|Year : 2012 | Volume
| Issue : 2 | Page : 166-168
Oral manifestations leading to the diagnosis of acute lymphoblastic leukemia in a young girl
BA Silva1, CRB Siqueira2, PHS Castro1, SS Araújo1, LER Volpato2
1 Department of Dentistry, Mato Grosso Cancer Hospital, Cuiabá, MT, Brazil
2 Master's Program in Integrated Dental Sciences, University of Cuiabá, Cuiabá, MT, Brazil
|Date of Web Publication||23-Aug-2012|
Hospital de Câncer de Mato Grosso - Departamento de Odontologia, Av. Historiador Rubens de Mendonça, 5500, Bairro Morada da Serra, CEP: 78055-500 Cuiabá, MT
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: oral complications may be leukemia's first presentation. Aim: to present a case of a young girl with a swelling on the face that led to the diagnosis of acute lymphoblastic leukemia is reported. Results: a 10-year old anemic girl was referred for evaluation and treatment of a swelling at the left-nasolabial region. Symptoms reported (tiredness, poor appetite, fever, lethargy, and musculoskeletal pain) and clinical findings (enlargement at the presternal region and brownish stain in the lumbar region) led to the suspicion of a hematopoietic malignancy. The diagnosis of lymphoblastic leukemia was attained after specific examination conducted by the pediatric oncologist and hematologist. Conclusion: dentists must be able to clearly recognize oral physiological characteristics, and, when identifying changes of normalcy, to fully investigate it requesting additional tests or referring the patient to specialized professionals.
Keywords: Acute, diagnosis, leukemia, leukemia, lymphoblastic, lymphoid, oral manifestations
|How to cite this article:|
Silva B A, Siqueira C, Castro P, Araújo S S, Volpato L. Oral manifestations leading to the diagnosis of acute lymphoblastic leukemia in a young girl. J Indian Soc Pedod Prev Dent 2012;30:166-8
|How to cite this URL:|
Silva B A, Siqueira C, Castro P, Araújo S S, Volpato L. Oral manifestations leading to the diagnosis of acute lymphoblastic leukemia in a young girl. J Indian Soc Pedod Prev Dent [serial online] 2012 [cited 2019 Aug 18];30:166-8. Available from: http://www.jisppd.com/text.asp?2012/30/2/166/100003
| Introduction|| |
Leukemia represents one-third of all childhood cancers. Seventy five percent of those pediatric patients suffer from acute lymphoblastic leukemia (ALL),  which may be of B or T cell origin. ,
Oral complications occur frequently in leukemia and may, indeed, be the presenting feature of the disease  or of its relapse.  Oral manifestations usually arise from an underlying thrombocytopenia, neutropenia, or impaired granulocyte function, or may result from direct leukemic infiltration. 
This paper describes the case of a young girl with occult hematological malignancy referred for dental evaluation that lead to the diagnosis of acute lymphoblastic leukemia.
| Case Report|| |
A 10-year-old girl was referred to the Municipal Emergency Hospital of Cuiabα for treatment of anemia. The responsible physician requested the oral and maxillofacial surgeon to evaluate a swelling in the left-nasolabial region of the patient. The surgeon then referred her to the Department of Dentistry at the Mato Grosso Cancer Hospital to speed up the evaluation and consequent treatment.
The symptoms reported by the patient during the interview were: tiredness, poor appetite, fever, lethargy, and musculoskeletal pain.
At the physical extra-oral examination, it was observed pale skin, facial asymmetry with swelling on the left-nasolabial region [Figure 1]a. Another volumetric enlargement was observed at the presternal region, hard and painless to palpation, with approximately 30 mm at its largest diameter [Figure 1]b. A brownish stain confined to about 20 mm in the lumbar region was also perceived [Figure 1]c.
|Figure 1: (a) Volumetric enlargement in the left nasolabial region. (b) Hard tumor in the presternal region. (c) Brownish stain in lumbar region|
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The intraoral examination showed a discrete swelling of fibrous consistency, painless to palpation, measuring approximately 30 mm, involving the area between the upper-right central incisor to the left canine with undefined limits leading to the relaxation of the gingival-labial sulcus [Figure 2].
|Figure 2: Discrete swelling from the upper right central incisor to the upper left canine|
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Requested laboratory exams included blood and coagulation tests, which showed a hematological picture of anemia and neutrocytic leukopenia. Imaging tests did not show any significant changes [Figure 3].
Given the signs and symptoms, it was suspected that the patient could present a hematopoietic malignancy. She was then referred for evaluation by the pediatric oncologist and hematologist, who requested specific tests such as myelogram, bone marrow biopsy, and immunophenotyping.
The morphology and immunohistochemistry led to the diagnosis of lymphoblastic leukemia of precursor cells with T-cell phenotype and proliferation
rate of 30%.
| Comment|| |
Acute lymphoblastic leukemia is the most common leukemia of childhood. It is a malignancy characterized by the uncontrolled clonal proliferation of a transformed lymphoblast with overgrowth and displacement of normal bone marrow precursors.  The etiology of leukemia remains speculative, although a number of factors have been implicated, including: exposure to ionizing radiation or electromagnetic fields, treatment with cytotoxic drugs, and viral infections.  Its initial presentation is nonspecific and may reflect various non-neoplastic and neoplastic processes such as idiopathic thrombocytopenic purpura, Epstein-Barr virus infection, juvenile rheumatoid arthritis, aplastic anemia, and hypereosinophilic syndrome to name a few.  As the disease progresses, anemia, neutropenia, and thrombocytopenia from failed hematopoiesis dominates the hematologic picture. ,, These are related to the co-abrupt onset of clinical symptoms such as fatigue, fever, petechia, ecchymosis, epistaxis, and bleeding.  Osseous changes, in association with the initial onset of leukemia, have been well documented. , Other symptoms include aseptic bone necrosis, lymphadenopathy, hepatosplenomegaly, respiratory discomfort, visual disturbances, and central nervous system manifestations (i.e., headache, vomiting, and nerve palsy). 
Oral manifestations usually arise from an underlying thrombocytopenia, neutropenia, or impaired function. It has been described a number of leukemic-induced oral changes including: pain, gingival swelling (especially if platelet counts are below 10 000 to 20,000/mm 3 ), ulcers, bleeding, ulceration, bony changes, and infections. ,,, Another manifestation is the infiltration of leukemic cells in an area of the oral mucosa (chloroma). ,
The complete blood count may be normal in early stages, or possibly reveal normochromic normocytic anemia and thrombocytopenia, needing to repeat the blood test to detect early changes suggestive of leukemia.  White blood cell count is occasionally very high, but often normal or decreased.
The dentist, and mainly the pediatric dentist, plays a fundamental role in the early diagnosis of leukemia. Frequently the first signs of the disease occur in the mouth, and patients usually seek dental care believing that the diseases are of local origin. Initial laboratory tests may be quite normal or show subtle changes that do not target for cancer. It is essential for the professional to be able to clearly recognize oral physiological characteristics, and, when identifying a change of normalcy, to fully investigate it requesting additional tests or referring the patient to specialized professionals.
| Acknowledgement|| |
The work was carried out at the Department of Dentistry and Department of Pediatric Oncology - Mato Grosso Cancer Hospital.
| References|| |
|1.||Benson RE, Rodd HD, North S, Loescher AR, Farthing PM, Payne M. Leukaemic infiltration of the mandible in a young girl. Int J Paediatr Dent 2007;17:145-50. |
|2.||Burke VP, Startzell JM. The leukemias. Oral Maxillofacial Surg Clin N Am 2008;20:597-608. |
|3.||Aronovich S, Connolly TW. Pericoronitis as an initial manifestation of Acute Lymphoblastic Leukaemia: A Case Report. J Oral Maxillofac Surg 2008;66:804-8. |
|4.||Prognostic factors in children and adolescents with Acute Lymphoblastic Leukaemia. Rev Bras Saúde Matern Infant 2007;7:413-21. |
|5.||Fatahzadeh M, Krakow AM. Manifestation of acute monocytic leukaemia in the oral cavity: A case report. Spec Care Dentist 2008;28:190-4. |
[Figure 1], [Figure 2], [Figure 3]
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