Diagnostic challenges in a diffuse large B-cell lymphoma of the maxilla presenting as exposed necrotic bone

Challenging differentiation of oral malignant lymphoma from osteomyelitis of the jawbone: A case report

Malignant lymphoma (ML) of the head and neck frequently occurs in the cervical lymph nodes and Waldeyer's ring. Although ML of the maxillofacial region is rare, extranodal ML can present with symptoms similar to those of inflammation and other tumors, making diagnosis difficult. The present study describes the case of a 59-year-old female patient with ML, which was difficult to distinguish from mandibular osteomyelitis. The patient presented to Department of Oral Medicine, Hokkaido University Hospital (Sapporo, Japan) for evaluation of left cheek swelling and osteomyelitis. The X-ray examination, and contrast-enhanced CT and MRI images indicated chronic odontogenic mandibular osteomyelitis. The diagnosis of chronic osteomyelitis was pathologically confirmed by biopsy of the tooth with an apical lesion and surrounding bone, and the extraction socket demonstrated early epithelialization. However, the swelling persisted. Therefore, a second biopsy was performed, which revealed only inflammatory findings. The blood test results were unremarkable, and the diagnosis was consistent between bone scintigraphy and FDG-PET. The swelling worsened 6 months after the initial examination, and a palpable hard lump was observed in the left mandibular vestibule. A third biopsy was performed due to the presence of left facial nerve paralysis, which confirmed the diagnosis of diffuse large B-cell lymphoma. The patient was treated with rituximab, cyclophosphamide, doxorubicin, vincristine and prednisolone. The soft tissue thickening and cheek swelling were resolved, and the patient achieved remission. In the present case, the diagnosis was challenging due to the presence of chronic mandibular osteomyelitis derived from periapical periodontitis and extranodal marginal lymphoma of the mandible. Establishing a diagnosis of ML by biopsy can be complex, and considering the possibility of ML when managing unusual and persistent facial swelling is important.

Uncommon presentation of diffuse large B-cell lymphoma: oral and pulmonary involvements in a young patient: a case report

BACKGROUND

Diffuse large B-cell lymphoma is the most common subtype of non-Hodgkin lymphomas that remains a major diagnostic challenge due to the variety of its clinical presentations. This case highlights the importance of early biopsy of oral lesions without tendency to heal to attain the diagnosis more quickly. To the best of our knowledge, this study is the first to focus on both oral and pulmonary involvements in a patient with diffuse large B-cell lymphoma.

CASE PRESENTATION

The presented case describes an Iranian 18-year-old girl with chronic cough and dyspnea referred for evaluation of the upper jaw due to bone exposure, bone loss, and soft tissue ulceration. Her medical history revealed mediastinal mass, cavitary lesion, and mediastinal lymphadenopathy. However, cytologic and immunohistochemical analysis did not show any evidence of malignancy. In this case a lymphoproliferative disease was suspected but ultimately the oral biopsy diagnosed diffuse large B-cell lymphoma and chemotherapy could be started.

CONCLUSIONS

Systemic conditions should be considered as a possible cause of oral lesions and a biopsy should also be performed immediately if there is any doubt concerning the nature of the lesion. Moreover, some conditions necessitate multiple biopsies to attain an accurate diagnosis.

Diffuse B-Cell Lymphoma of the Mandible Disguised as Acute Osteomyelitis

Background

Primary bone lymphoma (PBL) is a rare form of extra nodal non-Hodgkin's lymphoma (NHL).

Case description

We describe a 39-year-old-male with no medical history who presented with unilateral facial swelling following a tooth extraction. Initial diagnoses after various presentations over the course of three weeks, based on inflammatory and infectious aetiologies. However, the patient was ultimately diagnosed with diffuse large B-cell lymphoma.

Discussion

Symptoms of PBL are very similar to inflammatory and infectious diseases of the bone, such as osteomyelitis or osteonecrosis. Clinical features of PBL involving the head and neck include persistent jaw pain, tooth mobility secondary to extensive destruction of bone, and in advanced cases, lip numbness and swelling. On examination it may present as an exposed necrotic bone with surrounding soft tissue oedema. Misdiagnosis of these lesions as an infectious or inflammatory aetiology may lead to an unnecessary delay in lymphoma treatment, and subsequently worsen the prognosis if caught at a later stage. Therefore, any concerning lesion, especially in the oral cavity, must be subjected to early histopathological evaluation to differentiate PBL from osteomyelitis and/or osteonecrosis.

Conclusion

This case report highlights the importance of an early histopathological evaluation to prevent delay in the diagnosis of primary bone lymphomas.

LEARNING POINTS

Resemblance in symptoms: Primary bone lymphoma (PBL) symptoms overlap with bone infections, necessitating careful consideration and differential diagnosis to prevent misjudgment.Head and neck manifestations: recognising PBL's signs in the head and neck region, such as jaw pain and bone destruction, aids in timely identification and treatment.Timely biopsy significance: swift histopathological assessment for suspicious lesions is critical to avoid delays in diagnosing primary bone lymphomas.