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\begin{document}

\title{Exophytic lesion in the anterior maxilla}



\author[1]{Ryan McConville}%
\author[1]{Amanda Willis}%
\affil[1]{Queen's University Belfast Dentistry}%


\vspace{-1em}



  
  \date{May 25, 2024}


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\selectlanguage{english}
\begin{abstract}
65-year-old man was referred to the Oral Medicine Department by his
General Dental Practitioner for investigation of a swelling in the
anterior maxilla, which had been present for 6 weeks and associated with
mobility in the upper central incisors%
\end{abstract}%



\sloppy


\textbf{Title}

Exophytic lesion in the anterior maxilla

\textbf{Authors}

Ryan McConville

Corresponding email -- rmcconville10@qub.ac.uk

Amanda Mary Willis

\textbf{Consent statement}

Written informed consent was obtained from the patient to publish this
report in accordance with the journal's patient consent policy

\textbf{CASE REPORT}

A 65-year-old man was referred to the Oral Medicine Department by his
General Dental Practitioner for investigation of a swelling in the
anterior maxilla, which had been present for 6 weeks and associated with
mobility in the upper central incisors. There was no resolution of the
lesion following extraction of the central incisors and three courses of
antibiotics.

The patient's medical history was significant for HIV which was managed
with a combination antiretroviral and Co-trimoxazole. He was a never
smoker and consumed 10 units of alcohol per week.

Extra orally, there was no lymphadenopathy. On intra oral examination a
firm, nodular, exophytic soft tissue swelling was noted in the upper
anterior maxilla extending to involve the labial sulcus (Figure 1).\selectlanguage{english}
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Figure 1. Exophytic lesion upper anterior maxilla and upper labial
mucosa

\textbf{WHAT IS YOUR DIAGNOSIS?}

Based on the patient's history and physical examination, which one of
the following is the most suspicious diagnosis?

\begin{enumerate}
\tightlist
\item
  Idiopathic gingival enlargement
\item
  Peripheral giant cell granuloma
\item
  Plasmablastic lymphoma
\item
  Pyogenic granuloma
\end{enumerate}

\textbf{DIAGNOSIS IMAGE}\selectlanguage{english}
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Figure 2a -- Immunohistochemistry positive for CD 138- a plasma cell
marker\selectlanguage{english}
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Figure 2b -- Negative immunohistochemistry for CD 20 -- a B- cell marker\selectlanguage{english}
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\end{center}
\end{figure}

Figure 2c -- EBER ISH -- Epstein Barr virus encoded RNA in-situ
hybridisation positive

\textbf{DIAGNOSIS}

The correct diagnosis is C, Plasmablastic lymphoma (PBL). An incisional
biopsy was undertaken and demonstrated extensive infiltration of the
lamina propria with sheets of neoplastic plamablasts.
Immunohistochemistry was positive for CD 138 and MUM 1 which are plasma
cell markers and negative for CD 20, a mature B cell marker (Figures 2a
and 2b). There was also marked positivity for Epstein-Barr virus-encoded
RNA in the sample (Figure 2c). These investigations confirmed the
diagnosis as Epstein Barr Virus-positive plasmablastic lymphoma,
consistent with viral-induced immunosuppression

Plasmblastic lymphoma is a rare but aggressive subtype of diffuse large
B-cell lymphoma (Non-Hodgkin lymphoma). It is estimated that PBL
comprises 2\% of HIV-related lymphoma cases. It has a male predominance
(3:1), with a median age of diagnosis in HIV-positive patients of 42
years. It is strongly associated with immunodeficiency with 79 \% of
cases having a concomitant HIV infection and 75\% having an associated
EBV infection (Rodrigues-Fernandes et al., 2018). The Plasmablast is the
precursor of the plasma cell and it is proposed that EBV leads to the
prevention of apoptosis of these cells (Castillo et al., 2015).

The most notable feature of plasmablastic lymphoma is its predilection
for the oral cavity with 66\% cases presenting here.
(Rodrigues-Fernandes et al., 2018) It most commonly presents as an
expanding mass lesion on the gingiva or palate. Patients can also
present with B symptoms: fevers, weight loss and night sweats in up to
40\% of cases, however lymph node involvement is less frequently seen in
these patients. (Lopez and Abrisqueta, 2018). Currently available
chemotherapy fails to achieve good results and the prognosis of patients
with PBL is generally poor with a median overall survival of 5--15
months (Castillo et al., 2015).

\textbf{OUTCOME}

The patient was referred to Haematology where he had a PET-CT scan which
showed subtle uptake in the maxilla and no further uptake seen
elsewhere. He is currently undergoing chemotherapy.

\textbf{CONFLICT OF INTEREST}

All authors have no conflicts of interest to disclose

\textbf{AUTHOR CONTRIBUTIONS}

Ryan McConville

Amanda Mary Willis

\textbf{REFERENCES}

\begin{enumerate}
\tightlist
\item
  Rodrigues-Fernandes CI, de Souza LL, Santos-Costa SFD, Silva AMB,
  Pontes HAR, Lopes MA, et al. Clinicopathological analysis of oral
  plasmablastic lymphoma: A systematic review. J Oral Pathol Med.
  2018;47(10):915-22
\item
  Castillo JJ, Bibas M, Miranda RN. The biology and treatment of
  plasmablastic lymphoma. Blood. 2015;125(15):2323-30
\item
  Lopez A, Abrisqueta P. Plasmablastic lymphoma: current perspectives.
  Blood Lymphat Cancer. 2018;8:63-70
\end{enumerate}

\textbf{ACKNOWLEDGEMENTS}

Thanks to Dr Seamus Napier and the Histopathology department, Royal
Victoria Hospital, Belfast

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