Successful therapy with interferon alpha-1b for a relapsing Epstein-Barr virus-positive mucocutaneous ulcer

Epstein-Barr Virus-Positive Mucocutaneous Ulcer on the Gingiva of a Patient in Whom Immunosuppressive Drugs Could Not Be Withdrawn: A Case Report and Review of the Literature

Epstein-Barr virus-positive mucocutaneous ulcer (EBV-MCU) is characterized by ulcers confined to the skin and mucus membranes. EBV-MCU is an EBV-positive lymphoproliferative disorder that occurs during the use of immunosuppressive drugs such as methotrexate. We herein report a case of EBV-MCU in the maxillary gingiva. A 73-year-old woman was referred to our department in March 2021. During the initial examination, bone exposure and ulceration were observed in the extraction socket of the maxillary bilateral central incisors. The patient was taking methotrexate for rheumatoid arthritis and was unable to stop due to disease progression. In March 2021, curettage of the extraction socket of the maxillary anterior teeth and extraction of the maxillary right lateral incisor, which was difficult to preserve due to severe tooth mobility, was performed under local anesthesia. The extraction site epithelialized and healed well. Three months later, inflammation flared, and ulceration was observed. Extraction of the unsalvageable maxillary teeth and an excisional biopsy of the palatal gingiva were performed. The histopathological diagnosis was EBV-MCU. The postoperative course was uneventful, and no evidence of recurrence was found two years postoperatively; follow-up will be continued. There are many reports of EBV-MCU remission with the cessation of methotrexate treatment. In our patient, withdrawal was difficult because of the progression of rheumatoid arthritis, but remission was achieved by improving the oral cavity environment through an excisional biopsy and tooth extraction.

Co-Occurrence of EBV-Positive Mucocutaneous Ulcer (EBV-MCU) and CLL/SLL in the Head and Neck Region

EBV-positive mucocutaneous ulcer (EBV-MCU) was classified as a rare new entity of the lymphoproliferative B-cell diseases by the WHO in 2017 and must be distinguished from head and neck squamous cell carcinoma by early biopsy. The aim of the study is to raise awareness of the disease and to give a review of the current literature and a recommendation for EBV-MCU management. All EBV-MCU cases of the head and neck region published so far were included. We also report a case of a pharyngeal EBV-MCU in an 89-year-old patient who was immunosuppressed by chronic lymphatic leukaemia/small lymphocytic lymphoma (CLL/SLL). In contrast to all previously described cases, histopathology showed a co-infiltration of EBV-MCU and CLL/SLL. A total of 181 cases were identified on PubMed and summarised. EBV-MCU was predominantly caused by immunosuppressive drug therapy. Complete remission could be achieved in 68% of cases and was mainly attributed to a reduction of the immunosuppressive therapy alone (72%). However, some severe cases require more aggressive treatment. Regarding the various histopathologic similarities to other lymphoproliferative disorders, the diagnosis of EBV-MCU can be misleading, with a great impact on patient care and treatment. This diagnosis must be made with caution and requires a combination of clinical, morphological and immunophenotypic features.