Diagnostic difficulty of a mandibular manifestation of diffuse large B-cell lymphoma: a case report

Abstract

An 87-year-old patient was referred by his dentist for multiple tooth extractions following pain on the lower right jaw (quadrant 4) and one month of unsuccessful antibiotics treatment. The patient had a medical history of slow progressing myeloma for more than two years with no treatment required, chronic kidney failure and atrial fibrillation. Extraoral examination revealed a right submandibular lymphadenopathy. Intraoral examination revealed severe periodontitis characterized by poor oral hygiene, tooth mobility especially in the molars sectors (score 3 and 4 of Muhlemann) and necrotic gum on quadrant 4. The patient also reported spontaneous loss of teeth. The orthopantomogram (OPT) showed a radiographic bone loss extending to mid third of the roots and beyond. The patient was treated by apixaban and bisoprolol. He had never received biphosphonate or RANK/RANKL inhibitor. The main complaint was pain in quadrant 4. Teeth 45 46 47 were hopeless and their extraction was planned. Extractions were performed with no premedication. After local anesthesia, analgesia was hard to obtain. The extractions revealed a necrotic aspect of the underlying bone and a biopsy was performed looking for osteitis or malignant disease (Fig. 1). Medication-related jaw osteonecrosis was excluded after exhaustive anamnesis. A CBCT was performed to evaluate the extension of the bone necrosis. At this stage it was not informative (Fig. 2). At follow-up appointment two weeks later, a worsening of the wound was observed, with pain preventing alimentation. A new CBCT was performed and showed small radiolucent lesions in the cortical bone surrounding the extraction site (Fig. 2). Surprisingly, histological result was in favor of actinomycosis.

Non-Hodgkin’s lymphoma with orbital, oral and systemic manifestations: A case report and review of literature

“…9 Diffuse Large B-cell Lymphomas involving bone leading to necrosis may be associated with Actinomyces israelii and lead to misdiagnosis. 10…”

Diagnostic challenges in a diffuse large B-cell lymphoma of the maxilla presenting as exposed necrotic bone

“…( 12 ) and Solomides et al . ( 9 ), respectively), relatively few publications have focused on this entity and its diagnosis remains challenging, especially considering the variety of its clinical presentations ( 20 - 32 ).…”