110

Case Report
s
Oral plasmablastic lymphoma as the first manifestation of AIDS*

Daniela Assis do Vale1 Carolina Martelli Rogado2

Danielle Lima Corrêa de Carvalho1 Marilia Trierveiler3
Karem López Ortega3

DOI: http://dx.doi.org/10.1590/abd1806-4841.20175417

Abstract: Plasmablastic lymphoma is a non-Hodgkin lymphoma characterized by its plasmacytic differentiation and predi-
lection for the oral cavity. It is among the lymphomas most commonly associated with AIDS. This report details a case of a
HIV-positive patient with a 1-month history of an exophytic mass in the gingival area of the upper left quadrant. The diagnosis
of plasmablastic lymphoma was made based on its histopathological and immunophenotypical features. She was treated with
chemotherapy followed by autologous hematopoietic stem cell transplantation. Despite complete resolution of the lesion,
the patient died of cardiorespiratory arrest. This case illustrates plasmablastic lymphoma as the first clinical manifestation of
AIDS, highlighting the importance of differentiating between a potentially malignant lesion and other pathologic processes.
Keywords: Acquired Immunodeficiency Syndrome; HIV; Lymphoma, AIDS-Related

INTRODUCTION
Plasmablastic lymphoma (PBL) is a non-Hodgkin lympho- nancies include squamous cell carcinoma, metastatic tumors and
ma, variant of the diffuse large B-cell lymphoma, rare, aggressive Kaposi sarcoma. Besides plasmablastic lymphoma, other types of
and characterized by its plasmacytic differentiation. PBL occurs lymphoma can also occur in the oral cavity, including diffuse large
in patients with some form of immunosuppression, especially the B-cell lymphoma, plasmacytomas and Burkitt lymphoma.5
one caused by HIV (human immunodeficiency virus) infection, There is no standard treatment for plasmablastic lymphoma.
and 80% of the cases associated with HIV are also positive for Ep- However, chemotherapy remains as the treatment of choice. Recently,
stein-Barr virus (EBV).1-4 autologous hematopoietic stem cell transplantation has been shown
It affects more men, with a 4:1 ratio and mean age of 39 years. to be an option, increasing patient survival.1,2,5
However, due to its rarity, the exact incidence remains unknown.1,2,4
The clinical presentation is of an exophytic, painless, rap- CASE REPORT
idly growing and sometimes ulcerated lesion. It has predilection Fifty-six-year-old female Caucasian pacient, smoker, was
for the mouth, particularly the gingivae and palate. Submandibular referred for the diagnosis of a lesion on the gingiva.
and cervical lymphadenopathy, as well as B-cell lymphoma symp- When the lesion first appeared, 1 month one month before
toms like fever, night sweats and weight loss can be present.1,5,6 the appointement, the patient sought a dental surgeon that upon
The differential diagnosis of an expanding oral lesion in- noticing intense bone loss on the right posterior maxillary region
cludes from infectious dental processes to malignancies. Malig- on the radiograph, suggestive of periodontal destruction, opted to

Study submitted on 22.11.2015

Approved by the Advisory Board and accepted for publication on 16.04.2016
* Study conducted at Special Patient Unit and Oral and Maxillofacial Pathology of the Department of Oral Medicine of the Faculdade de Odontologia -
Universidade de São Paulo (FO-USP) – São Paulo (SP), Brazil.
Financial Support: None.
Conflict of Interests: None.

1
 ost-graduation Program in Dental Sciences –Area of Oral and Maxillofacial Pathology and Special Patients of the Faculdade de Odontologia - Universidade
P
de São Paulo (FO-USP) – São Paulo (SP), Brazil.
2
Special Care Dentistry Center, Faculdade de Odontologia - Universidade de São Paulo (CAPE-FOUSP), São Paulo (SP), Brazil.
3
Department of Oral Medicine, discipline of Oral and Maxillofacial Pathology of the Faculdade de Odontologia - Universidade de São Paulo (FO-USP) – São
Paulo (SP), Brazil.

©2017 by Anais Brasileiros de Dermatologia

An Bras Dermatol. 2017;92(5 Suppl 1):110-2.

Oral plasmablastic lymphoma as the first manifestation of AIDS 111

remove the affected teeth and prescribe antibiotics. Since there was served (Figure 2A). Immunohistochemistry revealed positivity to
no improvement, the patient was referred to our clinic. anti-plasma cell marker and immunoglobulin kappa light chain,
Concomitantly, the patient was under investigation of er- and was negative to anti-CD3, CD20 and lambda light chain, con-
ythematous patches, spread throughout her body that appeared firming monoclonality and plasmacytic origin of the tumor. In situ
11 months earlier, leading to the diagnosis of HIV infection and cu- hybridization was positive for EBV (Figure 2B). The final diagnosis
taneous rash. She did not have any other associated conditions or of PBL was made based on the histological and immunophenotypic
history of opportunistic infections. features.
CD4+ cell count and viral load (VL) before antiretroviral The patient was referred to chemotherapy treatment, hav-
treatment was 146 cells/mm3 and 1,111,978 copies/ml, respective- ing had 9 cycles of EPOCH (etoposide, prednisone, vincristine, cy-
ly. Fifteen days after starting treatment with lamivudine, tenofovir clophosphamide and doxorubicin). Afterwards, she presented with
and efavirenz, CD4+ cells went to 189 cells/mm³ and VL to 13,504 complete remission of the lesion (Figure 3). She then underwent
copies/ml. autologous hematopoietic stem cell transplantation and progressed
We collected a detailed history and on physical examination with sepsis, bronchospasm and died due to cardiorespiratory arrest
a painless tumor with an erythematous surface and an ulcerated 10 months after being diagnosed with PBL.
area was observed on the right upper gingiva (Figure 1). The radio-
graph showed intense, generalized periodontal bone loss. Incisional DISCUSSION
biopsy was performed, and the sample was sent to the laboratory With the advent of HAART, the incidence of opportunis-
for analysis. tic infections as well as the morbidity and mortality associated
Histopathology showed a fragment of lymphoid neopla- to HIV infection decreased, a trend that could also be seen with
sia, represented by a layer of bulky cells, similar to immunoblasts. oral lesions.7,8 The incidence of lymphomas associated with HIV
Intense pleomorphism and multiple mitotic figures were also ob- infection in general decreased 50% after HAART was made avail-

A B
Figure 1: A. Clinical aspect of the lesion on the first visit. B. Clinical aspect of the lesion on the first visit

A B
Figure 2: A. Histopathology showing lymphoid proliferation and intense cellular pleomorphism (Hematoxylin & eosin, X40). B.
hybridization confirming the presence of Epstein-Barr virus(X40)

An Bras Dermatol. 2017;92(5 Suppl 1):110-2.

112 Vale DA, Rogado CM, Carvalho DLC, Trierveiler M, Ortega KL

A B
Figure 3: A and B. Complete remission of the lesion after chemotherapy

able. However, because of the small number of cases, there is not Even though the prognosis of PBL remains somber, with mean
enough information to affirm that the advent of HAART altered survival of 11 to 13 months, the combination of HAART with chemo-
the prevalence of PBL.7 therapy has yielded better survival for HIV-positive patients. Promis-
The diagnosis of oral lymphomas can be challenging be- ing results have also been reported with the use of targeted therapies
cause there is low clinical suspicion, leading to diagnostic errors and against EBV, such as zidovudine, ganciclovir and interleukin-2.4,10
delayed treatment.9 A careful assessment, knowledge about HIV in- PBL, an AIDS defining lesion, can be the first clinical mani-
fection and its oral manifestations will help correctly and promptly festation of HIV infection and physicians must be vigilant to make
diagnosing malignant lesions, avoiding situations such as in our an accurate and early clinical diagnosis, being able to differentiate
case, where the initial diagnosis was of a dental infection. a potentially malignant lesion from other neoplastic or infectious
processes in patients, regardless of their serology, increasing their
chances of survival.q

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E-mail: [email protected]

How to cite this article: Vale DA, Rogado CM, Caravalho DLC, Trierveiler M, Ortega KL. Oral plasmablastic lymphoma as the first
manifestation of AIDS. An Bras Dermatol. 2017;92(5 Suppl 1): 110-2.

An Bras Dermatol. 2017;92(5 Suppl 1):110-2.