Wednesday, January 06, 2021

Oral Hairy Leukoplakia in a Healthy Teen

Presented by Dr. Rosamonde St. Pierre,  Laval, PQ, Canada

The patient, a 14-year-old girl, who presented with a mildly painful process on the lateral borders of the tongue for about 4 months. She is a healthy child whose only medication is oral contraceptives for heavy menstrual cycles.  She has never used inhaled steroids or nose drops; but did have mononucleosis at 4 or 5 years old. There is no history of blood transfusions.  The affected areas are sensitive when she eats spicy or acidic foods.

OE: The examination shows rough, whitish papillae on the lateral margins of the tongue.  KOH prep was negative for Candida

Clinical Images:

October 2020 (taken by patients mother:



January 2021 (taken at dermatologist office)

 Diagnosis: Oral Hairy Leukoplakia (OHL) must be considered. Although OHL was first described in association with HIV/AIDS, it has been reported in otherwise healthy individuals.

OHL was first described in 1984, and initially all OHL patients had HIV/AIDS.  Over the years, it has been seen in people with other immunedeficiencies and even in patients with normal immune systems.  This patient has no risk factors for immune compromise or HIV/AIDS. The question Dr. St. Pierre asks is how aggressively this 14 year-old should be worked up?  Florid OHL is much more impressive in its appearance.  This patient's lesions are subtle and appear to be resolving without treatment.



References:.

1. Oral Hairy Leukoplakia
Manu Rathee  1 , Prachi Jain  2
In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan.

2020 Apr 22.  Free Full Text.

2.  Darling MR et al. Oral Hairy Leukoplakia in Patients With No Evidence of Immunosuppression: A Case Series and Review of the Literature. J Can Dent Assoc 2018 May;84:i4.
Abstract
: Objectives: Oral hairy leukoplakia (OHL) is caused by Epstein-Barr virus (EBV) and is often associated with HIV and other immunosuppressive conditions. It is rare in HIV-negative patients, but has been reported in patients who use immune-modulating medications (e.g., cyclosporine).

Study design: A series of 7 new cases of OHL among HIV-negative patients is described. Langerhans cells were counted using an immunoperoxidase stain for CD1a and light microscopy.

Results: The 7 patients were male, ranging in age from 26 to 69 years. Clinically, all lesions were diagnosed as leukoplakia on the lateral border of the tongue. Microscopic examination revealed hyperparakeratosis and candidiasis in some cases, acanthosis and a band-like zone with clearing of cells in the upper spinous layer, which were EBV-positive by in-situ hybridization. There was a significant decrease in Langerhans cell counts in OHL patients.

Conclusion: OHL can occur in HIV-negative patients.

3.  Shanahan D et. al. Oral hairy leukoplakia in healthy immunocompetent patients: a small case series. Oral Maxillofac Surg. 2018 Sep;22(3):335-339.
Conclusion: Physicians must have a high index of suspicion for OHL when considering a differential diagnosis for white patches on the lateral borders of the tongue in apparently healthy immunocompetent patients. OHL should no longer be solely attributed to HIV infection, or immunosuppression. Greater awareness of OHL may lead to further cases in immunocompetent people being reported, particularly as our population ages.


4.
Kyle Burke Jones, Richard Jordan. White lesions in the oral cavity: clinical presentation, diagnosis, and treatment. Semin Cutan Med Surg. 2015 Dec;34(4):161-70

Keywords: geographic tongue; hairy tongue; leukoedema; nicotine stomatitis; oral frictional hyperkeratosis; oral leukoplakia; oral lichen planus; oral lichenoid reaction; oral squamous cell carcinoma; smokeless tobacco keratosis; white sponge nevus. (see comment # 7)

 

 

 

 


6 comments:

  1. From Dato Cheng Leng Ong, Malaysia: er history of mononucleosis at age of 4 to 5 year of age is the hidden clue. Hairy Leukoplakia is mainly caused by EBV which is notoriously difficult to clear. EBV is detectable in sporadic or endemic Burkitt’s lymphoma and is suspected to be its cause.

    A gentle and considerate history to rule out high risk behaviour and smoking habit will make it even more likely. Since prognosis is good, may be a long course of oral acyclovir at 400mg four hourly is worth trying, since acyclovir is so harmless.

    I notice she has some small sores over her chin ( probably acne) and lower lip, wonder whether this is another clue to something?

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  2. I would recommend getting an HIV lab screen on this patient, no matter what the history of risks factors might be (a second year medical school mantra – Never miss diagnosing a potentially life-threatening infectious disease). If that is negative, my concern would then be if her oral hairy leukoplakia might be associated with an increased risk of other more serious EBV maladies that target children and adolescents including Burkitt’s lymphoma, EBV‐associated T/natural killer‐cell lymphoproliferative disorder and, if the patient has Asian ancestry, nasopharyngeal carcinoma.
    A potential silver lining of the Covid-19 pandemic could be that the new recombinant DNA vaccine technology might provide new approaches to preventing the reactivation of latent viruses such as EBV.

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  3. Robert Shapiro, Hilo, Hawaii: This young girl needs a check for HIV. That’s exactly the type of teen to have a hidden life totally opposite of how it appears. Everyone is supposed to be screened for HIV. It’s a population wide recommendation. Do it matter of factly, don’t seem alarmed. Since you’ve made that dx you are obliging yourself to check the test. Just don’t make a big deal about it. Don’t think about the implications if it were positive, most likely it will be negative. The chance is not zero that it would be positive and the implications for missing it would be severe.

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  4. William James, University of Pennsylvania:
    It appears to me to more likely repetitive friction as a possible cause, i wonder if she has a habit of biting this area. Oral hairy leukoplakia is usually heavily colonized by Candida. While the lesion will not rub off a koh should be positive and she should have some predisposing factor it seems to me. A biopsy might help. George Lupton and I published the path of OHL a long time ago in the Arch Derm. [Note: reference to this paper will be placed in References.]

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  5. Prof. Bhushan KumarJanuary 12, 2021

    Difficult to explain in a healthy adolescent with no history of using steroids puffs or nasal drops and no addictions and the development of OHL. Also difficult to implicate EBV without any other symptomatology – old infection cannot be implicated. OHL is known to regress of its own. I don’t know if we can wait. No active treatment without any identifiable cause can be recommended. I would only suggest regular follow up

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  6. From an academic oral surgeon: So difficult to say without the complete hx and clinical exam. That said I favor traumatic hyperkeratosis for the following reasons:

    Lesions appear slightly anterior to the area normally involved especially on R side. Resolving on their own. Commonly seen in younger population who have a parafunctional habit of pressing tongue against the teeth especially if patient is under stress.

    It would be prudent to check “sharpness” of her teeth adjacent to the areas involved, determine salivary function and if returns biopsy.

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