Gum Hypertrophy- Warning Sign of acute myeloblastic leukemia (AML M2): A Case Report
Abstract
Many systemic diseases are early indicated by oral manifestations. Among such systemic diseases Leukemia is one which shows characteristic oral manifestations. Acute myeloid leukemia (AML) is characterized by maturation arrest of myeloid cells which leads to increase in number of myeloblasts in the bone marrow and hemopoietic insufficiency. Patients with AML in general may present with a wide variety of (atypical) symptoms, which may range from minor symptoms to lifethreatening complications. Gingival hyperplasia is most commonly seen with the AML subtypes acute monocytic leukemia (M5) and acute myelomonocytic leukemia (M4). Here, an unusual case of diffuse gum hypertrophy in a 25 year old Asian female which led to laboratory studies yielding a rapid and relatively early diagnosis of acute myeloblastic leukemia (AML M2) was reported. This case emphasizes that clinicians and dentists should be well acquainted with the oral manifestations of systemic diseases and stresses the role of gingival hypertrophy as a diagnostic indicator in leukemia.
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Introduction
Gingival swellings may manifest as a localized metastatic deposit or hematological disorder such as lymphoma or a leukemic infiltrate. The differential diagnosis of a patient presenting with gingival hypertrophy would include drug-induced hypertrophy, chronic gingivitis, idiopathic or neoplastic processes1 .
Leukemia is a heterogenous group of hematological disorders that arises from a hematopoietic stem cell characterized by a disordered differentiation and proliferation of neoplastic cells1 . This neoplastic proliferation in marrow may result in pancytopenia. Also, the neoplastic cell infilteration may be observed in organs such as lymph nodes, spleen, gingiva, central nervous system and skin2 .
Leukemia is divided into acute or chronic variety, based on its clinical course, and into lymphocytic and myelocytic, based on its histogenetic origin. Acute myelocytic leukemia (AML). leukemia, is commonly classified under 8 subgroups according to the French-American-British (FAB) classification system including M0 (undifferentiated leukemia), M1 (acute myeloblastic leukemia), M2 (acute myeloblastic leukemia with maturation), M3 (acute promyelocytic leukemia), M4 (acute myelomonocytic leukemia), M5 (acute monocytic leukemia), M6 (acute erythroblastic leukemia) and M7 (acute megakaryoblastic leukemia). 3,4
Leukemia is the most common childhood malignancy in India ranging between 25 and 40%. Sixty to 85% are acute lymphoblastic leukemia (ALL) of all reported leukemias. 5 Oral lesions associated with leukemia have been well documented. 6 Signs and local symptoms of leukemia in the oral cavity include oral mucosa paleness with gum bleeding, ulcerative necrotic lesions and gingival hyperplasia. 7
Conclusion
This case emphasizes that clinicians and dentists should be well acquainted and informed with the oral manifestations of systemic diseases and stresses the role of gum hypertrophy as a diagnostic indicator of leukemia. An accurate history is critical for establishing the diagnosis and subsequent management in all patients. This case also shows that gingival hyperplasia due to leukemic infiltration commonly improves by chemotherapy and no periodontal treatment is required.