原文題目

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口腔病理科 On-Line KMU Student Bulletin

原文題目(出處)： Oral ulcer: an uncommon site in primary tuberculosis. Aust Dent J 2015;60:119–22

原文作者姓名： N Aoun, G El-Hajj, S El Toum

通訊作者學校： Oral Pathology and Diagnosis, School of Dentistry, Lebanese University, Beirut, Lebanon

報告者姓名(組別)：張媛婷（InternＡ組）

報告日期： 104.08.04

內文：

Abstract

a case of primary tuberculosis manifested as a non- healing, tender ulcer on the lingual mucosa of the edentulous right mandibular arch molar zone, an uncommon site.

1. histopathology examination, polymerase chain reaction purified protein derivative tests chest radiograph.

2. treatment plan: six months with four anti-tuberculotic antibiotics.

3. Clinically, the oral ulcer disappeared three months after the commencement of treatment. >>>>>>>> differential diagnosis

Introduction

1. Tuberculosis (TB)

(1) chronic infectious disease caused by Mycobacterium tuberculosis (2) a major cause of morbidity and mortality worldwide.

(3) transfer by

a. direct person-to-person spread through airborne droplets

b. ingestion of unpasteurized cow milk infected by Mycobacterium bovis or by other atypical Mycobacteria.

2. Depending on the infected site, tuberculosis is classified clinically as pulmonary and extrapulmonary.

(1) pulmonary: remains the most common form of the disease but other sites may be involved, including the lymphatic, skeletal and central nervous systems, the skin, kidneys, pharynx and gastrointestinal tract.

(2) extrapulmonary: is uncommon, accounting for approximately 10% to 15% of all infected people.

3. Oral tuberculosis lesions are uncommon.

>> 0.05% to 5.00% of tuberculosis cases.

>> Most cases appear as a chronic painless ulcer.

>> Most represent a secondary infection from initial pulmonary lesions

>>> on- tongue, lips, buccal mucosa and rarely on the palate, gingival mucosa and lingual frenum.

>> Primary oral tuberculosis without pulmonary involvement is extremely rare

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>>> common in younger patients

>>> mucobuccal fold, areas of inflammation adjacent to teeth, in extraction sites, with enlarged palpable cervical lymph nodes.

4. The aim of this article was to report a case of non- healing tender ulcer of primary tuberculosis

Case report 1. S:

CC: Tender, non-healing oral ulcer on the lingual aspect of the edentulous right molar mucosa of the mandible which over three months had increased in size from 1 cm to 3 cm.

PI: A 65-year-old male was referred to the Oral Pathology and Oral Diagnosis Department at the Lebanese University School of Dentistry with a chief complaint of tender, non-healing oral ulcer on the lingual aspect of the edentulous right molar mucosa of the mandible which over three months had increased in size from 1 cm to 3 cm. The ulcer was treated with miconazole. Topical mouthwashes of an undisclosed brand were also used for three weeks prior to referral but with no positive outcome.

PMH: type II diabetes in April 2010 2. O:

extraoral examination: a single enlarged submandibular lymph node on the right side was detected. It was firm, tender and fixed to deeper anatomical layers

Intraorally examination: there was an ulcer on the lingual aspect of the edentulous right mandibular second molar mucosa of an irregular oval shape and measuring about 1.5 X3.0 cm. The ulcer had a well-defined and slightly elevated border that altered to ill-defined on the lower perimeter. It was covered by an inhomogeneous grey yellowish layer with a granular aspect sur- rounded by an erythematous halo.

The base and borders of the ulcer were indurated on digital palpation.

Ｘ -ray finding: a multitude of ill- shaped radiopacities forming a circular configuration of 1 cm diameter and superimposed with the right angle of the mandible.

On the left side, a few millimetres higher, there were fewer radiopacities.

3. Impression:

(1) squamous cell carcinoma >>>biopsy (2) lymphoma >>> biopsy

(3) giant aphthous ulcer >>> The ulcer was chronic, tender and non- recurrent (4) traumatic ulcer >>> no history of trauma

(5) infections (bacterial, fungal or viral) >>> The ulcer was chronic, tender and non- recurrent

(6) drug reaction. >>> not on any medication 4. Biopsy:

(1) peripheral giant cell granuloma on the alveolar crest ridge, corresponding to the first left molar

(2) The connective tissue exhibited granulomatous inflammation containing epithelioid and multinuclear giant cells. Some of these granulomas showed a central acidophilic, granular and acellular necrosis with a leucocytic infiltrate.

>>>>> This raised the possibility of granulomatous lesion, including tuberculosis or sarcoidosis.

>>> polymerase chain reaction (PCR) >>> positive for Mycobacterium complex 5. The patient was then referred to a pneumologist for further care.

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>>>肺臟Ｘ光沒有病兆，PPD test正常，Complete blood count (CBC)正常除了WBC 偏高，Hepatitis C and HIV tests陰性>>>>判定為Primary oral tuberculosis

discussion

1. Primary oral tuberculosis is an uncommon occurrence probably because

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(1) the intact squamous epithe- lium of the oral mucosa acts as a mechanical and biological barrier.

(2) the inhibitory effect of saliva

作者歸納此case得病的原因是帶了污染的tuberculosis bacilli的痰液或牛奶接觸到患者口內的傷口或不好的口腔條件如： poor dental hygiene, peri- odontitis, leukoplakia, traumatic ulcers, recent opened dental extraction sites and jaw fracture.

作者推測此患者得病原因是不合的RPD造成的ulcer及受污染的牛奶 conclusion

Dental practitioners need to be aware that TB may occur in the oral cavity.

儘早發現儘早治療

題號題目

1 Which is the most involved organ in primary tuberculosis?

(A) Lungs

(B) Oral cavity

(C) Kidney

(D) Stomache

答案 (A)

出處：Oral and Maxillofacial PATHOLOGY,3rd edition , Neville, et al.

P.195

題號題目

2 Which method is we usually use for TB diagnosis?

(A) purified protein derivative (PPD) test (B) Complete blood count(CBC)

(C) Weber’s test

(D) Creatine

答案 (A)

出處： Oral and Maxillofacial PATHOLOGY,3rd edition , Neville, et al.

P.198