Extraordinary Case: Unique Presentation of an Aggressive Epstein-Barr Virus-Positive Mucocutaneous Ulcer

ABSTRACT

Epstein-Barr virus-positive mucocutaneous ulcer is a recent and unusual type of lymphoproliferation, mostly associated with various forms of immunosuppression. In most cases, they regress spontaneously, but an increasing number of reports describe a spectral behavior of the lesion, which ranges from a simple ulcer with eosinophilia to aggressive ulcers. In these cases, Epstein-Barr virus-related lymphomas are the main differential diagnosis. We report a unique observation of this rare disease with mandibular involvement. Due to bone erosion, the patient was treated with 6 cycles of R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) with complete healing of the ulcer on clinical examination and PET-scan control.

Characteristics of aquaporin 1, 3, and 5 expression during early murine salivary gland development

Aquaporins (AQPs) are essential to coordinate the transit of water and ions through the cell membrane. In salivary glands (SGs), AQPs have been associated with saliva formation, facilitating water absorption through the epithelium during the formation of hypotonic saliva, which is then secreted into the oral cavity. Different members of the AQP family have been suggested to play distinct roles during embryonic development, highlighted by their specific expression patterns. Here, we have investigated the expression patterns of AQP-1, AQP-3 and AQP-5 by immunofluorescence at key stages of salivary gland development, utilising cultured mouse embryonic submandibular (SMG) and sublingual (SLG) glands. The expression of AQPs was compared to a mitotic marker, phospho-histone 3 (PH3), a myoepithelial marker, smooth muscle actin (SMA), and a vascular marker, CD31. Qualitative analysis revealed that AQP-1 and AQP-3 were primarily expressed during the earlier phases of SG morphogenesis and were associated with cells undergoing mitotic processes (PH3-positive). AQP-5, in contrast, was not associated to mitotic figures, but was predominantly expressed during late stages of SG morphogenesis. Our results highlight that AQPs are expressed from early stages of SG morphogenesis and exhibit complimentary expression patterns that may contribute to the morphogenesis of salivary glands.

Peculiar histopathological features in minor salivary gland in lupus erythematosus

Salivary glands (SGs) can be affected by lupus erythematosus (LE). Many authors debate whether this condition is a secondary manifestation of Sjögren syndrome (SS) or a glandular aspect of LE. The present study investigated the histopathological aspects of biopsied minor salivary glands from LE patients to analyze their peculiar features that lead to xerostomia. Twenty-three minor labial salivary gland (MLSG) cases were included in the study; the diagnosis of LE was rendered according to the American College of Rheumatology criteria. Twenty-three healthy MLSGs were used as a control, for comparison. Regarding lupus MLSG, the presence of hyalinization and thickening of ductal basement membrane, perivascular inflammatory infiltrate, epithelial spongiosis with no ductal lymphocytic aggression, vacuolar degeneration of the ductal cells and acinar serous metaplasia were statistically significant compared to the control group. In the LE group, there was a statistically significant correlation between acinar atrophy and acinar fibrosis; acinar atrophy and ductal ectasia; acinar fibrosis and ductal ectasia; ductal atrophy and ductal spongiosis with no lymphocytic focus, interstitial inflammatory infiltrate intensity and vasculitis as well as vascular thrombi and vasculitis. There were no morphological differences between the three subtypes of lupus analyzed. Minor salivary glands from patients diagnosed with LE present peculiar histopathological changes and may be a multisystemic presentation.

The lip in lupus erythematosus

Lupus erythematosus (LE) frequently compromises the skin, lips and oral mucosa. There is a large body of medical and dental literature about the cutaneous and mucosal lesions of LE, but very little has been written specifically about labial lupus. The lip has a peculiar anatomical and histological architecture, and LE lesions at this site may have some distinct features. This article reviews the existing data and adds some new concepts to the issue of labial lupus in all of its presentations, comparing such lesions to the well-established characterization of cutaneous LE (in acute, subacute and chronic lesions), and highlighting some special clinical features that may enable a better diagnosis and differential diagnosis of lip diseases.

Divided naevus of the penis: two paediatric cases with dermoscopic findings

Divided or kissing naevi are located on adjacent parts of the body that are separated during embryogenesis. Divided naevus of the penis (DNP) is exceedingly rare, with < 15 cases reported in the English language literature. Divided penile naevi affect the glans penis and inner foreskin, which are anatomical structures believed to have a common embryological origin. We report the clinical, dermoscopic and histopathological findings of two children with DNP. To our knowledge, this is the first report of patients with DNP seen in South America, and the first in which dermoscopic findings are discussed; these included a large globular pattern in one patient, and homogeneous, streaked and globular patterns in the other.

Reflectance confocal microscopy as a new tool in the in vivo evaluation of desquamative gingivitis: patterns in mucous membrane pemphigoid, pemphigus vulgaris and oral lichen planus

BACKGROUND

Desquamative gingivitis refers to a clinical manifestation associated with several mucocutaneous disorders. The most common are mucous membrane pemphigoid, pemphigus vulgaris and lichen planus. Their specific diagnosis is better established by histopathological and immunofluorescence evaluation.

OBJECTIVES

To examine cases of desquamative gingivitis using reflectance confocal microscopy (RCM) and compare the findings with those of normal gingiva. To compare RCM findings in desquamative gingivitis with conventional histopathology of the biopsied lesions, in order to establish criteria for this noninvasive diagnostic technique.

METHODS

A total of 25 cases of suspected mucous membrane pemphigoid, pemphigus vulgaris and lichen planus were included. RCM was performed on the gingiva of a healthy person and on gingival lesions. All lesions were biopsied in order to perform a RCM-histopathological correlation.

RESULTS

Reflectance confocal microscopy examination of the gingival lesions suspected to be mucous membrane pemphigoid revealed a separation at the level of the dermal-epidermal junction, filled with small, bright structures interpreted as blood cells. Histopathological and immunofluorescence findings confirmed the diagnosis. For pemphigus vulgaris, RCM features were intraepithelial clefts with round, detached cells interpreted as acantholytic keratinocytes, similar to the histopathological features. Hyperkeratosis and spongiosis associated with infiltration of inflammatory cells, seen as small, bright cells intermingling with the honeycomb keratinocyte epithelial structure, were seen in lichen planus. Mildly bright, round structures interpreted as necrotic keratinocytes and mildly bright, stellate structures, interpreted as melanophages, were also seen in the dermis. These features were present on histopathology, confirming the diagnosis of lichen planus.

CONCLUSION

We propose that RCM is a useful tool to help distinguish between the three most common causes of desquamative gingivitis.

Oral lesions in four cases of subacute cutaneous lupus erythematosus

Patients with subacute cutaneous lupus erythematosus (SCLE) present with intense photosensitivity. Clinical patterns comprise papulosquamous or annular lesions on sun-exposed areas; although the face is usually spared. Intraoral lesions have not been reported in most case series of SCLE, but are well-documented in other forms of lupus erythematosus. This study included four female patients diagnosed with SCLE, who presented with specific oral involvement consisting of palatal patches (three cases), buccal mucosal patches (one case), gingival keratotic erythema (one case), and lip lesions (one case). All patients presented with exuberant facial lesions, a condition not often observed in SCLE. Our findings suggest that oral involvement in SCLE may not be as rare as once thought, and that patients with intense facial lesions are at particular risk of developing oral lesions.

Oral mucosal melanoma of the mandibular gingiva: a case report

Oral mucosal melanoma is rare and is reported to be more aggressive than cutaneous melanoma. The incidence of oral mucosal melanoma peaks at 41 to 60 years of age and the male to female ratio is 2 to 1. Preferred sites in the oral mucosa include the hard palate and maxillary alveolar crests. Risk factors have not been clearly identified, but melanotic pigmentation is present in one-third of patients prior to the diagnosis of melanoma. We report an unusual case of oral mucosal melanoma of the mandibular gingiva with the main characteristics of an in situ lesion and areas of superficial invasion in a 45-year-old woman. The patient was treated with surgical resection of the lesion and a 54-month follow-up shows no evidence of recurrence. Oral mucosal melanomas are aggressive neoplasms that may arise from prior pigmented lesions in the oral mucosa. Classification of these tumors is not well-established and the main prognostic factor appears to be lymph node compromise. The main treatment modality is surgical resection.

Oral manifestations of inflammatory bowel disease: a review based on the observation of six cases

Inflammatory bowel disease (IBD) comprises two chronic, tissue-destructive, clinical entities: Crohn's disease (CD) and ulcerative colitis (UC), both immunologically based. Bowel symptoms are predominant, but extra-intestinal complications may occur, including involvement of the oral cavity. Oral involvement during IBD includes several types of lesions: the most common are aphthae; uncommon lesions include, among others, pyostomatitis vegetans and granulomatous lesions of CD. Starting with a presentation of six patients with oral manifestations, which were crucial for the final diagnosis of IBD, a review on the subject is presented. Oral involvement in IBD may be previous or simultaneous to the gastrointestinal symptoms. However, in the majority of cases, bowel disease precedes the onset of oral lesions by months or years. In many patients, the intestinal symptoms may be minimal and can go undetected; thus, most authors believe that the bowel must be thoroughly examined in all patients with suspected IBD even in the absence of specific symptoms. Usually, the clinical course of oral lesions is parallel to the activity of IBD; therefore, oral manifestations are a good cutaneous marker of IBD.

Oral manifestations of inflammatory bowel disease: a review based on the observation of six cases

Inflammatory bowel disease (IBD) comprises two chronic, tissue-destructive, clinical entities: Crohn's disease (CD) and ulcerative colitis (UC), both immunologically based. Bowel symptoms are predominant, but extra-intestinal complications may occur, including involvement of the oral cavity. Oral involvement during IBD includes several types of lesions: the most common are aphthae; uncommon lesions include, among others, pyostomatitis vegetans and granulomatous lesions of CD. Starting with a presentation of six patients with oral manifestations, which were crucial for the final diagnosis of IBD, a review on the subject is presented. Oral involvement in IBD may be previous or simultaneous to the gastrointestinal symptoms. However, in the majority of cases, bowel disease precedes the onset of oral lesions by months or years. In many patients, the intestinal symptoms may be minimal and can go undetected; thus, most authors believe that the bowel must be thoroughly examined in all patients with suspected IBD even in the absence of specific symptoms. Usually, the clinical course of oral lesions is parallel to the activity of IBD; therefore, oral manifestations are a good cutaneous marker of IBD.

Chloroquine -induced hair depigmentation

A case of hair depigmentation induced by chloroquine diphosphate subacute overdosage in an 11-year-old patient with dermatomyositis is presented. Normal coloured hair growth occurred after normalisation of chloroquine dosage. A discussion on possible pathomechanisms of this phenomenon is made based on experimental data and previously reported patients with the same condition.

Dyskeratosis congenita--report of a case with emphasis on gingival aspects

A case of dyskeratosis congenita (DC) of an 11-year-old male is reported. He presented with the characteristic clinical triad of reticular pigmentation of the skin, dystrophic nails and oral lesions, and up to the present he had not developed hematological compromise. Oral lesions consisted of extensive tongue erosions and keratosis, and exuberant gingivitis associated. Appropriate periodontal treatment was performed with discrete improvement only. We emphasize that severe gingival inflammation, although infrequent, may represent an alteration specific to DC and therefore should be considered as an additional sign of this syndrome.

Relationship of adhesion molecules expression with epithelial differentiation markers during fetal skin development

BACKGROUND

Cadherins and integrins are important for maintenance of tissue integrity and in signal transduction during skin development. Distribution of these molecules in human skin development was investigated and associated with markers of differentiation, cytokeratins (CK) and involucrin (INV).

METHODS

Using immunohistochemistry expression of E- and P-cadherins, integrins beta-1 and -4, CK10, CK14 and INV was assessed in skin fragments of 10 human fetuses (gestational weeks ranged from 4 to 24, all weighing up to 500 g).

RESULTS

At initial phases of development, integrins beta-1 and -4 and E- and P-cadherins were present on epithelial cell membranes in all layers. CK14 and CK10 were expressed in all epithelial layers and INV weakly detected in the superficial layer. In more advanced stages, integrins were detected in all layers, but a marked polarized expression was seen in basal layer. E-cadherin was detected in all layers, but the cornified stratum and P-cadherin were observed in the lower layers. CK14 was expressed in basal layer, CK10 in suprabasal stratum and INV was observed in cornified layer.

CONCLUSIONS

Cadherins and integrins are essential for skin development, being spatially and temporally regulated. Their expression is related with the expression of maturation markers of the epidermis.

Mucocele in pediatric patients: analysis of 36 children

Mucoceles are common benign lesions of the oral cavity that develop following extravasation or retention of mucous material from major or minor salivary glands. Most series report a higher incidence of mucocele in young patients but no studies exist for this specific age group. The records of 104 patients presenting with mucocele who underwent surgery in the Oral Diseases Clinic of the Department of Dermatology of the University of São Paulo, Brazil, between 1991 and 2006, were reviewed. Of these, 36 (34.6%) were 15 years old or younger, the youngest being 2 years old. Twenty-six patients were girls, 10 were boys. Lesions were located on the lower labial mucosa (30 patients), tongue (three), floor of the mouth (one), buccal mucosa (one), and in one patient the location was unknown. Histopathology revealed an extravasation pattern in 35 patients and a retention pattern in one. Of the distinct subtypes of mucocele, tongue lesions (mucocele of the glands of Blandin-Nuhn) seem to be more prevalent and retention mucoceles seem to be very rare in children.

'Decubital candidosis': a study of 26 cases

BACKGROUND

Candidoses are infections caused by yeasts of the genus Candida. 'Decubital candidosis' is a particular form of cutaneous candidosis that occurs on the dorsal skin of chronically bedridden patients; there are very few studies about this presentation in the medical literature.

OBJECTIVE

To study the clinical, mycological and histopathological features of 26 cases of 'decubital candidosis' along with factors that may predispose to it.

METHODS

Twenty-six patients were included and their general characteristics and clinical lesions were carefully studied. The presence of candidosis in other organs and the occurrence of predisposing factors were searched by reviewing the medical records. Mycological studies were performed and cutaneous biopsies were taken.

RESULTS

Median age of patients was 46 years, 11 were male and 15 were female, 25 were caucasian, one was Asian and no one was Afro-Carribean. This finding suggests a greater resistance of Afro-Carribean skin to this form of candidosis. The median time of hospitalization until rash occurrence was 24.8 days. Clinical lesions consisted of erythema, erosions, pustules, papules and desquamation. The most significant predisposing factors for this eruption were prolonged bedrest and broad-spectrum antibiotics. Candidosis on other body sites was diagnosed in 10 cases and additional specific predisposing factors were observed in all 10. Potassium hydroxide examination was a reliable test for diagnosing this disease. Candida albicans was the agent in all 26 cases. Spongiform pustules were the most significant histopathological findings and yeasts were restricted to the horny layer in all biopsied cases.

CONCLUSION

'Decubital candidosis' is probably induced by prolonged bedrest and facilitated by long-term use of antibiotics. This cutaneous infection does not seem to predispose to systemic candidosis.

Olmsted syndrome: the clinical spectrum of mutilating palmoplantar keratoderma

Olmsted syndrome is a rare variety of transgredient palmoplantar keratoderma with an undefined inheritance pattern. It starts in the neonatal period or in childhood and has a progressive and extremely disabling course. We report two new, unrelated patients with Olmsted syndrome, one with the early signs and symptoms of the disorder, the other showing the full-blown spectrum of the syndrome during a 30-year follow-up period.

Rothmund-thomson syndrome in three siblings and development of cutaneous squamous cell carcinoma

Rothmund-Thomson syndrome (RTS) is a rare autosomal recessive genodermatosis. It is characterized by early onset of progressive poikiloderma and several other cutaneous and extracutaneous findings including alopecia, dystrophic teeth and nails, juvenile cataracts, short stature, hypogonadism, and bone defects. There are several reported cases of skin malignancies in RTS patients, indicating a possibly higher incidence of cutaneous and noncutaneous malignancies. We report three siblings with RTS who developed cutaneous squamous cell carcinoma (SCC).

Miliary osteoma of the face: a report of 4 cases and review of the literature

Osteoma cutis (OC) is a rare disorder characterized by compact bone formation in the dermis and subcutaneous tissue. It is classified in primary and secondary forms according to the presence or absence of previous cutaneous lesions. Miliary osteoma of the face (MOF) is a form of primary OC that generally occurs in middle-aged and older adult women. We report 3 cases of typical MOF and one additional case in a black patient, which to our knowledge has not been described previously.