Minor salivary gland changes in patients with chronic fatigue and immune dysfunction syndrome

ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 80, Number 4 nantly mature nodular lesions with occasional lesions having a less advanced plaque pattern. POST biopsies showed residual tumor in 8 of 13 biopsies. The tumor cells were immunoreactive with CD34. Most POST tumors showed a micronodular pattern with fibrosis, numerous small vascular channels and diffuse hemosiderin deposits. Foci of lymphoplasmacytic aggregates were common. CMV was present in 3 PRE and 1 POST KS lesions. HPV was absent in all cases. Candidiasis was identified by PAS in 3 cases. PCNA was expressed in 62.8% of PRE tumor cells and in 10.4% of POST tumor cells. No residual tumor was present in 3 cases. These POST biopsies showed dense fibrosis with bemosiderin deposits. Two POST biopsies were of recurrent tumor after complete clinical resolution. One recurrent tumor showed transitional areas resembling angiosarcoma. The other recurrent lesion showed ectatic vessels with atypical cells. Intralesional vinblastine administration in Kaposi's sarcoma results in regression of the lesion with a decrease in active proliferating cells and complete microscopic resolution in some cases. Despite clinical resolution, microscopic evidence of tumor is still present in most cases and implies that intralesional vinblastine treatment after clinical resolution may be indicated.

DEEP MYCOTIC AND PROTOZOAN INFECTIONS OF THE HEAD AND NECK REGION IN HIV INFECTION.JHicks, C Flaitz, M Nichols, P Cohen. Baylor College of Medicine, Texas Children's Hospital, University of Texas-Houston Dental Branch, Bering Dental Clinic, University of Texas Medical School-Houston, Houston, Tex. Opportunistic infections of the head and- neck region are relatively uncommon except in immunocompromised and debilitated hosts. These lesions are usually difficult to distinguish from viral, bacterial, and neoplastic processes based on clinical appearance alone. The purpose of this study was to review deep mycotic and protozoan infections involving the head and neck region in HIVinfected persons. Surgical and consultation pathology services were reviewed for mycotic and protozoan infections in HIVinfected patients during a 5-year period. Ten cases of deep mycotic and 2 cases of protozoan infections were identified. The study population consisted of five pediatric cases (three males, two females, vertically acquired HIV category B or C disease, age range 18 to 42 months, CD4 range 475 to 890/ram 3) and 7 adult cases (7 males, 3 IDU, 4 homosexual with AIDS, age range, 27 to 42 yrs, CD4 range 4 to 276/mm3). The patients had head/neck cutaneous and/or oral mucosal ulcerative lesions and underwent biopsy for definitive diagnosis. Deep mycotic infections were identified by histotogic examination in 10 cases and confirmed by culture of tissue obtained at biopsy in 7 cases. Zygomycestes (mucot and rhizopus) was identified in 4 cases, Histoplasma in 3 cases, Aspergillus in 2 cases and Cryptococcus in 1 case. Protozoan infections were found in 2 cases. One case was histologically consistent with ameba and was confirmed to be acanthamoeba by the CDC. The second case was a consultation case from the Middle East and proved to be leishmaniasis. Four patients died due to their mycotic (2 with zygomyces, 1 with cryptococcus) and protozoan (1 case with leishmaniasis) infections. Cutaneous and mucosal lesions of the head and neck region may represent disseminated or primary involvement by unusual mycotic or protozoan organisms in HIV infection. Histologic and microbiologic studies are of considerable benefit in providing appropriate antimicrobial therapy. ORAL PARACOCCIDIOIDOMYCOSIS IN IMMUNOCOMPROMISED PATIENTS. O.P. Almeida, L. Bozza, J. Jorge, M.A. Lopes.

Campinas University Piracicaba, Sao Paulo, Brazil

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Oral manifestations of systemic mycosis are of increasing importance in immunocompromised patients. Paracoccidioiodomycosis is common in South America and endemic in some areas of Brazil such as Sao Paulo State. Most patients are adult white males, and oral involvement includes the alveolar process, gingiva, lips, buccal mucosa, and oropharynx. Two patients, one male and one female, who were being treated with corticosteroids, presented gingival lesions similar to Wegener's granulomatosis, diagnosed as paracoccidioidomycosis. Both patients had pustular lesions in the skin and pulmonary involvement. Microscopically, the lesions presented predominately a polymorphonuclear infiltrate with many P. brasiliensis in the extracellular tissue. There were few multinuclear ceils and no evidence of typical granulomas. These clinical and microscopic aspects seem to be the main oral characteristics of patients with paracoccidioidomycosis associated with cortisteroid therapy. ISCHEMIC OSTEONECROSIS OF THE JAWS: HISTOPATHOLOGY OF 2867 SAMPLES FROM PATIENTS WITH FACIAL PAIN.

J. Bouquot, M. Byron. The Maxillofacial Center, Morgantown, West Virginia and USAF, Lincoln, Neb. A large number o f persons have now been diagnosed with the j a w b o n e subtype o f ischemic osteonecrosis (IO), reported in the literature as NICO (neuralgia-inducing cavitational osteonecrosis) because of its association with idiopathic, neuralgia-like facial pain, typically diagnosed as atypical facial neuralgia/pain or trigeminal neuralgia. The present paper summarizes the clinical and histopathologic characteristics of 2,867 intramedullary biopsy samples taken from 1,333 facial pain patients. RESULTS: 75% of patients were female; 71% were middle-aged; 45% of lesions were in the third molar regions; 40% of patients had multiple sites. NICO lesions demonstrated features of intraosseous ischemia, such as reticular fatty degeneration (marrow fibrosis, " c r e e p i n g " fibrosis, fibrous islands), sinusoidal dilation, multifocal loss of osteocytes, and minimal osteoblastic and osteoclastic activity. Evidence of intraosseous infarction was also abundant: fat necrosis with "'oil c y s t " formation, extravasation, and necrosis o f erythrocytes ("ghost erythrocytes"), microcracking of bony trabeculae, complete delamination of trabeculae ("exploded trabeculae"), calcific fat necrosis (often aggregated around exploded trabeculae to produce " N I C O globules' '), and a minimal inflammatory cell response. Nerves in affected areas sometimes demonstrated myelin degeneration and other degenerative signs. CONCLUSION: this disease has distinctive histopathologic features and

should be included in the differential diagnosis of idiopathic facial pain. MINOR SALIVARY GLAND CHANGES IN PATIENTS WITH CHRONIC FATIGUE AND IMMUNE DYSFUNCTION SYN DROME. R. Glass. University of Oklahoma, Oklahoma City, Okla. Previous studies of patients with chronic fatigue and immune dysfunction syndrome (CFIDS) found xerostomia in 77% of the patients (ODAJ 1993;83:18-23). Labial minor salivary gland biopsies of many or'these showed a variety of subtle changes. To study the salivary changes in CFIDS patients, labial minor salivary gland biopsies were performed on 25 criteria-met CFIDS patients, presenting for evaluation of their xerostomia. The following minor salivary gland changes were found in at least 80% of the CFIDS patients: (1) exclusion of all other known salivary gland diseases (e.g. mucocele, Sj6gren's disease, tumors, etc.); (2) generalized glandular and acinar atrophy (small acini), but with focal large and tortuous acini (usually all mucous cells) and acinar mucous retention; focal organ adiposity frequent; (3) periacinar hyperceltularity (appearing like serous demilunes) with fine periaci-

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nat fibrosis; (4) ductal cell eosinophilia (more in secretory ducts than excretory ducts) with fine periductal fibrosis; (5) ductal dilatation (more c o m m o n in excretory ducts than secretory ducts) with marked mucous retention; (6) light (to occasional moderate) mixed c e l l u l a r infiltrate o f predominantly plasma ceils with scattered lymphocytes, but in a periacinar location rather than periductal; (7) multiple areas of intense periodic acid-Schiff positive granularity in acini; and (8) fi to ~ acinar cells showing metachromasia (magenta or purple instead of blue) with Ethyl-stains-all at pH = 2.5 and retained more intensely at pH = 4.4. ORAL MALIGNANT MELANOMA. I. Koutlas, R. Carlos, H.

Sedano. Minnesota University Minneapolis, Marroquin University Guatemala, a n d UCLA, Los Angeles. Seven patients, four m e n and three women, are reported with oral malignant m e l e n o m a (OMM). Four cases in the maxillary gingiva and one each, in palate, mandibular gingiva, and peritonsilar area. Ages ranged from 23 to 63 years. The duration of O M M was known in four patients to be 3 months, 8 months, 20 months, and 7 years. The lengthy presence of O M M in three of these patients suggests that superficial O M M also occurs in the oral mucosas possibly due to lateral rather than vertical growth. ! m m u n o histochemical studies of six cases with avidin-biotin-complex (ABC) and alkaline phosphatase, anti-alkaline phosphatase (APAAP) included S-100, HMB-45, NSE, PCNA, p53 and bcl-2. The A B C method showed positive cases as: five for S-100, HMB-45, PCNA, p53, and bcl-2 and three for NSE. The presence of abundant melanin pigment obscured interpretation in one case. The A P A A P method showed positive cases as: S-100 6, PCNA and NSE 4, p-53 2, bcl-2 one and in one case HMB-45 fail to identify spindle neoplastic cells, bl & E stain showed epitheliod cells with eosinophilic cytoplasm as well as clear and spindle cells. Occasional mitosis were also identified. Melanin pigment with varied distribution was seen in all cases. The stroma in the seven cases was very vascular and neoplastic cells exhibited angiotropism. The seven cases were of the nodular type. Early diagnosis o f superficial examples of O M M should improve prognosis and survival rate.

ONCOLOGIC ASPECTSOFTHE VERMILIONECTOMY IN SQUAMOUS CELL CARCINOMA OF THE LOWER LIP.J. van der Wal, J. de Visscher, J. Baart, 1. van der Waal. Free University Hospital, Amsterdam and Medical Centre Leeuwarden, The Netherlands. The vermilion border of the lower lip is predisposed to the appearance of (pre)cancerous lesions because of sunlight exposure. Surgery (local wedge excision) and radiotherapy are the most used treatment modalities in cases of squamous cell carcinoma. The question is whether the vermilionectomy is a justified procedure in a case of microinvasive squanaous cell carcinoma of the Jower lip. Therefore 14 vermilionectomies with a carcinoma of the lower lip or a biopsy finding of carcinoma in the period 1985 to 1992 have been studied. There were 13 m e n and 1 w o m a n with a mean age of 68.0 years (range, 46 to 90). All slides have been reviewed. The status o f the surgical margins has been examined, and the m a x i m u m tumor thickness (MTT) has been measured. Follow-up data were available of 13 o f the I4 patients. The mean follow-up period was 3.3 years (range, 1 to y years). The M T T in all cases varied between 1.1 and 3.1 m m (mean, 1.7 ram). None o f the patients had a local recurrence. W e conclude that the vermilionectomy is a justified procedure in case of microinvasive carcinoma of the lower lip with a M T T up to 3 mm.

ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY October 1995 P53 EXPRESSION IN PROLIFERATIVE VERRUCOUS LEUKOPLAKIA. R. Gopalakrishnan, G. Bijur, F.M. Beck, S.R. Mallery,

G.D. Stoner. The Ohio State University, Columbus. Proliferative verrucons leukoplakia (PVL) is a highly recmTent premalignant lesion of the oral cavity that has an almost 90% to 95% chance of malignant transformation. Mutations in the p53 gene are considered to be key events in the induction of malignant transformation in m a n y cancers, including oral squamous cell carcinoma (SCC). Because the exact stage of p53 expression in carcinogenesis is not well understood, demonstration of altered expression in premalignant lesions such as PVL would be significant. The purpose of-this study was to examine p53 expression in PVL and compare the expression with normal oral rnucosa and oral SCC. Formalin-fixed, paraffin-embedded sections were used for immunohistochemical staining of p53 using mouse monoclonal (DO-7) antibody and avidin-biotin-peroxidase procedure. Fourteen PVL, 14 SCC, and 10 normal oral mucosa specimens were evaluated. Qualitative analyses demonstrated that although normal m u c o s a showed minimal staining for p53, 10 of 14 P V L samples revealed moderate basilar staining and 8 of 14 SCC samples exhibited moderate to intense diffuse staining for p53. Preliminary quantitative analyses demonstrated that the mean optical densities (i.e. Normal vs PVL vs SCC, n = 3 each, >-400 cells analyzed/sample), determined by Roche R P W imaging system~ was found to be significantly different at p < 0.01 level. These results imply that aberrant expression of p53 in PVL m a y play a crucial role in the malignant transformation o f PVL. Our findings suggest that identification o f aberrant p53 expression m a y provide an important marker in the diagnosis of the premalignant lesion, PVL, and lead to effectiv e preventive and treatment procedures.

ABERRANT P53 EXPRESSION IN ORAL LICHEN PLANUS. V.A, Murrah, L.M. Perez, E.P. Gilchrist. Emory University School of Medicine, Atlanta, Ga. Oral lichen planus patients are classically described in the literature as having a slightly higher potential for squamous cell carcinoma than the general population. Malignant transformation is reported to be more c o m m o n in the atrophic and erosive forms of the disease. Lichenoid dysplasia has also been described in the literature as an entity that m a y be histologically confused with lichen planus, The tumor suppressor gene product, p53, is an important modulator in the regulation of cell proliferation and has been shown to play a role in carcinogenesis in multiple anatomic sites, including the head and neck. Aberrant overexpression of p53 can result from mutation of the gene or from complexing of the protein with viral gene products. The prevalence of aberrant p53 expression in squamous cell carcinomas of the head and neck has been reported to be between 50% and 70% in a number of studies. The purpose of this study was to characterize aberrant p53 expression in 100 cases of randomly selected accessions from the files of the Division of Oral, Head, & Neck Pathology at Emory University that were diagnosed as lichen planus or lichenoid keratosis. Primary criteria for the diagnosis of lichen planus included hyperkeratosis, liquefactive degeneration of the basal layer and a band-like lymphocytic infiltrate. Additional criteria were the presence of saw-toothed fete ridges and Civatte bodies. One hundred cases containing normal epithelium were used as controls. The paraffin-embedded lesions were immunostained with the monoclonal antibody, NCL-DO7, to p53 (Vector Laboratories, Burlingame, Calif.) using the avidin-biotin technique. Eight of the 100 lesions demonstrated overexpression of p53. This expression was Confined primarily to the basal layer and was focal in all of the cases. Expression did not seem to correlate with intensity o f inflammatory cell infiltrate, subepithelial vesicle for-