Actinomycotic Osteomyelitis and Myiasis in Oroantral Communication: Clinicopathological and Tomographic Findings

Actinomycotic osteomyelitis of the maxilla presenting with oroantral communication is very rare, herein we report the first case of this condition in association with myiasis. A 50-year-old man reported chronic sinusopathy and a non-healing maxillary lesion, with 30 years of evolution, presenting occasional nasal and intraoral purulent discharge, with foul smell, and recurrent episodes of larvae presence. Cone beam computed tomography showed a large hyperdense image inside the left maxillary sinus, with focal areas with soft tissue density, and extensive discontinuity of the maxillary sinus floor, confirming the oroantral fistula. The necrotic tissue curetted during surgery presented hard consistency, and dark greenish color, and was submitted for histopathological analysis. Microscopically, necrotic bone, masses of filamentous bacteria colonie s, compatible with actinomycosis, and large rhomboidal structures surrounded by eosinophilic capsule - suggestive of larvae, were observed. The diagnosis of actinomycotic osteomyelitis with presence of structures compatible with larvae was established.

La osteomielitis actinomicótica del maxilar que se presenta con comunicación oroantral es poco frequente. En este trabajo reportamos el primer caso de esta condición en asociación con miasis. Un hombre de 50 años que refiere sinusopatía crónica y lesión maxilar que no cicatriza, de 30 años de evolución, presenta secreción ocasional purulenta nasal e intraoral, con mal olor y episodios recurrentes de presencia de larvas. La tomografía computarizada de haz cónico mostró una gran imagen hiperdensa en el interior del seno maxilar izquierdo, con áreas focales con densidad de partes blandas y una extensa discontinuidad del piso del seno maxilar, lo que confirma la fístula oroantral. El tejido necrótico legrado durante la cirugía presentó consistencia dura, coloración verdosa oscura, y fue remitido para análisis histopatológico. Microscópicamente se observó hueso necrótico, masas de colonias de bacterias filamentosas compatibles con actinomicosis y grandes estructuras romboidales rodeadas de cápsula eosinofílica sugestiva de larvas. Se estableció el diagnóstico de osteomielitis actinomicótica con presencia de estructuras compatibles con larvas.

Perfil inmunohistoquímico del mixoma odontogénico, con énfasis en marcadores de agresividad tumoral y microdensidad vascular / Perfil imuno-histoquímico do mixoma odontogênico, com ênfase em marcadores de agressividade tumoral e microdensidade vascular / Immunohistochemical profile of odontogenic myxoma, with a focus on microvascular density and tumor aggressiveness markers

Con el fin de tener una mayor comprensión sobre el comportamiento biológico del mixoma odontogénico (MO), se realizó inmunohistoquímica en 31 muestras, utilizando marcadores relacionados con mecanismos de progresión tumoral (adhesión, angiogénesis, apoptosis, inflamación y proliferación celular). El epitelio odontogénico fue detectado en cuatro muestras mediante CK19 y CD138, este último, mostró expresión baja en matriz extracelular (MEC) y alta en las células tumorales. La microdensidad vascular (MDV) media fue de 7.51 y 5.35 vasos marcados con CD34 y VEGF-A respectivamente. Una alta expresión de Orosomucoide-1 y Mast Cell Tryptase se observó células tumorales y en MEC. El MO mostró negatividad para Calretinina. Este perfil inmunohistoquímico, la baja expresión para Ki-67, Bcl-2 y p53, y la relativamente baja MDV, sugieren que la actividad proliferativa, anti-apoptótica o angiogénica no representan los principales mecanismos de crecimiento del MO, los cuales podrían estar asociados a eventos como inmunomodulación y degradación de la MEC.

Immunohistochemistry tests were performed in 31 samples to elucidate the biological behavior of the odontogenic myxoma (OM), using markers related to mechanisms of tumor progression (adhesion, angiogenesis, apoptosis, inflammation and cell proliferation). Odontogenic epithelium was detected in four samples with CK19 and CD138; the latter had a low expression in the extracellular matrix (ECM) and a high expression in tumor cells. The mean microvascular density (MVD), assessed with CD34 and VEGF-A, was 7.51 and 5.35 blood vessels. A high expression of orosomucoid-1 and mast cell tryptase was observed in tumor cells and ECM, while calretinin was negative. The immunohistochemical profile mentioned above, as well as the low expression of Ki67, Bcl-2 and p53 and the relatively low MVD, suggest that the proliferative, antiapoptotic and angiogenic activities do not represent the main growing mechanisms of OM, which could be associated to other events, such as immunomodulation and ECM degradation.

Para melhor compreensão do comportamento biológico do mixoma odontogênico (MO), imuno-histoquímica foi realizada em 31 amostras, utilizando marcadores relacionados aos mecanismos de progressão tumoral (adesão, angiogênese, apoptose, inflamação e proliferação celular). Epitélio odontogênico foi detectado em quatro amostras por CK19 e CD138, o último mostrou baixa expressão na matriz extracelular (MEC) e alta em células tumorais. A microdensidade vascular (MDV) média foi de 7.51 e 5.35 vasos marcados com CD34 e VEGF-A, respectivamente. Uma alta expressão de Orosomucoide-1 e Mast Cell Tryptase foi observada nas células tumorais e na MEC. O MO mostrou negatividade para Calretinina. O perfil imuno-histoquímico mencionado acima, a baixa expressão de Ki-67, Bcl-2 e p53 e a relativamente baixa MDV, sugerem que a atividade proliferativa, anti-apoptótica ou angiogênica não representam os principais mecanismos de crescimento do MO, os quais poderiam estar associados com eventos como imunomodulação e degradação da MEC.

Generalized hereditary gingival fibromatosis in a child: clinical, histopathological and therapeutic aspects

Hereditary gingival fibromatosis (HGF) is a rare genetic condition characterized by slow and progressive gingival enlargement. The gingival overgrowth often delays teeth eruption and may cause serious functional and aesthetic problems. We reported a case of a 10-year-old female child presenting a generalized gingival enlargement covering almost all the maxillary and mandibular teeth and resulted in problems for swallowing, speaking, and poor aesthetics. An incisional biopsy was performed and revealed a hypocellular and hypovascular dense collagenous tissue covered by squamous epithelium exhibiting acanthosis and elongated rete ridges. The diagnosis was HGF. The treatment instituted was an association of gingivectomy with a rigorous program of oral hygiene and follow-up. Herein, we describe a rare non-syndromic case of generalized HGF, including clinical and microscopical features, as well as highlighting the importance of correct diagnosis of this genetic condition.

Spindle cell carcinoma of the maxillary sinus with extension to the oral cavity

Spindle cell carcinoma (SCC) is a rare variant of squamous cell carcinoma characterized by elongated and pleomorphic epithelial cells that resemble a sarcoma. Due to its rareness, and histological resemblance to various sarcomas, the diagnosis of this neoplasia is challenging. Herein we present the case of an 82-year-old female with a polypoid, ulcerated, soft tissue mass located on the left side of the maxilla. The tomographic examination showed a hyperdense mass that infiltrated the orbital cavity, ethmoidal cells, middle and lower nasal concha, maxillary sinus, zygomatic arch, and mandibular ramus on the left side. Histopathologically, the tumor was composed of spindle cells that were sarcomatous in appearance, with aberrant mitosis, along with a group of pleomorphic cells with a more epithelioid and hyperchromatic appearance on a stroma of densely vascularized fibrous tissue. The immunohistochemistry panel used to determine the lineage of the tumor rendered the diagnosis of SCC. The diagnosis of SCC is challenging to the pathologist since its morphology can resemble a sarcoma. Thus, immunohistochemistry is a valuable resource to support the diagnosis. We propose that SCC should be considered when examining a biphasic neoplasm with the aforementioned histological characteristics and markers.

COVID-19 y la odontología: una revisión de las recomendaciones y perspectivas para Latinoamérica / COVID-19 and dentistry: a review of recommendations and perspectives for Latin America

COVID-19 es una enfermedad altamente contagiosa y potencialmente mortal que nos acompañara por largo tiempo. Las profesiones de la salud y la vida en general ha sido afectada de forma significativa en todo lugar del mundo. La odontología ha pasado de una etapa de gran desarrollo clínico a una etapa donde el manejo de barrera de protección, el control de tratamientos y el tiempo asignado a los pacientes cambiará la forma de realizar la profesión. El presente trabajo pretende resumir las indicaciones y recomendaciones basadas en la evidencia disponible y realizar un análisis de la condiciones de salud oral para Latinoamérica en esta época de pandemia.

COVID-19 is a profound, highly contagious and life-threatening viral disease that will be with us for a long time. Health Care-related professions and life in its entirety are significantly, and perhaps irreversibly affected, all around the World. COVID-19 is and will continue to transform Dentistry and its practise. Based on the available evidence accrued to date, this work attempts to address such changes, current and anticipated, as well as present recommendations for clinical practise implementation, tailored for Latin/South America, in light of such lifealtering momentous pandemic.

Intraoral EBV-positive sporadic Burkitt lymphoma in an elderly patient with bilateral presentation

Sporadic Burkitt lymphoma (SBL) is a variant of Burkitt lymphoma that occurs worldwide, affecting mainly children and young adults. Association with Epstein-Barr virus (EBV) can be identified in approximately 20-30% of cases. Herein we described a case of a 63-year-old male presenting intraoral bilateral mandibular swelling, subjacent to fixed dental prosthesis, with one month of duration. Incisional biopsies were performed, and after two days, the patient was hospitalized due to malaise and breathing difficulty, and died after a week when an abdominal tumor was detected. The mandibular biopsies revealed a diffuse proliferation of medium-sized monomorphic atypical lymphoid cells exhibiting numerous mitoses and areas of "starry-sky" pattern. The tumor showed immunohistochemical positivity for CD20, CD10, Bcl-6, and Ki-67 (≈ 100%); it was negative for CD3, Bcl-2, Vs38c, and MUM-1. Positivity for EBV was found by in situ hybridization. The final diagnosis was intraoral SBL positive for EBV. Clinical, morphological and molecular criteria are necessary for the correct diagnosis of aggressive B-cell neoplasms positive for EBV in elderly patients.

Distribution of dendritic cells in aids-associated oral kaposi's sarcoma

Abstract The aim of this study was to determine if the distribution of Langerhans cells (LC) and interstitial dendritic cells (IDC) is altered in AIDS-associated oral Kaposi's sarcoma when compared to HIV-negative highly vascular oral lesions. Fifty-one cases of AIDS-associated oral Kaposi's sarcoma and 20 of highly vascular oral lesions were retrospectively retrieved. All cases of Kaposi's sarcoma were confirmed with immunoreactions against CD34 and HHV-8. Clinical data regarding sex, age and lesions location were obtained from pathology reports. Immunohistochemistry against CD207 (immature dendritic cells) and CD83 (mature dendritic cells) were done. LC were in the epithelium and IDC in the stroma. CD207+ cells predominated in the epithelium of the lesions, whereas CD83+ cells predominated in their stromal compartment. Kaposi's sarcoma had a lower CD207+ immature LC count (p=0.02) and an increased CD207+ IDC than highly vascular oral lesions (p<0.001). Moreover, Kaposi's sarcoma also showed an increased number of mature CD83+ IDC than highly vascular oral lesions (p<0.001). There were significant alterations in the distribution of LC and IDC in AIDS-associated Kaposi's sarcoma when compared to HIV-negative vascular oral lesions, suggesting that changes in their concentrations may play a role in the pathogenesis of Kaposi's sarcoma.

Resumo O objetivo deste estudo foi determinar se a distribuição das células de Langerhans (CL) e das células dendríticas intersticiais (CDI) está alterada no sarcoma de Kaposi oral associado à AIDS quando comparado às lesões orais altamente vasculares HIV-negativas. 51 casos de sarcoma de Kaposi oral associado à AIDS e 20 de lesões orais altamente vasculares foram recuperados retrospectivamente. Todos os casos de sarcoma de Kaposi foram confirmados pela positividade para os anticorpos CD34 e HHV-8. Dados clínicos sobre sexo, idade e localização das lesões foram obtidos dos laudos histopatológicos. Foram realizadas imunoistoquímica contra CD207 (células dendríticas imaturas) e CD83 (células dendríticas maduras). As CL estavam presentes no epitélio enquanto as CDI estavam presentes no estroma. As células CD207+ predominaram no epitélio das lesões, enquanto as células CD83+ predominaram no estroma. O sarcoma de Kaposi teve uma contagem mais baixa de CD imaturas CD207+ (p = 0,02) e número aumentado de CDC CD207+ do que lesões orais altamente vasculares (p<0,001). Além disso, o sarcoma de Kaposi também mostrou um número aumentado de CDI CD83+ maduras do que lesões orais altamente vasculares (p<0,001). Houve alterações significativas na distribuição de CL e CDI no sarcoma de Kaposi associado à AIDS quando comparado às lesões orais vasculares HIV-negativas, sugerindo que alterações na distribuição das mesmas podem desempenhar um papel na patogênese do sarcoma de Kaposi.

Diagnosis, management, and follow-up of extensive dermoid cyst of the submental region

Dermoid cyst (DC) is a cystic lesion of developmental origin and uncertain etiology that rarely affects the floor of the mouth. We report a case of a large lesion found in the submental and submandibular region in a 25-year-old male patient. Computed tomography revealed extensive hypodense lesion in the submental and submandibular space without peripheral enhancement. The microscopical analysis showed a cystic cavity lined by orthokeratinized stratified squamous epithelium. The cystic capsule was composed of dense fibrous connective tissue containing cutaneous attachments, such as sebaceous and sweat glands. The diagnosis of DC was made. The differential diagnosis of expansive sublingual lesions can be clinically challenging due to the similarity with several lesions frequently observed in this region. Herein, we describe a case of extensive DC arising in the floor of the mouth, presenting clinical, imaging, and microscopical features.

Late Diagnosis of Oral Melanoma / Diagnóstico Tardío de Melanoma Oral

ABSTRACT: Oral melanoma (OM) is an extremely rare and aggressive malignancy. A 67-year-old patient presented with complains of a slightly symptomatic spot in the mouth since the past 2 years. Extraoral examination revealed left cervical lymphadenopathy, and intraoral examination a blue-black multinodular sessile mass, with irregular margins, involving the attached gingiva of teeth 27 and 28, extending to vestibular sulcus and hard palate, measuring approximately 3.5 cm. The lesion presented focal areas of ulceration. Panoramic radiograph did not show bone involvement. The main diagnostic hypothesis was oral melanoma. Microscopic findings of the incisional biopsy revealed a proliferation of densely pigmented pleomorphic cells, invading the subepithelial connective tissue in sheets or nests showing an organoid pattern. Immunopositivity for S-100, Melan-A and HMB-45 confirmed the diagnosis of melanoma. The patient was referred to an oncology hospital in which multiple metastases were detected, and the patient was subjected to palliative care. Herein we report an OM in advanced clinical stage, and discuss the clinical, morphological and immunohistochemical diagnostic criteria with emphasis on the importance of early diagnosis.

RESUMEN: El melanoma oral (MO) es una malignidad extremadamente rara y agresiva. Un paciente de 67 años acudió a consulta con la queja de una mancha intraoral ligeramente sintomática, presente desde hace dos años. Al examen clínico extraoral, se encontró adenopatía cervical del lado izquierdo, y al examen intraoral, se observó una masa sésil multinodular de color negro azulado, focalmente ulcerada, con bordes irregulares, afectando la encía de los dientes 27 y 28, extendiéndose hasta el surco vestibular y el paladar duro, midiendo aproximadamente 3,5 cm. La radiografía panorámica no mostró involucramiento óseo. La principal hipótesis diagnóstica fue MO. Los hallazgos microscópicos de la biopsia incisional revelaron una proliferación de células pleomórficas densamente pigmentadas, invadiendo difusamente el tejido conectivo en forma de sábanas o nidos con patrón organoide. La positividad inmunohistoquímica para S-100, Melan-A y HMB-45 confirmó el diagnóstico de melanoma. El paciente fue referido a un hospital oncológico, en el cual se le detectaron múltiples metástasis y fue sometido a cuidados paliativos. Este es el reporte de un caso de MO diagnosticado en estado avanzado, en el que se discuten los criterios clínicos, morfológicos e inmunohistoquímicos para su diagnóstico, haciendo énfasis en la importancia del diagnóstico temprano.