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Clinical Challenge
Pathology
May 30, 2019

Perforation of the Hard Palate

Author Affiliations
  • 1Division of Allergy, Immunology and Infectious Diseases, Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
  • 2Department of Pathology and Laboratory Medicine, New Brunswick, New Jersey
JAMA Otolaryngol Head Neck Surg. Published online May 30, 2019. doi:10.1001/jamaoto.2019.0926

A 45-year-old man was admitted to the hospital following 3 weeks of dysphagia; 1 week of nasal regurgitation, nonproductive cough, and breathy voice; and a 25-pound weight loss over the preceding 2 months. He had been diagnosed a year earlier with HIV infection and hepatic tuberculosis. Baseline CD4 count was 7 cells/μL, and following treatment with HAART (highly active antiretroviral therapy) consisting of dolutegravir, emtricitabine, and tenofovir-disoproxil-fumarate, he achieved full virological suppression; however, CD4 counts remained low at 31 cells/μL. He had completed 12 months of directly observed therapy with ethambutol, moxifloxacin, and rifabutin—a liver-sparing regimen—owing to toxic effects from the first-line regimen 1 month prior to admission. Physical examination revealed evidence of perforation of the hard palate (Figure, A). A computed tomographic scan of the chest revealed necrotic lymph nodes, and a palatine biopsy was performed (Figure, B and C).

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