Identification of An Etiologic Agent by Ultrastructural Evaluation of an
Ulcerated Intraoral Nodule

A 37 year old male presented to a local dental clinic complaining of an intraoral ulcerated nodule. The nodule had been present for several weeks and caused considerable discomfort on mastication and deglutition. The patient had also noted a recent weight loss, night sweats and a chronic cough without hemoptysis. He had been hospitalized for pneumonia approxmiately two months previously, but was uncertain of the etiology. He reported a two-pack per day tobacco history, alcohol usage (6 beers/day), and had a remote history of drug usage (marijuana). He had underwent surgery when he was 20 years of age for an automobile accident and required blood product transfusion. Other medical history was non-contributory. An oral examination showed a nodular, red to purple soft tissue mass with an ulcerated surface (Figure 1).

Figure 1. Palatal soft tissue lesion. Magnify Image

The mass was movable and did not appear to be bound to bone or invading the soft tissue. Oral radiographs showed no bony erosion. There was a mild to moderate degree of cervical lymphadenopathy. Incisional biopsy was performed and tissue was submitted for histopathologic examination.

Clinical Differential Diagnosis

1. Squamous Cell Carcinoma of the Oral Cavity
2. Primary Intraoral Presentation of NonHodgkin's Lymphoma
3. Mycobacterial Intraoral Infection
4. Angiomatosis Neoplasm, including Kaposi's Sarcoma
5. Bacillary Angiomatosis
6. Salivary Gland Neoplasm
   

Additional Clinical Information
This patient had several risk factors for infection with human immunodeficiency virus. HIV testing proved to be positive and the patient had a low CD4 count (<200/cubic mm) and a high viral load (>400,000 BPA). Following obtaining the laboratory information, the patient denied intravenous drug usage, but indicated that he had been involved in a homosexual relationship several years previously. Review of his medical record showed that his recent hospitalization was for pneumocystis carinii pneumonia. It is unlikely that prior blood product transfusion 20 years previously had resulted in HIV transmission. Blood transfusion mode of HIV infection is usually associated with a more rapid progression to AIDS.