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Unusual oral manifestations of chronic lymphatic leukemia
UNUSUAL
ORAL MANIFESTATIONS
OF CHRONIC
LYMPHATIC
LEUKEMIA Report of a Case A. Y. Chuudhwy, B.D.S., X.N., Ph.D.,* I/I’. R. Subes, D.D.S., and R. J. Gorlin., D.D. fl., MS., Minneapolis, Uim. Division
of Oral Pathology,
School of Dentistry,
University
of Minnesota
IXJ!RODUCTION
in the lcukcmias have been extensively reported jn both dental and medical literature by several investigators.‘-” The most common manifestations have I)ccn described as gingival hypcrtrophy, petechial hemorrhage, ecchymosis, ulccrat,ion, infection, and necrosis. The gingivae arc’ characteristically swollen, spongy in consist,ency, and freely movable. Not uncommonly, there may be multiple localized tumorlike growths of the gingivatt However, such localized growths arc rarely as a result of leukemic infiltration. The present case is being reported bcseen in other pa,rts of the oral cavitp. cause it presented an unusual manifestation of’ chronic lymphatic leukemia caharacterized by bilateral swellings of the palat,e in an edentulous patient,.
0
RAL MANIBXST~ZTIONS
(‘4SE ,a L REPORT An 82.year-old white woman was first. seen at the School of Dentistry, University of Minnesota, on July 1, 1960, with the chief c.omplaint that, because of palatal swellings, 1~ dentures no longer fit properly. Intraoral examination at this time revealed two identical bilateral swellings which wcr~ soft and semifluctuant, each measuring 4 by 3 by 1 cm. They were first noticed in 1957 and had progressively enlarged in size. These swellings extended anteriorly from the palatal rugae to the posterior border of the hard palate and laterally from the alveolar ridge to thcl midline of the palate. They were in close contac,t with earh other in the midline but w:L’(* not, fused. The overlying mucosa was thin and shiny, with no ulceration (Fig. 1). No gross abnormality was visible cxtraorally although there Tvas a questionable cervical lymphadcnopathy. The past medical history revealed that the patient had heen suffering from angina pectoris for several years and from Parkinson’s disease since 1956. Her last admission into one of the Twin Cities’ hospitals was on April 4, 1957, at which time she had experienced severe chest pains. Her blood pressure and pulse rate were normal. Chest roentgenograms showed right and left areas of pleural effusion. The cardiogram was diagnost,ic of lrft ventricular hypertrophy and chronic COI’OIl~lry insufficiency. Urinalysis showed a speeifila gravity 1.021, albumin It, sugar 0, and pus cell l-2. The hemoglobin was 13.9 Gm. Thcrc~ count was a red blood count of 4,390,OOO and a white blood count of 23,000. The differential wrsity
*At present Professor and Chairman, Department of Pittsburgh, Pittsburgh, Pennsylvania. 446
of Pathology,
School of Dentistry,
ZJni-
~lll$~ ”
‘4’
showed neutrophila lymphocytes were forms. The blood On July 19, palatal mass. The
Wig. l.-Photograph
CHRONIC
LYMPHATIC
LEUKEMIA
447
22 per cent, lymphocytes 77 per cent, and monoeytes 1 per cent. The small, mature, and similar in morphology except for occasional young picture was compatible with the diagnosis of chronic lymphatic leukemia. 1960, under local anesthesia, biopsy specimens were procured from each tumor mass was found to be soft but solid and fleshy, and it cut easily.
showing
symmetrical bilateral enlargement tion by leukemic cells.
of the palate
due to infiltra-
Microscopically, the overlying mucosa was slightly keratinized and relatively thin because of the partirtl loss of rete pegs. The superficial submucosal connective tissue contained relatively few leukemic cells. The deep portions were completely infiltrated and replaced by small, uniform lymphocytes with relatively large round nuclei and scant rims of cytoplasm. The monotonous lymphocytio picture was quite striking. Mitotic figures were present, but no immature lymphocytes could be identified. The microscopic findings supported the diag uosis of chronic lypmhatic leukemia (Figs. 2 and 3). DISCUSSION
Wentz and his co-workers1 reviewed case histories of 140 leukemic patients and reported that such symptoms as gingival enlargement, hemorrhage, and ulceration were more common in acute leukemia than in the chronic varieties of the disease. In addition, they found that hyperplastic gingivae resulting from leukemic infiltration were most frequent in acute monocytic leukemia. Their findings were substantiated by Sinrod, who examined records of ninetynine leukemic patients treated at the Walter Reed Hospital in the last five years. Sinrod found that 55 per cent of the patients with acute leukemia and 15 per Similarly, positive cent of those with chronic leukemia had oral involvement. oral findings were also more common in monocytic leukemia in their series. Duffy and Driscol13 examined periodically thirty-eight patients with leukemia There were only and found that 80 per cent of them had oral manifestations. five edentulous patients, and two of them had oral symptoms. Glickman4 stressed the important role of chronic irritation in leukemic He found minimal gingival enlargement in leukemic pagingival enlargement.
Volume IS Number 4
CHRONIC
LYMPHBTIC
LEUKEMIA
449
SUMMARY
A case of chronic lymphatic leukemia characterized by the formation of bilateral year-old woman has been discussed.
with unusual oral manifestations swellings in the palate in an 82-
REFERENCES
Histopathologic Changes in Leukemia, J. PerioF. M., Anday, G., and Orban, B.: dont. 20: 119-128, 1949. Sinrod, H. S.: Leukemia as a Dental Problem, J. Am. Dent. A. 55: 809-818, 1957. Oral Manifestations of Leukemia, ORAL SURG., ORAL Duffy, J. H., and Driscoll, E. J.: MED. & ORAL PATH. 11: 484-490, 1958. Glickman, I.: Clinical Periodontology, Philadelphia, 1953, W. B. Saunders Company, p. 462. Thoma, K. H.: Oral Pathology, St. Louis, 1954, The C. V. Mosby Company, p. 114. the Oral Cavity, J. Periodont. 30: Scopp, I. W., and Quart, A. M. : Leukemia Involving 223-229, 1960.
1. We&z, 2. 3. 4. 5. 6.
ORAL MANIFESTATIONS
OF CHRONIC
LYMPHATIC
LEUKEMIA Report of a Case A. Y. Chuudhwy, B.D.S., X.N., Ph.D.,* I/I’. R. Subes, D.D.S., and R. J. Gorlin., D.D. fl., MS., Minneapolis, Uim. Division
of Oral Pathology,
School of Dentistry,
University
of Minnesota
IXJ!RODUCTION
in the lcukcmias have been extensively reported jn both dental and medical literature by several investigators.‘-” The most common manifestations have I)ccn described as gingival hypcrtrophy, petechial hemorrhage, ecchymosis, ulccrat,ion, infection, and necrosis. The gingivae arc’ characteristically swollen, spongy in consist,ency, and freely movable. Not uncommonly, there may be multiple localized tumorlike growths of the gingivatt However, such localized growths arc rarely as a result of leukemic infiltration. The present case is being reported bcseen in other pa,rts of the oral cavitp. cause it presented an unusual manifestation of’ chronic lymphatic leukemia caharacterized by bilateral swellings of the palat,e in an edentulous patient,.
0
RAL MANIBXST~ZTIONS
(‘4SE ,a L REPORT An 82.year-old white woman was first. seen at the School of Dentistry, University of Minnesota, on July 1, 1960, with the chief c.omplaint that, because of palatal swellings, 1~ dentures no longer fit properly. Intraoral examination at this time revealed two identical bilateral swellings which wcr~ soft and semifluctuant, each measuring 4 by 3 by 1 cm. They were first noticed in 1957 and had progressively enlarged in size. These swellings extended anteriorly from the palatal rugae to the posterior border of the hard palate and laterally from the alveolar ridge to thcl midline of the palate. They were in close contac,t with earh other in the midline but w:L’(* not, fused. The overlying mucosa was thin and shiny, with no ulceration (Fig. 1). No gross abnormality was visible cxtraorally although there Tvas a questionable cervical lymphadcnopathy. The past medical history revealed that the patient had heen suffering from angina pectoris for several years and from Parkinson’s disease since 1956. Her last admission into one of the Twin Cities’ hospitals was on April 4, 1957, at which time she had experienced severe chest pains. Her blood pressure and pulse rate were normal. Chest roentgenograms showed right and left areas of pleural effusion. The cardiogram was diagnost,ic of lrft ventricular hypertrophy and chronic COI’OIl~lry insufficiency. Urinalysis showed a speeifila gravity 1.021, albumin It, sugar 0, and pus cell l-2. The hemoglobin was 13.9 Gm. Thcrc~ count was a red blood count of 4,390,OOO and a white blood count of 23,000. The differential wrsity
*At present Professor and Chairman, Department of Pittsburgh, Pittsburgh, Pennsylvania. 446
of Pathology,
School of Dentistry,
ZJni-
~lll$~ ”
‘4’
showed neutrophila lymphocytes were forms. The blood On July 19, palatal mass. The
Wig. l.-Photograph
CHRONIC
LYMPHATIC
LEUKEMIA
447
22 per cent, lymphocytes 77 per cent, and monoeytes 1 per cent. The small, mature, and similar in morphology except for occasional young picture was compatible with the diagnosis of chronic lymphatic leukemia. 1960, under local anesthesia, biopsy specimens were procured from each tumor mass was found to be soft but solid and fleshy, and it cut easily.
showing
symmetrical bilateral enlargement tion by leukemic cells.
of the palate
due to infiltra-
Microscopically, the overlying mucosa was slightly keratinized and relatively thin because of the partirtl loss of rete pegs. The superficial submucosal connective tissue contained relatively few leukemic cells. The deep portions were completely infiltrated and replaced by small, uniform lymphocytes with relatively large round nuclei and scant rims of cytoplasm. The monotonous lymphocytio picture was quite striking. Mitotic figures were present, but no immature lymphocytes could be identified. The microscopic findings supported the diag uosis of chronic lypmhatic leukemia (Figs. 2 and 3). DISCUSSION
Wentz and his co-workers1 reviewed case histories of 140 leukemic patients and reported that such symptoms as gingival enlargement, hemorrhage, and ulceration were more common in acute leukemia than in the chronic varieties of the disease. In addition, they found that hyperplastic gingivae resulting from leukemic infiltration were most frequent in acute monocytic leukemia. Their findings were substantiated by Sinrod, who examined records of ninetynine leukemic patients treated at the Walter Reed Hospital in the last five years. Sinrod found that 55 per cent of the patients with acute leukemia and 15 per Similarly, positive cent of those with chronic leukemia had oral involvement. oral findings were also more common in monocytic leukemia in their series. Duffy and Driscol13 examined periodically thirty-eight patients with leukemia There were only and found that 80 per cent of them had oral manifestations. five edentulous patients, and two of them had oral symptoms. Glickman4 stressed the important role of chronic irritation in leukemic He found minimal gingival enlargement in leukemic pagingival enlargement.
Volume IS Number 4
CHRONIC
LYMPHBTIC
LEUKEMIA
449
SUMMARY
A case of chronic lymphatic leukemia characterized by the formation of bilateral year-old woman has been discussed.
with unusual oral manifestations swellings in the palate in an 82-
REFERENCES
Histopathologic Changes in Leukemia, J. PerioF. M., Anday, G., and Orban, B.: dont. 20: 119-128, 1949. Sinrod, H. S.: Leukemia as a Dental Problem, J. Am. Dent. A. 55: 809-818, 1957. Oral Manifestations of Leukemia, ORAL SURG., ORAL Duffy, J. H., and Driscoll, E. J.: MED. & ORAL PATH. 11: 484-490, 1958. Glickman, I.: Clinical Periodontology, Philadelphia, 1953, W. B. Saunders Company, p. 462. Thoma, K. H.: Oral Pathology, St. Louis, 1954, The C. V. Mosby Company, p. 114. the Oral Cavity, J. Periodont. 30: Scopp, I. W., and Quart, A. M. : Leukemia Involving 223-229, 1960.
1. We&z, 2. 3. 4. 5. 6.