A 24-year-old woman with reactive HIV serology for 5 years, without antiretroviral treatment or clinical controls, who reported starting approximately one month ago with pain in the right lower jaw region.
He consulted a dental service where swelling was found in the right lower jaw region, at the level of the lower third molar.
Antibiotic treatment and nonsteroidal anti-inflammatory drugs were indicated.
Two weeks later, the patient consulted again without improvement of symptoms, reporting increased pain and swelling.
The clinical picture is interpreted as a dental phlegmon and amoxicillin/clavulanic acid and corticosteroids are indicated.
One week before admission, due to the increase in the size of the tumor described, surgical drainage was performed, obtaining a voiding material.
Analgesics are indicated and the same antibiotic scheme is maintained.
Five days after this procedure, the patient was admitted to our hospital.
The epidemiological history referred to inhaled cocaine, marijuana and smoking.
On admission, there was a dry mouth, coughing, oriented in time and space; the physical examination highlighted the existence of a tumor formation in the right lower jaw region extending to the submentonian area 10 cm.
It involved the gingiva, including teeth, blade perioral tissues and the right lower jaw.
Homolateral, indurated, painless, submandibular adenomegaly adhered to skin and deep planes.
The rest of the physical examination showed no clinically relevant alterations.
The chest X-ray was normal.
The admission laboratory showed: 35% Hto, GB: 7,200/mm3 (N: 70%, E: 0.3%, pregnancy: 1.6%, M mEq/mEqol: 98%, TL: 136 mg GL: 21dl negative, GL:
Serology for Chagas and hepatitis B and C virus were negative and for toxoplasmosis: IgM: negative and IgG: positive 1/64.
The CD4+ T lymphocyte count was 235 cells/ml (16.3%), CD8: 872/mm3 (60.5%) and the HIV viral load yielded 154,263 copies/ml (log10 4.74).
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Abdominal ultrasound revealed mild heterogeneous adenomegaly, the rest without abnormalities.
Excisional biopsy was performed for diagnostic purposes. Histopathological examination of the material showed proliferation of lymphoid cells obtained at medium to large size cytoplasm with regular nuclei, laxa chromatin, presence of nucleic acid nuclei.
Numerous mitoses and apoptosis phenomena were also observed.
Immunohistochemical analysis revealed positivity for CD45, CD3, CD20, CD10 and Bcl-6 in mutant cells, and negativity for CD138, MUM-1 and Bcl-2.
Ki67 cell proliferation index was 99%.
Microbiological studies of biopsy material were negative for AFB and common germs.
The definitive histopathological diagnosis was primary BL of the oral cavity.
Bone marrow biopsy showed no evidence of atypical lymphoid cells.
Gram stains, Gram staining and Ziehl Neelsen staining were negative.
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The patient received 6 cycles of chemotherapy based on the COPDH-R scheme (etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, rituximab and intrathecal methotrexate).
Neutropenia episodes were treated with granulocyte colony stimulating factor.
After treatment, complete disappearance of the gingival lesion was observed.
Four years later, the patient is asymptomatic, with no evidence of disease, undetectable viral load and CD4 362 cells/ml.
