med 313:1606, 1985PubMedCrossRefGoogle Scholar
  72. 72.
    Levy J, Greenspan D: HIV in saliva.Lancet ii:1248, 1988CrossRefGoogle Scholar
  73. 73.
    Tucker B, Schaeffer D, Berson R, Mungo R, Miller R, Gomperts E, Warfield D: A comparison of HIV antibody and HIV viral findings in blood and saliva of HIV antibodypositive juvenile hemophiliacs.Pediatr Dent 10:283–286, 1988PubMedGoogle Scholar
  74. 74.
    Ho D, Moudgil T, Alam M: Quantitation of human immunodeficiency virus type 1 in the blood of infected persons.N Engl J Med 321:1621–1625, 1989PubMedCrossRefGoogle Scholar
  75. 75.
    Coombs R, Collier A, Allain J, Nikora B, Leuther M, Gjerset G, Corey L: Plasma viremia in human immunodeficiency virus infection.N Engl J Med 321:1626–1631, 1989PubMedCrossRefGoogle Scholar
  76. 76.
    Levy J, Kaminsky L, Morrow W, Steimer K, Luciw P, Dina D, Hoxie J, Oshiro L: Infection by the retrovirus associated with the acquired immunodeficiency syndrome.Ann Intern Med 103:694–699, 1985PubMedGoogle Scholar
  77. 77.
    Michaelis B, Levy J: Recovery of human immunodeficiency virus from serum.JAMA 257:1327, 1987PubMedCrossRefGoogle Scholar
  78. 78.
    Fultz P: Components of saliva inactivate human immunodeficiency virus.Lancet ii:1215, 1986CrossRefGoogle Scholar
  79. 79.
    Fox P, Wolff A, Yeh C, Atkinson J, Baum B: Saliva inhibits HIV-1 infectivity.J Am Dent Assoc 116:635–637, 1988PubMedGoogle Scholar
  80. 80.
    Fox P, Wolff A, Yeh C, Atkinson J, Baum B: Salivary inhibition of HIV-1 infectivity: functional properties and distribution in men, women, and children.J Am Dent Assoc 118:709–711, 1989PubMedGoogle Scholar
  81. 81.
    Archibald D, Zon L, Groopman J, McLane M, Essex M: Antibodies to human T-lymphotrophic virus III (HTLV-III) in saliva of acquired immunodeficiency syndrome (AIDS) patients and in persons at risk for AIDS.Blood 67: 831–834, 1986PubMedGoogle Scholar
  82. 82.
    Archibald D, Barr C, Torosian J, McClane M, Essex M: Secretory IgA antibodies to human immunodeficiency virus in the parotid saliva of patients with AIDS and AIDS-related complex.J Infect Dis 155:793–796, 1987PubMedGoogle Scholar
  83. 83.
    Archibald D, Johnson J, Nair P, Alger L, Hebert C, Davis E, Hines S: Detection of salivary immunoglobulin A antibodies to HIV-1 in infants and children.AIDS 4:417–420, 1990PubMedGoogle Scholar
  84. 84.
    Sun D, Archibald D, Furth P: Variations of secretory antibodies in parotid saliva to human immunodeficiency virus type I with HIV-1 disease stage.AIDS Res Hum Retroviruses 6:933–941, 1990PubMedCrossRefGoogle Scholar
  85. 85.
    Johnson A, Parry J, Best S, Smith A, de Silva M, Mortimer P: HIV surveillance by testing saliva.AIDS 2:369–371, 1988PubMedCrossRefGoogle Scholar
  86. 86.
    Mandel I: The role of saliva in maintaining oral homeostasis.J Am Dent Assoc 119:298–303, 1989PubMedGoogle Scholar
  87. 87.
    Mandel I, Turgeon L, Barr C: Parotid fluid flow rate and composition in HIV infection.J Dent Res 69:301 (abstract no. 1538), 1990Google Scholar
  88. 88.
    Mandel I, Barr C, Turgeon L: Longitudinal study of parotid saliva in HIV infection.J Dent Res 70:287 (abstract no. 172), 1991Google Scholar
  89. 89.
    Atkinson J, Yeh C, Oppenheim F, Bermudez D, Baum B, Fox P: Elevation of salivary antimicrobial proteins following HIV-1 infection.J Acquir Immune Defic Synd 3:41–48, 1990Google Scholar
  90. 90.
    Atkinson J, Yeh C, Bermudez D, Fox P, Baum B: Longitudinal evaluation of major salivary gland function in HIV-1 infected patients.J Oral Pathol Med 18:469–479, 1989PubMedCrossRefGoogle Scholar
  91. 91.
    Yeh C, Fox P, Ship J, Busch K, et al.: Oral defense mechanisms are imparied early in HIV-1 infected patients.AIDS 1:361–366, 1988Google Scholar
  92. 92.
    Marder M, Barr C, Mandel I: Cytomegalovirus presence and salivary composition in acquired immunodeficiency syndrome.Oral Surg 60:372–376, 1985PubMedGoogle Scholar
  93. 93.
    Schiodt M, Greenspan D, Levy J, Nelson J, Chernoff D, Hollander H, Greenspan J: Does HIV cause salivary gland disease?AIDS 3:819–822, 1989PubMedGoogle Scholar
  94. 94.
    Couderc L, D'Agay M, Danon F, Harzic M, Brocheriou C, Clauvel J: Sicca complex and infection with human immunodeficiency virus.Arch Intern Med 147:898–901, 1987PubMedCrossRefGoogle Scholar
  95. 95.
    Ulirsch R, Jaffe E: Sjogren's syndrome-like illness associated with the acquired immunodeficiency syndrome-related complex.Hum Pathol 18:1063–1068, 1987PubMedGoogle Scholar
  96. 96.
    Ioachim H, Ryan J: Salivary gland lymphadenopathies associated with AIDS.Hum Pathol 19:616–617, 1988PubMedCrossRefGoogle Scholar
  97. 97.
    Smith F, Rajdeo H, Panesar N, Bhuta K, Stahl R: Benign lymphoepithelial lesions of the parotid gland in intravenous drug users.Arch Pathol Lab Med 112:742–745, 1988PubMedGoogle Scholar
  98. 98.
    Shaha A, Thelmo W, Jaffe B: Is parotid lymphadenopathy a new disease or part of AIDS?Am J Surg 156:297–300, 1988PubMedCrossRefGoogle Scholar
  99. 99.
    Yeh C, Fox M, Travis W, Lane H, Baum B: Kaposi's sarcoma of the parotid gland in acquired immunodeficiency syndrome.Oral Surg 67:308–312, 1989PubMedCrossRefGoogle Scholar
  100. 100.
    Ioachim H, Ryan J, Blaugrund S: Salivary gland lymph nodes. The site of lymphadenopathies and lymphomas associated with human immunodeficiency virus infection.Arch Pathol Lab Med 112:1224–1228, 1988PubMedGoogle Scholar

Copyright information

© Springer-Verlag New York Inc 1992

Authors and Affiliations

  • Charles E. Barr
    • 2
    • 1
  1. 1.Mount Sinai School of MedicineNew YorkUSA
  2. 2.Beth Israel Medical CenterNew YorkUSA

Personalised recommendations