Australian Doctor Australian Doctor 30th June 2017 | Page 15

Oral pathology
Dr Anna Talacko
Changes in the hard palate
HAROLD, 40, has been referred for
further assessment of hard palate
changes noted by his dentist. He is
asymptomatic and has no previous
history of oral pathology.
Harold has no history of serious
medical illness, but has been unwell
Discussion
Spinal epidural lipomatosis is the pathological over-
growth of physiological fat tissue in the extradural
space leading to spinal cord compression. It is uncom-
mon, and has been reported in inflammatory bowel
disease only twice previously. 1,2
Spinal epidural lipomatosis can be a complica-
tion of long-term corticosteroid treatment (55.3%
of cases), but rarely presents acutely or in as short
a period of treatment as in our patient.3,4 Around
24.5% of cases are attributed to obesity alone, and
the increase in background extradural fat in obese
people might predispose them to more rapid onset of
corticosteroid-induced spinal epidural lipomatosis. 3,5
Nearly 17% of cases have no identifiable cause and
we are unaware of any previous reports of cyclo-
sporin associated with spinal epidural lipomatosis.
One-quarter (25%) of reported cases of spinal
Q. Describe the clinical
appearance of the hard
palate.
a. Brown melanin
pigmentation with a
superficial ulcer on the
right side
b. An ulcerated soft
tissue mass in the right
posterior hard palate
near the midline
c. Grey/black
pigmentation of the
posterior hard palate
with an ulcerated soft
tissue mass on the
right side
d. Dusky red/purple
pigmentation and
diffuse soft tissue
swelling of the
right and left lateral
posterior hard palate
with a region of
ulceration to the right
of the midline
A. The answer is d.
The pigmentation is
more marked in the
left posterior hard
palate. There is diffuse
nodularity/swelling
on both sides of the
hard palate but more
prominent on the right.
References on request.
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Dr Talacko is an oral medicine
specialist, and an oral and maxillofacial
pathologist in Melbourne, Victoria.
THE QUIZ
epidural lipomatosis associated with steroid use are
treated conservatively, with removal of exogenous
steroids and weight loss. 3
Surgical laminectomy with debulking has been
more frequently reported as an alternative treatment
(75% of cases) and has a similar reported response
rate to conservative management (77%). 3
Few cases have been reported of patients with spi-
nal epidural lipomatosis as extensive as in our patient,
which is noteworthy both because of the extent of
disease on MRI and the speed of onset of symptoms.
Steroids remain the mainstay of treatment in
many medical conditions, and in acute severe ulcer-
ative colitis they can be life-saving. However, in the
setting of an increasingly obese population, spinal
epidural lipomatosis is an important — albeit rare
— complication to keep in mind.
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with a persistent URTI and cough for
the past three months. He is a non-
smoker and his alcohol intake is not
excessive.
Q. Which blood tests
may be helpful?
a. FBC with differential
cell count
b. Fasting blood glucose
and autoimmune
markers
c. Syphilis serology,
hepatitis B and C, and
HIV antibody status
d. Iron studies, vitamin
B12 and red blood cell
folate
A. The answer is a and c.
The differential diagnosis
includes lymphoma
and Kaposi’s sarcoma.
Both may be pigmented
and present as diffuse
swellings in the posterior.
A lymphoma may have a
bluish hue while Kaposi’s
sarcoma often has dusky
purple pigmentation.
Q. What is the
most appropriate
investigation?
a. An oral swab
b. CT scan
c. Incisional biopsy
d. Fine needle aspiration
biopsy
A. The answer is c. The
clinical appearance is
thanks to William Harvey’s discovery of the
circulatory system in 1628 and subsequent
animal-to-animal transfusions, French
physician Dr Jean-Baptiste Denys decided
to replenish his patient’s blood supply.
Conveniently, most people believed that
animals were soulless, allowing them to
justify cruel experiments and the emittent
animal’s death. But not everyone agreed.
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transfusion would also transfer the soul of
the donor creature, leading to chimeras or
hybrid monsters.
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not diagnostic. Tissue
submitted for formalin-
fixed histopathological
assessment will
most likely require
staining with a panel of
immunohistochemical
markers to help identify
the tumour cell type. If
lymphoma is suspected,
fresh tissue wrapped
in saline-soaked gauze
should also be submitted
for genetic studies.
Q. What is your clinical
differential diagnosis?
a. Melanosis with
traumatic ulceration
b. Lymphoma
c. Melanoma
d. Kaposi’s sarcoma
The correct answer is
b, c and d. In this case,
the biopsy showed
features consistent with
Kaposi’s sarcoma. The
patient’s respiratory
infection was further
investigated and found
to be pneumocystis
pneumonia. A more
detailed social history
revealed Harold is a man
who has sex with men.
and so chose animals associated with
positive, therapeutic characteristics,
including cows, dogs and sheep.
The transfusions that followed had less
positive outcomes until, in 1818, British
obstetrician Dr James Blundell successfully
transfused the blood of a man to his wife,
who had haemorrhaged during childbirth.
Finally, the discovery of blood groups
in 1901 and a greater understanding of
compatibility helped make human donation
a safer, more viable practice — and
animals everywhere breathed a collective
sigh of relief.
Sophie Attwood
30 June 2017 | Australian Doctor |
15