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  1. #1
    Asclepius1's Avatar
    Asclepius1 is offline Ultimate Member 537 points
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    painless circular 1 cm white spot inside his mouth

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    A 46 yr old male comes to youur office with a painless circular 1 cm white spot inside his mouth which he noticed three days ago. He is being treated with propanolol and you know he is an alocholic. After physical examination your tentative diagnosis is leukoplakia. You elect to observe him after 2 weeks. After 2 weeks there was no change in the size of the lesion.what is ur next best step?

    a.continue to observe and reassure the patient
    b.perform a biopsy
    c.prescribe him oral dose of nystatin
    d.discontinue propanolol

  2. #2
    Asclepius1's Avatar
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    b.perform a biopsy

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    Asclepius1's Avatar
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    Oral hairy leukoplakia (OHL) is a painless, white, plaquelike lesion typically located on the lateral aspect of the tongue.

    Epstein-Barr virus (EBV) is implicated in its etiology, and OHL is a result of replication EBV in the epithelium of keratinized cells.

    ♦ EPIDEMIOLOGY & DEMOGRAPHICS

    OHL is usually found in human immunodeficiency virus (HIV) seropositive individuals but may also be identified in other immunocompromised patients such as transplant recipients (particularly renal) and patients taking steroids. A diagnosis of OHL is an indication to institute a workup to evaluate and manage HIV disease. Despite a high incidence of EBV seroprevalence in HIV-seropositive individuals, OHL occurs in only 25% of these cases.

    ♦ PHYSICAL FINDINGS & CLINICAL PRESENTATION

    Varying morphology and appearance
    May be unilateral or bilateral
    White and can be small with fine vertical corrugations on the lateral margin of the tongue (Fig. 1-162)
    Irregular surface; may have prominent folds or projection, occasionally markedly resembling hairs
    May spread to cover the entire dorsal surface or spread onto the ventral surface of the tongue where they usually appear flat
    Rarely lesions manifest on the soft palate, buccal mucosa, and in the posterior oropharynx
    Usually asymptomatic, but some have mouth pain, soreness, or a burning sensation, impaired taste, or difficulty eating; others complain of its unsightly appearance
    OHL may progress to oral squamous cell carcinoma, which has a poor prognosis

    ♦ DIFFERENTIAL DIAGNOSIS

    Candida albicans
    Lichen planus
    Idiopathic leukoplakia
    White sponge nevus
    Dysplasia
    Squamous cell carcinoma

    ♦ WORKUP

    Requires physical examination and evaluation of HIV disease

    ♦ LABORATORY TESTS

    The provisional diagnosis is clinical and based on:

    Visual inspection
    Inability to scrape the lesion off the tongue with a blade
    Failure to respond to antifungal therapy
    The presumptive diagnosis requires biopsy and histologic demonstration of:

    Epithelial hyperplasia with hairs
    Absence of inflammatory cell infiltrate
    The definitive diagnosis requires:

    In situ hybridization of histologic or cytologic specimens revealing EBV DNA or Electron microscopy of specimens revealing herpeslike particles
    Measurement of the DNA content in cells of oral leukoplakia may be used to predict the risk of oral carcinoma.

    NOTE: Specimens obtained from lesions may demonstrate hyphae of Candida albicans, which may coexist and potentiate EBV-induced OHL.

    ♦ NONPHARMACOLOGIC THERAPY

    OHL is usually asymptomatic and requires no specific therapy. It may resolve spontaneously and has no known premalignant potential.

    ♦ ACUTE GENERAL Rx

    Highly active antiretroviral (HAART) therapy has considerably changed the frequency of oral lesions caused by opportunistic infections in HIV-seropositive individuals.

    Topical retinoids (0.1% vitamin A) may improve the appearance of OHL-affected oral surfaces through their dekeratinizing and immunomodulation effects; however, they are expensive and prolonged use may result in a burning sensation over the treated area.

    Topical podophyllin resin 25% solution has been reported to induce resolution.

    Surgical excision and cryotherapy may help, but the lesions may recur.

    High-dose acyclovir or ganciclovir will cause lesions to resolve, but only temporarily.

  4. #4
    Asclepius1's Avatar
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    Can someone describe what is the difference between hairy leukoplakia and leukoplakia?

  5. #5
    Asclepius1's Avatar
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    anyone there?

  6. #6
    md77 is offline Newbie 510 points
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    prescribe nystatin

    I chose this ans, because,they specifically mentioned that lesion has not changed in weeks,but OHL does chage in clolr daily,or oftenly.

    In any case we first prescribe this pt nystatin to rule out Oral candidiasis the most common and imp D/D Of OHL (if there had been a choice to scrape the lesion and see if it is nonadherent,its more likely candida,that was my next best step)

    Since OHL is not premalignant lesion,howevr it is biopsied to rule out dysplasia and SCC but ther r no risk factors in Q and also its never first step.

    the source that helped me making this opinion is,
    http://www.emedicine.com/med/topic938.htm

    Goodluck

  7. #7
    AUCMD2006's Avatar
    AUCMD2006 is offline Ultimate Member 6129 points
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    could be

    could be just an aphtous ulcer though most are painless but if on b blocker and diabetic can't feel it?
    AUCMD2006
    Bored Certified

  8. #8
    Unregistered Guest

    leukoplakia

    b. biopsy the lesion b/c leukoplakia can lead to squamous cell CA.

  9. #9
    Unregistered Guest
    i read at emedicine that OHL is not precanserous.

    plz moderator or somebody correct it, hwo knows for sure,appreciate

  10. #10
    elcubano is offline Junior Member
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    leukoplakia = possible scc
    hairy leukoplakia = EBV

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