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DOI: 10.5604/01.3001.0014.7909 casestudy
POL OTORHINO REV 2021: 10 (1): 62-64
Inflammatory tumor of the base of the tongue
as a clinical presentation of HIV infection
Guz zapalny nasady języka jako jedyna manifestacja
zakażenia wirusem HIV
Klaudyna Zwierzyńska, Tomasz Gotlib, Kazimierz Niemczyk
Department of Otolaryngology, Medical University of Warsaw; Head: Prof. Kazimierz Niemczyk MD PhD
Article history: Received: 08.01.2021 Accepted: 02.03.2021 Published: 03.03.2021
ABSTRACT: Introduction: AIDS is a fatal disease that impairs the immunity, increasing the risk of developing opportunistic infections.
Case report: We present a case of a 47-year-old patient from the ER, with bleeding from a tongue tumor. The patient reported that he had lost 25 kg in about six months and complained of swallowing disorders. HIV infection was confirmed in the pa- tient during the diagnosis. The inflammatory tumor of the tongue was the only manifestation of HIV infection.
KEYWORDS: emergency room, HIV, tongue tumor
STRESZCZENIE: Wstęp: AIDS jest śmiertelną chorobą, która powoduje upośledzenie odporności organizmu, zwiększając ryzyko zachorowa- nia na infekcje oportunistyczne.
Opis przypadku: Przedstawiono przypadek 47-letniego pacjenta z ostrego dyżuru, z krwawieniem z guza języka. Pacjent po- dawał, że od około pół roku schudł 25 kg i skarżył się na zaburzenia połykania. W toku diagnostyki potwierdzono zakażenie wirusem HIV. Guz zapalny nasady języka był jedyną manifestacją zakażenia.
SŁOWA KLUCZOWE: guz języka, ostry dyżur, HIV
ABBREVIATIONS
AIDS – acquired immunodeficiency syndrome CECT – Contrast Enhanced Computed Tomography CT – computed tomography
HAAART – highly active antiretroviral therapy HIV – human immunodeficiency virus
KS – Kaposi’s sarcoma
NHL – non-Hodgkin lymphoma
INTRODUCTION
Acquired immunodeficiency syndrome (AIDS) is a lethal disease compromising the immune system, which leads to an increased risk of opportunistic infections. Sometimes the laryngologist is the first physician to make the diagnosis.
We present the following case report to raise awareness about non-specific symptoms of an human immunodeficiency virus (HIV) infection.
CASE REPORT
A 47-year-old male patient was transported to the emergency de- partment by the emergency medical services team due to bleeding from a tongue tumor. The patient has not been treated or assessed by a physician before. He reported a weight loss of 25 kg over the past six months as well as difficulty swallowing.
At admission to the ED, the patient appeared cachectic, dehydrated and was actively bleeding from the tumor. On examination, there was a large disintegrating mass of the tongue with ulceration on the left side of the soft palate, between the uvula and the upper pole of the palatoglossal arch, covered with greyish and brown coating.
The lower pharynx was inaccessible for examination. On indirect laryngoscopy, the larynx could not be evaluated.
Because of the need for airway protection and pronounced tri- smus, tracheostomy under local anesthesia and classic gastrosto- my were performed. The control of bleeding was achieved. At the same time, direct laryngoscopy with biopsy was performed. The endoscopy revealed a disintegrating tumor covered with necrotic
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tissues, located at the base of the tongue and reaching the tonsil, the posterior and later pharyngeal walls. The tumor was reaching epiglottis without infiltrating it. Multiple biopsy samples were ta- ken, both superficial and deep.
Antibiotics were commenced and diagnostic tests were ordered.
The computed tomography (CT) scans showed an extensive infil- tration of the tongue occupying the base, located in the midline and about 44 x 45 x 24 mm in size, which showed signs of disin- tegration. Also, enlarged lymph nodes up to 26 mm were identi- fied. The reporting radiologist described the image as non-spe- cific (differential diagnosis including inflammatory or malignant infiltration) and emphasized the need for further pathology study.
The laboratory tests showed no significant abnormalities except for signs of dehydration. After two days of antibiotics and feeding via gastrostomy, the patient’s condition improved significantly.
The stench of the necrotic tissues and the trismus resolved, and the patient started do stand up from his bed.
Due to immense local and general improvement, additional labo- ratory tests were run including HIV screening, which was positive.
The pathology study did not confirm the diagnosis of malignancy, instead massive inflammation with focal necrosis was reported.
Because the patient’s condition improved and the tumor size de- creased to about 1 cm, the second biopsy was planned. On direct laryngoscopy, healing was noticed with no signs of necrosis. The infiltration of the lateral and posterior pharyngeal wall resolved.
The patient was transferred to the Infectious Disease Hospital and antiretroviral therapy was instigated. The second pathology study, once again, showed no malignancy but inflammation.
The patient continues antiretroviral therapy. His condition gra- dually improved. He has remained under the outpatient care of our clinic for 10 months. The tracheostomy tube was removed two months after discharge. Over time, dysphagia resolved, the gastrostomy was removed and the patient started oral feeding.
The scar on the tongue was noted in the location of the previous mass. Further evaluation revealed that the patient also suffered from schizophrenia and syphilis.
DISCUSSION
HIV infection/AIDS is widespread throughout many countries in the world. In 2012, around 35.3 million people worldwide te- sted positive for HIV, and there are about 2.3 million new cases annually [1].
HIV is an infection which compromises the immune system le- ading to opportunistic infections, neurological symptoms and malignancy. Oral and nasal lesions constitute a broad group of non-specific complains reported by patients. They can cause pain, discomfort, difficulty swallowing or even make swallowing impossible and lead to malnutrition and cachexia as presented in our patient. About 40.3% of HIV-positive patients report oral lesions [2, 3]. The spectrum of abnormalities includes candidia- sis, herpes, shingles, hairy leukoplakia, recurrent aphthous sto- matitis, xerostomia, Kaposi’s sarcoma (KS), NHL (non-Hodgkin lymphoma), squamous cell carcinoma, gingivitis and periodon- tal disease [4].
In the study by Berberi et al. [5], fifty patients with confirmed HIV infection and oral lesions were evaluated. The most commonly identified lesion was pseudomembraneous candidiasis accounting for 76% of cases (38/50), followed by periodontal disease – 34%
(17/50). Four patients (8%) suffered from extensive oral ulcers.
Fang [6] reported a series of 20 HIV-positive patients with oral and esophageal ulcerations. Ulcers affected mainly the vestibule (10 cases), tonsils (3 cases) and epiglottis (3 cases). The treatment consisted of stabilizing T CD4(+) lymphocyte count, which took between 2 weeks and 3 months when the patients received highly active antiretroviral therapy (HAART) along with immunomo- dulation, analgesics, anti-inflammatory and antifungal agents.
Li [7] reported 55 cases of patients with otolaryngological mani- festation of HIV infection. The most common empty symptom was parotid swelling (30.9%). A similar number of patients pre- sented with Kaposi’s sarcoma of the nose, oral cavity or pharynx.
Neck tumor was present in 20% of patients, while oral tumor was present in 12.7%. Oral ulceration affected 10.9% of patients. In the study by Ramirez [8] conducted on 1,000 patients, HIV-re- lated oral lesions affected 47.1% of patients. The most common pathologies included: oral candidiasis (36.1%), hairy leukoplakia (22.6%), erythematous candidiasis (21.0%) and pseudomembra- Fig. 1. Neck CECT. In the midline, there is a huge mass with signs of disintegration. Enlarged
lymph nodes can also be appreciated .
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neous candidiasis (15.8%). Oral Kaposi’s sarcoma (2.3%), HIV- -related periodontal disease (1.7%) and non-Hodgkin lympho- ma (0.1%) were rare.
Prasad [9] studied a large group of HIV-infected individuals (986 patients), and found otolaryngological symptoms in 79% of them.
The lesions usually affected the oral cavity and pharynx (59%), usually oral candidiasis, less commonly nasal lesions (17%), and ear-related symptoms were present in 13% of patients, most com- monly chronic suppurative otitis media.
Berberi [5] studied in details the relationship between the CD4+
count and oral lesions in HIV-positive patients, and conclu- ded that 62% of lesions occurred with CD4+ < 200 cells/mm3, and about 26% of oral lesions were present with CD4+ count 201–499 cells/mm3. In 12% of patients, the lesions occurred
despite normal CD4+ lymphocyte count. This was true in our patients as well.
Oral candidiasis is definitely the most common oral pathology in HIV-infected patients. It is assumed that it affects between 30%
and 90% of patients [9]. In HIV-positive patients, another com- mon oral pathology is major aphthous ulcers (a couple of cm in size). Their cause is unknown.
CONCLUSIONS
The presented case report is supposed to raise awareness among laryngologists about clinical symptoms suggestive of a HIV in- fection. The early diagnosis allows to introduce appropriate tre- atment, which improves the overall quality of life of the patients.
References
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Corresponding author: Klaudyna Zwierzyńska MD; Department of Otolaryngology, Medical University of Warsaw; Banacha street 1a, 02-097 Warsaw, Poland; Phone: +48 (22) 599 25 21;
E-mail: kzwierzynska@wp.pl
Cite this article as: Zwierzynska K., Gotlib T., Niemczyk K.: Inflammatory tumor of the base of the tongue as a clinical presentation of HIV infection; Pol Otorhino Rev 2021; 10 (1): 62-64
