Epstein-Barr virus-positive mucocutaneous ulcer arising in a post-hematopoietic cell transplant patient followed by polymorphic posttransplant lymphoproliferative disorder and cytomegalovirus colitis

Epstein-Barr virus (EBV)-positive mucocutaneous ulcer (EBVMCU) is a newly described entity occurring in elderly or iatrogenically immunocompromised patients. We describe a case of EBVMCU arising in a post-hematopoietic cell transplant patient and followed by EBV-positive polymorphic posttransplant lymphoproliferative disorder (EBV⁺ polymorphic PTLD). The patient, a 52-year-old woman, received chemotherapy and autologous peripheral blood stem cell transplantation for relapsed diffuse large B-cell lymphoma (DLBCL). She achieved complete remission and was followed up in an outpatient clinic after discharge. One year later, EBVMCU appeared in the tongue and exhibited spontaneous regression. Six months after the regression of the EBVMCU, she had EBV⁺ polymorphic PTLD, analogous to EBV⁺ polymorphic DLBCL. The therapy for PTLD was not effective, and the patient finally died of disease progression. This was the first case of EBVMCU characterized by both an association with autologous peripheral blood stem cell transplantation and subsequent emergence of malignant lymphoma in a patient with relapsed DLBCL.

Primary mucocutaneous histoplasmosis in an immunocompetent patient

We report a case of primary mucocutaneous histoplasmosis in an immunocompetent individual. The patient, a 61-year-old woman, presented with a non-healing ulcer on the lateral border of her tongue. Excisional biopsy of the lesion was consistent with histoplasmosis and no evidence of pulmonary or disseminated infection was found. Although mucocutaneous infection has been well-described as a manifestation of disseminated disease, especially in immunocompromised individuals, oral infections in immunocompetent patients are rare.

Common tongue conditions in primary care

Although easily examined, abnormalities of the tongue can present a diagnostic and therapeutic dilemma for physicians. Recognition and diagnosis require a thorough history, including onset and duration, antecedent symptoms, and tobacco and alcohol use. Examination of tongue morphology and a careful assessment for lymphadenopathy are also important. Geographic tongue, fissured tongue, and hairy tongue are the most common tongue problems and do not require treatment. Median rhomboid glossitis is usually associated with a candidal infection and responds to topical antifungals. Atrophic glossitis is often linked to an underlying nutritional deficiency of iron, folic acid, vitamin B12, riboflavin, or niacin and resolves with correction of the underlying condition. Oral hairy leukoplakia, which can be a marker for underlying immunodeficiency, is caused by the Epstein-Barr virus and is treated with oral antivirals. Tongue growths usually require biopsy to differentiate benign lesions (e.g., granular cell tumors, fibromas, lymphoepithelial cysts) from premalignant leukoplakia or squamous cell carcinoma. Burning mouth syndrome often involves the tongue and has responded to treatment with alpha-lipoic acid, clonazepam, and cognitive behavior therapy in controlled trials. Several trials have also confirmed the effectiveness of surgical division of tongue-tie (ankyloglossia), in the context of optimizing the success of breastfeeding compared with education alone. Tongue lesions of unclear etiology may require biopsy or referral to an oral and maxillofacial surgeon, head and neck surgeon, or a dentist experienced in oral pathology.

Traumatic ulcerative granuloma with stromal eosinophilia of the oral mucosa: histological and immunohistochemical analysis of three cases

Traumatic ulcerative granuloma with stromal eosinophilia is an ulcerated oral lesion which pathogenesis is still unclear. Clinically, this disease is characterized by the presence of chronic ulcerative lesions with elevated and indurated borders in the oral mucosa. It usually develops rapidly and persists for several weeks or months, it presents mainly on the tongue but other areas such as gingival, cheek and vestibular mucosa may also be involved. We report three cases showing their clinical, histological and immunohistochemical analysis. In this study the authors underline the importance of a correct differential diagnosis and monitoring of these patients in order to prevent the development of possible serious complications.

Expression of interleukin-8 and its receptor IL-8RA in chronic hyperplastic candidosis

INTRODUCTION

Neutrophils are the main opponents of Candida albicans in chronic hyperplastic candidosis. They migrate from the circulation to the epithelium where they form microabscesses. We therefore hypothesized that the neutrophil chemokine interleukin-8 (IL-8) might play a role in the neutrophil-Candida interaction.

METHODS

Biopsies from patients with chronic hyperplastic candidosis (n = 10) were stained using the avidin-biotin-peroxidase complex protocol for IL-8 and IL-8 receptor A and were compared to healthy control mucosa (n = 3). A set of C. albicans agar sections was similarly analysed.

RESULTS

In chronic hyperplastic candidosis lesions IL-8 was strongly expressed in both vascular endothelium and mucosal epithelium. Many resident and immigrant inflammatory cells, including intraepithelial neutrophils, were IL-8 receptor A positive. In addition, IL-8 (or an analogue) was found in the candidal mother cell in chronic hyperplastic candidosis and in agar, whereas the tips of the hyphae expressed IL-8 receptor A (or an analogue).

CONCLUSION

IL-8 may play a role in the recruitment of neutrophils from the vascular compartment to the epithelial microabscesses. C. albicans may have developed an ability to sense IL-8. The IL-8 ligand-receptor interaction may help to direct the growth of the IL-8-receptor-containing tips of the hyphae away from the IL-8-producing candidal cell body (a centrifugal growth pattern to facilitate host tissue penetration). Later, this ability might help to keep the vulnerable hyphal tips away from areas with high concentrations of host IL-8 and candidacidal neutrophils. We suggest that this phenomenon, in contrast to chemotropism, is named chemophobia.

Repeated massive tongue swelling due to the combined use of estramustine phosphate and angiotensin-converting enzyme inhibitor

A 70-year-old man presenting with a chief complaint of tongue swelling had been diagnosed with prostate cancer 1 year earlier. He had been on an oral angiotensin-converting enzyme inhibitor (ACE) inhibitor for hypertension for 20 years. Two months before the first of 4 episodes of tongue swelling within a period of 40 days, he had been prescribed oral estramustine phosphate (EMP) for the prostate cancer. He was admitted to our hospital for the evaluation after massive swelling of the tongue and epiglottis which necessitated tracheotomy. Food allergies, allergic reactions to environmental factors, and hereditary angioneurotic edema were excluded. Massive swelling of the tongue and epiglottis disappeared completely after EMP was discontinued. We concluded that angioedema was induced by EMP used concurrently with the ACE inhibitor.

Endodontic treatment in cases of allergic reaction to rubber dam

The prevalence and severity of latex allergies have rapidly increased recently. This article presents two cases of patients with rubber latex allergy. The patient in case A was unaware of her sensitivity to latex and presented symptoms of contact dermatitis-stomatitis during endodontic treatment. The patient in case B reported latex allergy before the initiation of the treatment and a different approach was followed. Certain aspects of latex allergy related to the endodontic treatment are discussed. Moreover, a protocol is proposed for treatment of patients with latex hypersensitivity with safety.

Tongue lesions: what can it be?

In the course of the examination of a patient their tongue is easily visualized and with the use of gauze can be gently dried, held with gauze and stretched for inspection of all aspects. This can be followed by palpation of both the tongue and the floor of mouth. In this manner, any altered tissue is likely to be detected and, with or without further investigations, a diagnosis established. Appropriate management can then be undertaken. A wide range of conditions may involve the tongue and this article outlines some of these using a classification based on aetiology.

[Hyper-IgE syndrome with ENT manifestations. Overview and case report of successful therapy with high dosage i.v. immunoglobulin]

Hyperimmunoglobulin E syndrome (Hiob syndrome or Buckley syndrome) is a rare disorder of the immune system that can show characteristic manifestations in the head and neck. Typical symptoms are fever, recurrent urticarial rashes, lymphadenitis, and bacterial infections of the skin and various parenchymatous organs. Diagnosis is established by elevated serum IgE concentrations with the absence of any signs of allergy or parasitic disease. We present our clinical experiences in managing of a 29-year old woman whose hyper IgE syndrome was diagnosed initially during of the treatment of lymphatic hyperplasia of the base of the tongue although she had typical symptoms of hyper IgE syndrome for some years. High-dose intravenous immunoglobulin therapy (IVIG) was found to be well-tolerated and effective. More than one year after a single course of immunoglobin therapy symptoms markedly improved. Current knowledge and therapeutic options in hyper IgE syndrome are discussed. We recommend that IVIG be considered as one of the first choices in the treatment of hyper IgE syndrome.

Oral mucosal lesions in experimental graft-versus-host disease: morphological and immunohistochemical characterization of infiltrating cells

To facilitate recognition of the oral mucosal lesion that develops in rats with graft-versus-host disease (GVHD) induced by injecting spleen cells of parental strain rats (Brown Norway) into non-irradiated (Brown Norway x Lewis) F1 hybrid rats, we followed the development of the tongue lesion histologically and immunohistochemically. This assessment revealed an increase in the number of MHC class II+ cells with dendritic shape in the lamina propria to be the earliest stage of the tongue lesions in GVHD rats. The subsequent mononuclear cell infiltration with epithelial cell destruction, characteristic of GVHD, consisted of CD8+ cells and macrophages. Our findings seem to indicate that MHC class II+ cells with dendritic shape may provide antigen presentation in the induction of local immunological responses, including tissue destruction, by CD8+ cells and macrophages in the tongue of GVHD rats.

Mucosal cell-mediated immunological changes associated with experimental graft-versus-host disease

This study examined the histological changes and local cellular immune response induced within the lingual mucosa in an allogeneic F1 hybrid rat model of graft-versus-host disease (GvHD) with a view to studying oral lymphocyte-epithelial cell reactions. Highest levels of disease, as reflected by both a GvHD index and the extent of the oral mucosal changes, were obtained using primed donor (Lewis rats) splenocytes and irradiated hosts (Lew/Da rats). The lingual mucosae of test animals were characterised by irregular epithelial keratosis, an absence of basal cell liquefaction and a diffuse inflammatory cell infiltrate, histological features consistent with an oral lichenoid tissue reaction. Immunohistochemical studies showed that mucosal involvement was characterised by infiltration of the lamina propria by NK cells (CD8+, CD5-), "activated" cells (CD25+) and T cells (CD5+) with selective migration of the latter, including a CD5+, CD8- subset (helper/inducer T cell), into the epithelium. Epithelial expression of Ia was invariably associated with these inflammatory cell infiltrates and correlated with the GvHD index. These findings suggest the presence of local mucosal T cell activation in the absence of detectable epithelial cell damage, which may be equivalent to the early initiating events in the pathogenesis of oral lichen planus. However, whilst experimental graft-versus-host disease appears to be a useful model for studying lymphocyte-epithelial interactions, the induced oral mucosal changes are more consistent with a lichenoid reaction rather than lichen planus.

[Clinical and immunological aspects of Lichen ruber planus]

Clinical and histopathologic features of lesions in lichen r. planus are characteristic of inflammatory reaction: this it is possible some pondering on immunologic performance related to uncertain etiology of the disease.

Tuberculosis of the tongue. A case report with immunologic study

A case of tuberculosis of the tongue in a 59-year-old woman with active pulmonary tuberculosis is described. The lingual tuberculosis was considered to be a secondary infection from the pulmonary disease, but the oral lesions were, in fact, noticed prior to recognition of the pulmonary lesion. This case was marked by a multiplicity or oral lesions arising on the bilateral surfaces of the tongue. Immunologic investigation revealed that cell-mediated immune responses in the patient were within the normal range in terms of the PPD skin test, DNCB skin test, lymphocyte transformation test, and subpopulation of the peripheral blood lymphocytes. Rosette-forming assay on the frozen sections disclosed that T-lymphocytes and macrophages were predominant in the lymphoid cells infiltrating the tuberculous lesion.