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Clinical Challenge
October 2015

Rapid Progression of Necrotic Lesion of the Mandibular Gingiva in a Pancytopenic Patient

Author Affiliations
  • 1Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
  • 2Department of Anatomic Pathology, Penn State Hershey Medical Center, Hershey, Pennsylvania
JAMA Otolaryngol Head Neck Surg. 2015;141(10):937-938. doi:10.1001/jamaoto.2015.1733

A woman in her 70s with a 7-year history of essential thrombocythemia was diagnosed as having acute myelogenous leukemia 4 days prior to hospital admission for induction chemotherapy. She was febrile at admission and treated empirically with antifungal, antibiotic, and antiviral medications in the setting of cultures that were negative for organisms. The initial chemotherapy regimen failed, requiring a more aggressive regimen, which left her pancytopenic. During the course of the second chemotherapy treatment, she developed left-sided mandibular pain. A computed tomographic scan revealed cellulitic changes along the buccal cortex of the mandible and a small 2 × 12-mm abscess formation. At initial evaluation by the otolaryngology service on hospital day 32, she had decreased sensation at the left mandibular branch of the trigeminal nerve and ecchymoses along the mandibular buccal-gingival borders bilaterally with induration of the left floor of mouth and buccal mucosa (Figure, A). She continued to receive broad spectrum antimicrobial and antifungal coverage. By hospital day 38, the patient had developed evidence of ischemia and necrosis along the gingival and lingual aspects of the left mandibular alveolar ridge, extending past midline to involve mucosa on the right side. Magnetic resonance imaging revealed a 7 × 10 × 35-mm abscess involving both gingival and lingual aspects of the left anterior mandible (arrowheads) (Figure, B). Biopsy specimens of the right mandibular gingiva are shown in the Figure, C and D.