Mark Schifter

Zoster sine herpete of the trigeminal nerve

Zoster sine herpete infection that involves the trigeminal nerve is rarely reported. The present case details a case of varicella zoster virus infection of the mandibular division of the left trigeminal nerve without evidence of a vesicular eruption. The diagnosis was established on clinical findings and was supported by the demonstration of an IgG antibody titer of > 1:640 during the acute phase of the disease.

Perineural spread of squamous cell carcinoma involving trigeminal and facial nerves

Perineural spread of squamous cell carcinomas in the orofacial region predominantly involves the trigeminal and facial nerves. Central spread, particularly along the trigeminal nerve, produces sensory impairment and involvement of other divisions through invasion of the gasserian ganglion, as illustrated in these case reports. Early diagnosis and medical referral is important because central invasion has a poor prognosis.

Antibiotic strategy in orofacial/head and neck infections in severe neutropenia

A strategy for empiric antibiotic therapy for orofacial/head and neck bacterial infections that appear as clinical swellings in patients with severe neutropenia is assessed. Daily examinations were made in the hospital. Only those with peripheral blood neutrophil counts < 100/mm3 that persisted for at least 5 days after the commencement of resolution of the swelling were included in this article. The strategy consisted of sequential additions of a beta-lactam/aminoglycoside combination, metronidazole to intensify anaerobe cover and a beta-lactamase stable agent (such as vancomycin and floxacillin) as dictated by clinical signs. Progressive and complete resolution of infection occurred in 26 of 27 patients treated.

Multiple oral squamous cell carcinomas associated with autoimmune polyendocrinopathy–candidiasis–ectodermal dystrophy

Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) is a rare autosomal recessive disorder characterized by chronic mucocutaneous candidiasis, hypoparathyroidism, and adrenal insufficiency. Chronic oral candidiasis is frequently the first manifestation of the condition. There is an increased incidence of oral squamous cell carcinomas at an early age in this population, and it is possible that chronic oral candidal infection has a role in oral carcinogenesis in patients with APECED. We present a case of multiple oral squamous cell carcinomas in a 35-year-old woman with chronic mucocutaneous candidiasis as a component of APECED. Our patient has had 3 confirmed oral squamous cell carcinomas to date, which have been managed with laser resection and ablation. She remains on systemic antifungal therapy and is under regular surveillance in a multidisciplinary head and neck clinic.

Oral presentation of histoplasmosis in an immunocompetent patient: a diagnostic challenge

Histoplasmosis is a rare systemic fungal infection, primarily affecting the pulmonary system. Oral lesions are usually a manifestation of the disseminated form of the disease and most frequently observed in severely immunocompromised patients, such as those with advanced human immunodeficiency virus infection and/or frank acquired immune deficiency syndrome. The clinical presentation of the oral lesions may be difficult to distinguish from oral squamous cell carcinoma. The histopathological features are usually characteristic, but occasionally the organisms are scanty and not readily identified, which can preclude obtaining the correct diagnosis and ensuring appropriate management. Histoplasmosis is an unusual and rare cause of chronic non-healing ulceration in the oral cavity. A case of histoplasmosis involving the oral cavity in an immunocompetent patient is reported, which was not recognized, resulting in the inappropriate management of the condition.

Paraneoplastic pemphigus: two cases of intra-abdominal malignancy presenting solely as treatment refractory oral ulceration.

Two patients with initial diagnoses of oral lichen planus and pemphigus vulgaris presented with refractory oral mucosal blistering. Subsequent positive serology results for paraneoplastic pemphigus led to the discovery of occult intra‐abdominal malignancies in both, unicentric Castlemans and non‐Hodgkins lymphoma. The diagnosis of paraneoplastic pemphigus should be considered in patients with recalcitrant oral ulceration, even in the absence of clinical features of malignancy.

Multiple Cranial Nerve Involvement Leading to Diagnosis of Nasopharyngeal Carcinoma: Case Report

Abstract The extent of nasopharyngeal carcinoma (NPC) at initial diagnosis is an important prognostic factor. 1,2 Prognosis clearly worsens with increasing size of the primary tumor, invasion of bone, and presence of regional, nodal, and distant metastases. Unfortunately, the anatomy of the nasopharynx frequently permits significant, often painless, local tumor expansion and early spread before patients seek consultation. 1 Intermittent epistaxis and progressive hearing impairment due to invasion of the nasal cavity and compression of the eustachian tube, respectively, are well documented findings. 3 Single or multiple cranial nerve palsies also may be found at initial presentation, depending on the extent and direction of tumor invasion. Invasion of the cavernous sinus and orbit may affect cranial nerves II to VI, while erosion of the bone in the posterior cranial fossa may induce palsies of IX to XII. The oral and maxillofacial surgeon is in an excellent position to assess abnormal cranial nerve function, which in the case of NPC may lead to earlier detection and improved prognosis. The case reported here is of a patient who presented with well-defined cranial nerve signs and symptoms involving swallowing and phonation that led to the diagnosis of NPC. The relevance of the functional anatomy to the diagnosis is discussed.

‘Oral’ vs ‘Dental Health’: Relevance to the general health of older Australians

This issue of the Australasian Journal of Ageing is graced by two articles pertaining to dentistry, specifically regarding the issues of the value and the problems with access to dental services by older Australian women and Cantonese-speaking older people. Both these articles identify that, ‘oral health is important to general health and well-being’; however, both articles, despite the stated concern about oral health, focus more specifically on dental health, that is, diseases of the dentition – caries, and of the supporting gingival and periodontal structures – periodontal diseases, and the consequent tooth loss – edentulism, and tooth replacement (dentures). This intensely narrow focus is the fundamental problem that besets ‘dentistry’. That is, for the general community and their representatives (politicians), the broader health sector, including our medical and nursing peers and its bureaucracy and administration, even the dental profession itself is this overwhelming focus just on ‘teeth’. Oral health pertains to the optimal functioning of the jaws (maxilla and mandible), the unique, specially adapted temperomandibular joints (TMJ’s), the complex integrated function of the muscles of mastication and their integration with the muscles of facial expression, and the muscles used in the gag and swallow reflexes, the dense general and specialised sensory apparatus of the mouth (touch and taste), and critical to the ongoing health of the soft tissue lining of the oral cavity and the teeth themselves, the three paired, major salivary glands.

Utility of serological assays in the diagnosis of paraneoplastic pemphigus

Background: Paraneoplastic pemphigus (PNP) is a rare autoimmune mucocutaneous blistering condition which has a universal association with malignancy and a poor prognosis. PNP, which is characterised by the presence of autoantibodies against plakins in the skin epithelial layer, can be a challenging diagnosis to make, particularly in those without an existing history of malignancy, as tissue biopsy findings may resemble other disorders that have similar clinical features. Thus, serology may be helpful in the diagnosis. Historically, indirect immunoflourescence (IIF) has been the most widely used assay in diagnostic laboratories with reasonable, but not ideal, specificity. Western blotting for various anti-plakin antibodies is more specific but not routinely available. Recently many antiplakin antibody specific assays have been developed commercially. Aim: The aim of our study was to compare the utility of three traditional assays, (IIF on rat bladder, monkey bladder and rat cardiac tissue) versus two newer plakin-based assays (envoplakin ELISA and HEK-transfected cell IIF) in patients presenting initially with oral ulceration alone. Method: Fifty-nine samples [PNP n = 5, healthy controls n = 10, and disease controls n = 44, including pemphigus vulgaris (PV), mucous membrane pemphigoid (MMP), lichen planus (LP) and miscellaneous oral ulcers] were analysed on the five different assays and results were compared. Results: The current assay employed by our laboratory, rat bladder IIF, is the most sensitive assay for our three confirmed PNP cases (3/3, 100%), and has high specificity among all controls (53/54, 98.1%). The Envoplakin ELISA was even more specific (54/54, 100%), although less sensitive (1/3, 33.3%). Monkey bladder IIF had equal sensitivity to rat bladder IIF, although poorer specificity (51/54, 94.4%). Rat cardiac and HEK-transfected cell IIF performed the most poorly with 78–88% specificity, with the latter also having 0% sensitivity. Conclusion: Our findings show that the newer envoplakin ELISA compares favourably with more traditional IIF in its high negative predictive value for PNP in both disease and healthy controls. However, traditional IIF seems to have superior sensitivity in our limited cohort of PNP patients.

Oral histoplasmosis: a rare cause of chronic non-healing ulcer in an immunocompetent individual

Background Non-healing chronic ulcers in the oral cavity should be regarded as suspicious. A variety of conditions may present as non-healing chronic oral ulcers including persistent trauma, infections, autoimmune diseases and malignant neoplasms. Objective A case of oral histoplasmosis is reported with the clinical and histopathological findings. Case report A 58-year-old male was referred with a 10-month history of chronic, non-healing ulcer involving buccal mucosa, adjacent gingiva and the tongue. An incisional biopsy of the gingiva at that time showed chronic granulomatous inflammation. Special stains for bacteria and fungi were negative. The patient failed to respond to conservative treatment. The ulcer from the buccal mucosa was biopsied at the Oral Medicine clinic at Westmead Hospital. Histopathological examination still showed chronic granulomatous inflammation. Special stains (Diastase and Gomori’s methenamine silver) confirmed the presence of small intra-cellular yeasts consistent with Histoplasma capsulatum. Subsequent investigations also suggested the presence of infection in the right lung and the right adrenal gland. The patient did not show any evidence of immunosuppression. He was treated successfully with systemic antifungal agents. Oral histoplasmosis is a frequent finding in patients with AIDS, however, it is rarely documented in immunocompetent patients.