Oral Hairy Leukoplakia in a Healthy Teen

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.

3.19.20 Addendum:
CBC and HIV tests are both normal.  We are considering the diagnosis of "oral frictional keratosis" in this otherwise healthy teenager.  Further history reveals that she is seeing an oral surgeon for bruxism.  Her tongue is symptomatic and she complains of pain when eating acidic foods. (See reference 5)

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)

5. Sook-Bin Woo, Dorothy Lin. Morsicatio mucosae oris--a chronic oral frictional keratosis, not a leukoplakia. J Oral Maxillofac Surg. 2009 Jan;67(1):140-6.
Conclusions: MMO is a form of chronic oral frictional keratosis that has no malignant potential, and should be signed out as such and not merely "hyperparakeratosis and acanthosis" so that it can be removed from the category of leukoplakia where it does not belong.