|Year : 2008 | Volume
| Issue : 4 | Page : 162-165
Oral non-Hodgkin's lymphoma as an initial diagnosis in a HIV positive patient
Elluru Venkatesh, Anjana Bagewadi, Vaishali Keluskar, Arvind Shetti
Department of Oral Medicine and Radiology, KLE'S Institute of Dental Sciences, Nehru Nagar, Belgaum, India
|Date of Web Publication||18-Jun-2009|
Department of Oral Medicine and Radiology, Kamineni Institute of Dental Sciences, Narketpally, Nalgonda Dist, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Patients with the acquired immunodeficiency syndrome (AIDS) present unique diagnostic challenges because of a propensity to develop unusual infections and neoplasms. Since the beginning of the AIDS epidemic, the number of documented clinical manifestations has considerably increased. Current estimates are that 40% of patients with AIDS have a malignant tumor at the time of initial diagnosis, and the percentage may increase to 70% over the course of the disease. It is generally recognized that Kaposi's sarcoma is the most common of these malignant conditions, but non-Hodgkin's lymphoma (NHL) is also being diagnosed in greater numbers. The purpose of this paper is to present one such case of oral NHL as initial diagnosis in a HIV positive patient.
Keywords: Acquired immunodeficiency syndrome, Burkitt′s lymphoma and non-Hodgkin′s lymphoma
|How to cite this article:|
Venkatesh E, Bagewadi A, Keluskar V, Shetti A. Oral non-Hodgkin's lymphoma as an initial diagnosis in a HIV positive patient. J Indian Acad Oral Med Radiol 2008;20:162-5
|How to cite this URL:|
Venkatesh E, Bagewadi A, Keluskar V, Shetti A. Oral non-Hodgkin's lymphoma as an initial diagnosis in a HIV positive patient. J Indian Acad Oral Med Radiol [serial online] 2008 [cited 2020 Jan 22];20:162-5. Available from: http://www.jiaomr.in/text.asp?2008/20/4/162/52824
| Introduction|| |
The rapid spread of the AIDS since it first appeared in 1981 has not only created concern among the general population, but has resulted in drastic changes in life styles and the manner in which medical and dental treatment is performed.  In 1983, the causative agent was identified as a retrovirus and was subsequently given the delineation of the Human Immunodeficiency Virus (HIV). This virus makes the T-cells as its primary targets and leads to progressive loss of these cells. This leads to immunosuppression and makes the affected individuals susceptible to various unusual infections and neoplasms. 
The escalating number of patients infected with HIV and the resulting cases of AIDS has produced an increased observation of oral manifestations associated with this syndrome. 
Various oral manifestations in AIDS: 
Linear gingival erythema
Herpes simplex infection
Salivary gland disease
Non-Hodgkin's lymphoma (NHL)
| Case Report|| |
The present case report details the features of a patient who manifested a large oral mass found to be a Burkitt's type of NHL and who was later found to have HIV disease.
A 29-year-old male patient was reported to our department with the chief complaint of intraoral growth and burning sensation [Figure 1]. Patient was apparently all right a month back when he noticed the peanut sized growth, which gradually increased to present size. The burning sensation was present on having hot and spicy food since a week. Past medical history revealed extraction of teeth in the right lower back region. Personal history revealed gutkha chewing for 4-5 times daily since 3-4 years.
Extraoral examination revealed mild diffuse swelling over the right zygomatic region with ill defined borders, non tender and soft in consistency with no regional lymphadenopathy. Intraoral examination revealed a large red exophytic growth on the buccal and palatal gingiva of the hard palate. The mass was 2 × 2cm on buccal side in relation to 16, 17, 18 and 4 × 4cm on palatal aspect extending from 14 anteriorly up to the maxillary tuberosity posteriorly and midpalatal raphe medially [Figure 2]. The mass was soft to firm in consistency, tender with superficial necrosis covered with necrotic slough. Other findings were missing 46, 47, discoloration with 22, generalized stains and deposits with severe halitosis.
Based on the clinical findings and positive history of habits, a provisional diagnosis of carcinoma of right hard palate and gingivobuccal sulcus was made with the following conditions as differential diagnosis, i.e.:
- Peripheral giant cell granuloma
- Necrotising sialometaplasia and
- Minor salivary gland tumor.
In addition, the patient was subjected to the following investigations:
- Routine blood examination
- Vitality test
- Incisional biopsy.
Radiograph [Figure 3] revealed missing 45, 46. Irregular periapical radiolucency about 1 × 1cm in diameter with 21, 22, 23. Band like widening of the periodontal ligament space with 16 and destruction of inferior wall of the maxillary sinus on the right side.
Vitality test showed negative response with 22 and the teeth associated with lesion showed positive response.
Histopathology [Figure 4a] and [Figure 4b] showed stratified squamous epithelium with parakeratinization and basal hyperplasia. Connective tissue showed high cellularity and dense infiltration by lymphocytes. These lymphocytes showed large vesicular nucleus with thin peripheral cytoplasm. Cells and nucleus being pleomorphic. Mitotic figures being numerous. Interspersed with in the sheets of lymphocytes are tangible macrophages giving starry sky appearance. Based on these findings a diagnosis of Burkitt's type of NHL was given.
As such intraoral NHL are rare in healthy persons. However, NHL is one of the manifestations of the AIDS. With the increasing incidence of AIDS, this lesion has now become common. Hence, HIV infection was suspected in our case. Review of the patient's personal history revealed contacts with multiple commercial sex workers. Hence, the patient was subjected for Tri-Dot for HIV, which was reactive, and later Western Blot confirmed the HIV infection in this patient. Hence, a final diagnosis was made as AIDS related intraoral Burkitt's lymphoma.
| Discussion|| |
Before the advent of AIDS, NHL of the oral cavity was uncommon.  Non-oral lymphomas were first reported in patients with AIDS in 1982.  NHL is the second most common HIV related tumor after Kaposi's sarcoma, the risk of NHL being 60 times greater in patients with HIV disease than in otherwise healthy persons. NHL occurs in 3% of individuals with HIV disease.  The age group affected by NHL related to AIDS is considerably younger than that of unrelated NHL. One survey of NHL in patients with AIDS found a median age of 37 years with a range from 20 to 61years.  The diagnosis of AIDS precedes the onset of the diagnosis of NHL in approximately 57% of patients, but in 30% of patients the diagnosis of AIDS is made at the time of the diagnosis of NHL and HIV positivity.  Lymphomas associated with AIDS are generally (60-90%) high-grade B-cell tumors. AIDS related lymphoma often involves extra nodal tissue. Indeed involvement of the extra nodal tissue is the rule rather than the exception and is often the site sampled for diagnosis. 
Oral NHL may be the first clinical manifestation of HIV disease.  Oral NHL manifests itself as painless swelling, ulceration, exophytic masses, mobility or early loss of the teeth, delayed healing of extraction sites, parasthesia, rapid growth and destruction. ,,,
Burkitt's lymphoma was first reported in African children by Denis Burkitt in 1958, that shows a propensity for extra nodal involvement.  Burkitt found that the maxilla was more frequently involved than the mandible. In Africa, it is considered endemic; it comprises 50% of all malignancies involving African children. A 2:1 predominance of males to females, with a peak incidence in the age group of 5-7 years. 60-80% of patients with Burkitt's lymphoma have jaw tumors. Abdominal tumor involvement occurs in approximately half of African cases. Unlike endemic African Burkitt's lymphoma, non-endemic American Burkitt's lymphoma presents more often with abdominal masses than jaw lesions. It has been noted that a higher incidence bone marrow and cervical lymph node involvement is present in the early stages of the disease. Involvement of the facial bones, jaws and other extra nodal sites in the head and neck occur in less than 10% of cases of American Burkitt's lymphoma. As compared with African Burkitt's lymphoma, American Burkitt's lymphoma has a 2.65:1 male predominance for those younger than 13 and 1.35:1 male predominance for those older than age 13 years. 
| Conclusion|| |
A person with AIDS is immunocompromised and can present to us with any of the lesions/conditions and even an oral lesion as initial sign of the underlying AIDS. Hence, any unusual oral presentation should be promptly considered and the patient should be subjected for HIV testing so that an early diagnosis of AIDS is made and appropriate treatment is instituted at the earliest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4a], [Figure 4b]