History of Present Illness Mr. Carl is a 37-year-old male who presents with a two month history of increasing pain involving the maxillary right posterior region. The patient complains of recent weight loss but is unsure of how much weight he has actually lost. He also complains of difficulty swallowing and a persistent cough that will not go away. He has had inconsistent dental care throughout his life and only visits a dentist when a “tooth needs to be pulled.” His overall affect leads you to suspect his compliance is suspect. A review of his medical history reveals: Medical History
Adverse drug effects: no known drug allergies
Medications: dolutegravir, abacavir, lamivudine
Pertinent medical history: human immunodeficiency virus (HIV) seropositive
Pertinent family history: paternal - unknown; maternal - IV drug abuser, currently in rehab for drug abuse
Social history: IV drug abuser; 15 pack year history of cigarettes; 6-8 beers per day
Clinical Findings Extraoral examination is unremarkable. Intraoral examination reveals a large mass involving the entire maxillary right posterior edentulous ridge distal to #6. The mass expands buccally and palatally. The surface is erythematous and demonstrates multiple ulcerations. An area of necrosis is noted in the center of the mass (Figure 1). An incisional biopsy is performed and the tissue submitted for histopathologic examination.
Figure 1. Large mass involving the maxillary right posterior edentulous ridge distal to #6.
Histopathologic Findings Histopathologic examination reveals ulcerated surface epithelium and subjacent connective tissue. The surface epithelium adjacent to the ulceration contains epithelial cells demonstrating enlarged multiple molded nuclei (Figure 2). The underlying connective tissue is well vascularized and contains an acute and chronic inflammatory infiltrate with numerous histiocytes. Small 6-8 µ circular structures are present within the histiocytes (Figure 3). The inflammatory infiltrate extends into the adjacent salivary gland lobules. The nuclei of several of the epithelial cells lining small ducts are enlarged, bright pink, and have a perinuclear clearing (Figure 4).
Figure 2. High power histologic image showing epithelium adjacent to the ulceration exhibiting viral cytopathic changes with multiple enlarged molded nuclei and homogenized chromatin.
Figure 3. High power histologic image showing acute and chronically inflamed granulation tissue with numerous histiocytes containing small 6-8 µ intracytoplasmic circular organisms.
Figure 4. High power histologic image showing chronically inflamed salivary gland tissue. The salivary ductal epithelial cells are enlarged and exhibit viral cytopathic changes with large bright pink inclusions and perinuclear clearing.