Home About us Editorial board Ahead of print Current issue Archives Submit article Instructions Subscribe Search Contacts Login 
  • Users Online: 212
  • Home
  • Print this page
  • Email this page


 
CASE REPORT
Year : 2008  |  Volume : 20  |  Issue : 4  |  Page : 162-165 Table of Contents   

Oral non-Hodgkin's lymphoma as an initial diagnosis in a HIV positive patient


Department of Oral Medicine and Radiology, KLE'S Institute of Dental Sciences, Nehru Nagar, Belgaum, India

Date of Web Publication18-Jun-2009

Correspondence Address:
Elluru Venkatesh
Department of Oral Medicine and Radiology, Kamineni Institute of Dental Sciences, Narketpally, Nalgonda Dist, Andhra Pradesh
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-1363.52824

Rights and Permissions
   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 2019 Apr 20];20:162-5. Available from: http://www.jiaomr.in/text.asp?2008/20/4/162/52824


   Introduction Top


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. [1] 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. [2]

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. [3]

Various oral manifestations in AIDS: [4]

  Candidiasis
  Hairy leukoplakia

Periodontal diseases:

  Linear gingival erythema
  Necrotizing gingivitis
  Necrotizing periodontitis
  Necrotizing stomatitis
  Herpes simplex infection
  Cytomegalovirus infection
  Varicella-zoster infection
  Apthous ulceration
  Salivary gland disease

Malignancies:

  Kaposi's sarcoma
  Non-Hodgkin's lymphoma (NHL)
  Oral warts/papilloma


   Case Report Top


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.:

  1. Peripheral giant cell granuloma
  2. Necrotising sialometaplasia and
  3. Minor salivary gland tumor.


In addition, the patient was subjected to the following investigations:

  1. Routine blood examination
  2. Radiograph
  3. Vitality test
  4. 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 Top


Before the advent of AIDS, NHL of the oral cavity was uncommon. [5] Non-oral lymphomas were first reported in patients with AIDS in 1982. [3] 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. [6] 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. [5] 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. [7] 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. [8]

Oral NHL may be the first clinical manifestation of HIV disease. [9] 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. [1],[5],[6],[10]

Burkitt's lymphoma was first reported in African children by Denis Burkitt in 1958, that shows a propensity for extra nodal involvement. [11] 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. [12]


   Conclusion Top


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.

 
   References Top

1.Hernαndez Vallejo G, Garcνa MD, López A, Mendieta C, Moskow BS. Anusual periodontal findings in an AIDS patient with Burkitt's lymphoma. J Periodontol 1989;60:723-7.  Back to cited text no. 1    
2.Greenberg MS, Glick M. Burket's oral medicine, diagnosis and treatment. 10 th ed. BC Decker Inc; 2003.  Back to cited text no. 2    
3.Brahim JS, Katz RW, Roberts MW. Non-Hodgkin's lymphoma of the hard palate mucosa and buccal gingiva associated with AIDS. J Oral Maxillofac Surg 1988;46:328-30.  Back to cited text no. 3    
4.Classification and diagnostic criteria for oral lesions in HIV infection. EC-Clearinghouse on Oral Problems Related to HIV Infection and WHO Collaborating Centre on Oral Manifestations of the Immunodeficiency Virus. J Oral Pathol Med 1993;22:289-91.  Back to cited text no. 4    
5.Kaugars GE, Burns JC. Non-Hodgkin's lymphoma of the oral cavity associated with AIDS. Oral Surg Oral Med Oral Pathol 1989;67:433-6.  Back to cited text no. 5    
6.Porter SR, Diz Dios P, Kumar N, Stock C, Barrett AW, Scully C. Oral plasmablastic lymphoma in previously undiagnosed HIV disease. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:730-4.  Back to cited text no. 6    
7.Knowles DM, Chamulak GA, Subar M, Burke JS, Dugan M, Wernz J, et al . Lymphoid neoplasia associated with acquired immunodeficiency syndrome (AIDS): The New York University Medical Center experience with 105 patients (1981-1988). Ann Intern Med 1988;108:744-53.  Back to cited text no. 7    
8.Scadden DT, Howard WW. AIDS-related malignancies. Oncologist 1998;3:119-23.  Back to cited text no. 8    
9.Wolvius EB, Schulten AJ, van der Waal I. NHL of the oral cavity as the first manifestation of AIDS. Br Dent J 1997;182:107-8.  Back to cited text no. 9    
10.Lozada-Nur F, de Sanz S, Silverman S Jr, Miranda C, Regezi JA. Intraoral non-Hodgkin's lymphoma in seven patients with acquired immunodeficiency syndrome. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82:173-8.  Back to cited text no. 10    
11.Burkitt DP. The discovery of Burkitt's lymphoma. Cancer 1983;51:1777-86.  Back to cited text no. 11    
12.Karlis V, Glickman RS, Isdith K, Jones JL. Right facial edema associated with localized gingival swelling. J Oral Maxillofac Surg 1998;56:760-4.  Back to cited text no. 12    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4a], [Figure 4b]



 

Top
 
  Search
 
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    Abstract
    Introduction
    Case Report
    Discussion
    Conclusion
    References
    Article Figures

 Article Access Statistics
    Viewed634    
    Printed21    
    Emailed0    
    PDF Downloaded183    
    Comments [Add]    

Recommend this journal