Clinically Unusual Pigmented Lesion of the Buccal Mucosa: A Case Report

We present a rare clinical case of a 64-year-old patient with a pigmented lesion localized in the left buccal mucosa. Subjective complaints of slight pain and discomfort in the process of eating and increased sensitivity when consuming hot food were reported. According to the information provided by the patient, the lesion had progressively increased in size. A history of previous dental manipulations was reported, namely, the extraction of teeth with amalgam obturations in the left half of the maxilla as per relevant indications. During the intraoral examination, a flat, black-colored lesion, 0.4 cm in diameter, with well-defined borders was observed in the buccal mucosa. Teeth 25, 26, and 27 were previously extracted five to seven years ago. An orthopantomography was performed as a routine procedure. It did not show any presence of X-ray contrast areas that could explain the symptoms of the patient. The symptomatic nature of the lesion as well as the negative radiological findings prompted surgical treatment and excisional biopsy with subsequent histological evaluation to rule out oral malignancy. An excision was performed. During the follow-up examination in the next eight days, all the symptoms of the patient were gone. The conclusion of the pathology report was "histological findings and clinical data consistent with amalgam tattoo". The amalgam tattoo is the most frequent iatrogenic pigmented lesion of the oral mucosa, which results from the implantation of amalgam particles in the soft tissues and it is usually asymptomatic. In this case, no surgical treatment is needed. However, in some rare cases, like the one we are presenting, some symptoms can occur and complicate the diagnostic process. In these cases, the complete excision of the lesion is to be performed with subsequent histological evaluation. The atraumatic intervention of teeth, obturated with definitive amalgam fillings, is a main factor for preventing this kind of pigmentation of the oral mucosa.

Prevalence of oral mucosal lesions in human immunodeficiency virus-infected children attending the Pediatric Infectious Diseases Clinic in Cape Town

Objective

Investigation of the prevalence of oral mucosal lesions in human immunodeficiency virus (HIV)‐infected children undergoing highly active antiretroviral therapy (HAART).

Materials and Methods

Cross‐sectional study of 66 HIV seropositive children, comprised of 28 (42.4%) females and 38 (57.6%) males (average age of 6 years). Study participants all required data regarding CD4+ T‐helper cell counts and the viral load. All participants underwent an orofacial clinical examination by calibrated clinicians. Associations between the presence of oral mucosal lesions, CD4+ cell counts, and viral load were analyzed using Poisson regression.

Results

The prevalence of oral manifestations was detected in 21 children (31.8%). Oral lesions were detected in 16 children with viral load copies <50 cells/mm³ and 22 children with CD4+ counts >500 cells/mm³. Predominant lesions identified included angular cheilitis (36.7%), candidiasis (13.3%) and atypical oral ulcers (13.3%). The presence of one lesion was the most prevalent represented by 19 children. Oral lesions in relation to the CD4+ counts >500 resulted in; 14 children with one oral lesion, 5 with two lesions and 3 with three oral mucosal lesions. The other half of this CD4+ count patient group presented with no oral mucosal lesions. Oral lesions in relation Viral load copies <50 resulted in; 9 children with one oral lesion, 3 with two oral mucosal lesions and 4 with three oral mucosal lesions. The other half of this Viral load patient group presented with no oral mucosal lesions. No significant correlations were established between the presence of oral mucosal lesions and low CD4+ counts (p = 0.715) nor with high viral load counts (p = 0.638).

Conclusion

HIV‐related oral mucosal lesions still presented in the participants despite management with HAART. Based on the results, CD4+ counts and viral load does not appear to be suitable markers of orofacial involvement in children.

Molecular characterization of recent HoBi-like pestivirus isolates from cattle showing mucosal disease-like signs in India reveals emergence of a novel genetic lineage

Natural infections with HoBi-like pestivirus (HoBiPeV) have been detected in cattle in South America, Europe and Asia with a range of clinical manifestations including fatal mucosal disease (MD). In India, although HoBiPeV in cattle has been reported, there is no information on currently circulating HoBiPeV strains and associated severe clinical disease. Between September 2018 and December 2019, suspected cases of bovine viral diarrhoea with severe disease in cattle were noticed in farmers' small holdings in Tamil Nadu State. To determine the extent of pestivirus infection, blood, serum, nasal or oral swab samples of 46 cattle from 18 villages were tested. Based on the real-time RT-PCR, antigen ELISA and nucleotide sequencing results, pestivirus was detected in nine cattle from eight villages in two districts and all pestiviruses were identified as HoBiPeV. All nine HoBiPeV-infected cattle displayed clinical signs resembling MD and HoBiPeV isolates (n = 9) obtained were characterized at genetic and antigenic level. Phylogenetic analyses based on 5'-untranslated regions (5'-UTR), N^pro and combined 5'-UTR-N^pro gene sequences revealed that eight HoBiPeV isolates clustered into a clade, distinct from all reported HoBiPeV clades (a-d), whereas one belonged to HoBiPeV-d clade, thus providing evidence of emergence of a novel HoBiPeV clade (e). This was also supported by HoBiPeV-e clade-specific amino acid substitutions in N^pro and the antigenic reactivity patterns. The study demonstrates the existence and independent evolution of five HoBiPeV clades (four main clades) globally and surprisingly three exclusive to India. Also we confirm first HoBiPeV occurrence in southern India with predominant prevalence of HoBiPeV-e strains. Besides demonstrating increased HoBiPeV genetic diversity, here we show association of HoBiPeV with severe clinical disease involving fatalities highlighting impact of HoBiPeV on cattle health. The emergence of a novel HoBiPeV lineage provides new insights on global HoBiPeV epidemiology and genetic diversity reiterating the need for continuous monitoring of HoBiPeV in India.

Candida albicans and candidalysin in inflammatory disorders and cancer

As our understanding of mycology progresses, the impact of fungal microbes on human health has become increasingly evident. Candida albicans is a common commensal fungus that gives rise to local and systemic infections, particularly in immunocompromised patients where it can result in mortality. However, C. albicans has also been quietly linked with a variety of inflammatory disorders, to which it has traditionally been considered incidental; recent studies may now provide new aspects of these relationships for further consideration. This review provides a novel perspective on the impact of C. albicans and its peptide toxin, candidalysin, on human health, exploring their contributions to pathology within a variety of diseases.

Mucosal Type of Chronic Suppurative Otitis Media and the Long-Term Impact on Hearing Loss

Introduction

Worldwide the chronic suppurative otitis media (CSOM) is one of the most common infectious diseases in childhood and is a common cause of impaired hearing. The disease remains a challenging entity for the healthcare system of resource-limited nations despite the advances in modern medicine. The nature of hearing loss in CSOM is mainly conductive, the sensorineural hearing loss (SNHL) is also reported in such patients. The purpose of the study was to identify SNHL in patients with the mucosal type of CSOM and to find the impact of long-term discharging ears on bone conduction (BC) thresholds.

Methods

Patients with a diagnosis of the mucosal type of CSOM were identified from the record of ENT, Head and Neck Surgery clinic between January 2019 and January 2020. The patients were divided into three groups based on the duration of the disease: groups I, II, and III for 1-5 years, 5-10 years, and 10-15 years, respectively. Pure tone audiogram was reviewed, and data of BC was recorded for 500, 1000, and 2000 Hz. The descriptive frequency was calculated for SNHL in each group and group I was compared with other groups using a chi-square test. The mean BC threshold of group I was compared with other groups using a t-test. SPSS version 26 (IBM Corp., Armonk, New York) was used for statistical analysis.

Results

A total of 154 patients were included in the study. There were 73 males and 81 females. The mean age was 26 years. The minimum age was 12 years and the maximum age was 58 years. Active ear discharge was the presenting complaint in 84 patients. The right ear was involved in 88 patients, and the left ear was involved in 66 patients. SNHL was present in 30 out of 154 patients, i.e., 19.5%. The number of patients in each of the groups I, II, and III was 95, 28, and 31, respectively. The group I was compared with group II using the chi-square test, the p-value was found not significant, i.e., >0.05. The group I was then compared with group III using the same statistical test, and the p-value was found significant, i.e., <0.05.

The mean BC threshold for an average of three speech frequencies for each of the three groups was 16.9, 18.7, and 22.9, respectively. The mean BC threshold of group I was compared with that of group II using a t-test, and the p-value was found not significant, i.e., >0.05. The mean BC threshold of group I was then compared with that of group III using a t-test, and the p-value was found significant, i.e., <0.05.

Conclusions

The findings of our study reproduce the presence of SNHL in a sizable proportion of the patients with a mucosal type of CSOM. Furthermore, the elevation of the BC threshold also appears statistically significant on analysis in association with the protracted duration of CSOM, highlighting the adverse impact of delaying the surgical repair. However, the clinical importance remains unclear because the maximum losses in the BC threshold seen in the patients are not severe enough to necessarily make them hard of hearing. Nevertheless, these statistically significant results influence clinical thought process and measures for an early remedy, including surgery, and need to be considered in time to prevent progressively worsening hearing loss in such cases.

Anti-p200 Pemphigoid: A Systematic Review

The many clinical aspects of anti-p200 pemphigoid are not well-characterized. We aimed to analyze and correlate known existing data on the epidemiological, clinical, histological, and immunological features of anti-p200 pemphigoid. We performed a review using Medline, Embase, and Web of Science databases (1900–2018). Case reports and series of patients were included. A total of 68 eligible studies that comprised 113 anti-p200 pemphigoid patients were included in the qualitative analysis, where there was a mean age of onset of 65.5 years. All patients presented with bullae/vesicles, and 54.3% had urticarial plaques. A similarity to bullous pemphigoid was reported in 66.1% of cases, but palmoplantar (51.4%), cephalic (40.3%), and mucosal (38.5%) involvement, besides frequent development of scars/milia (15.7%), were reported. Autoantibodies against recombinant laminin γ1 were detected in the sera of 73.1% of patients. Psoriasis was present in 28.3% of anti-p200 pemphigoid patients, particularly among Japanese patients (56.4%). The incidence of pustular psoriasis in this subgroup, was significantly greater than in the normal population. In conclusion, the diagnosis of anti-p200 pemphigoid may be suspected when a subepidermal autoimmune blistering disease develops in a younger age group, along with significant acral and cephalic distribution and mucosal involvement.

Platelet-to-lymphocyte Ratio and Neutrophil-to-lymphocyte Ratio Predict Mucosal Disease Severity in Ulcerative Colitis

Background

We investigated the sensitivity of neutrophil to lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR), as well as a combination of NLR and PLR to predict endoscopic disease severity based on mucosal assessment in ulcerative colitis (UC).

Methods

The study group consisted 104 patients with active UC, 104 patients in remission, and 105 healthy individuals. Disease activity was described with Rachmilewitz endoscopic activity index (EAI). Curve analysis was used to determine the optimal cutoff values of NLR and PLR for obtaining remission. The patients with both PLR and NLR values higher than the cutoff values were coded as »high risk,« those with one parameter higher were coded as »moderate risk«, those with both parameters lower than the cutoff values were coded as »low-risk« patients.

Results

The mean NLR and PLR values in the endoscopically active disease group were higher than the others, with higher values in the endoscopic remission group compared with the control group (p<0.001). Rachmilewitz EAI in high-risk patients was significantly higher than that in others (p<0.001). In Cox regression analyses, moderate and high risk, high erythrocyte sedimentation rate and high EAI were found as independent predictors of endoscopic active disease.

Conclusions

This is the first study that investigated the use of NLR and PLR combination to assess endoscopic disease severity in UC. Either high NLR or PLR levels can predict active endoscopic disease. However, the use of these parameters in combination is more accurate in evaluating mucosal disease and inflammation in UC.

Natural Outbreak of BVDV-1d-Induced Mucosal Disease Lacking Intestinal Lesions

Bovine viral diarrhea virus (BVDV) belongs to the Pestivirus genus, which is further divided into subgenotypes (1a-1u and 2a-c). When persistent infection occurs, the calf will be immunotolerant to BVDV and possibly develop mucosal disease. This study describes an outbreak of BVDV-1d-induced mucosal disease lacking intestinal lesions. Eleven calves presented with anorexia, sialorrhea, lameness, recumbency, and death. Three calves were necropsied, showing ulceration of the interdigital skin and the oral and nasal mucosa; linear ulcers in the tongue, esophagus, and rumen; and rounded ulcers in the abomasum. Microscopically, mucosa and skin had superficial necrosis, with single-cell necrosis and vacuolation in epithelial cells, and severe parakeratosis. Immunohistochemistry (IHC) showed BVDV antigen in the cytoplasm of epithelial cells in skin and mucosa. All 11 dead calves were positive upon reverse transcription-polymerase chain reaction (RT-PCR) for the detection of Pestivirus along with another 11 live calves from the herd, which were positive again by RT-PCR and IHC after a 4-week interval. Sequencing of the 5' untranslated region and N-terminal protease showed that viruses from these 22 calves were homologous and of subgenotype BVDV-1d. Cytopathic BVDV was isolated from 8 of 11 dead calves, but only noncytopathic BVDV was isolated from the 11 live animals. The findings indicate that this was an outbreak of mucosal disease caused by BVDV-1d, with high morbidity, and lesions restricted to the upper alimentary system and skin and absent from intestine. Thus, the epidemiological and pathological features in this form of mucosal disease may be similar to vesicular diseases, including foot and mouth disease.

Expansion of inflammatory innate lymphoid cells in patients with common variable immune deficiency

BACKGROUND

Common variable immunodeficiency (CVID) is an antibody deficiency treated with immunoglobulin; however, patients can have noninfectious inflammatory conditions that lead to heightened morbidity and mortality.

OBJECTIVES

Modular analyses of RNA transcripts in whole blood previously identified an upregulation of many interferon-responsive genes. In this study we sought the cell populations leading to this signature.

METHODS

Lymphoid cells were measured in peripheral blood of 55 patients with CVID (31 with and 24 without inflammatory/autoimmune complications) by using mass cytometry and flow cytometry. Surface markers, cytokines, and transcriptional characteristics of sorted innate lymphoid cells (ILCs) were defined by using quantitative PCR. Gastrointestinal and lung biopsy specimens of subjects with inflammatory disease were stained to seek ILCs in tissues.

RESULTS

The linage-negative, CD127(+), CD161(+) lymphoid population containing T-box transcription factor, retinoic acid-related orphan receptor (ROR) γt, IFN-γ, IL-17A, and IL-22, all hallmarks of type 3 innate lymphoid cells, were expanded in the blood of patients with CVID with inflammatory conditions (mean, 3.7% of PBMCs). ILCs contained detectable amounts of the transcription factors inhibitor of DNA binding 2, T-box transcription factor, and RORγt and increased mRNA transcripts for IL-23 receptor (IL-23R) and IL-26, demonstrating inflammatory potential. In gastrointestinal and lung biopsy tissues of patients with CVID, numerous IFN-γ(+)RORγt(+)CD3(-) cells were identified, suggesting a role in these mucosal inflammatory states.

CONCLUSIONS

An expansion of this highly inflammatory ILC population is a characteristic of patients with CVID with inflammatory disease; ILCs and the interferon signature are markers for the uncontrolled inflammatory state in these patients.

An outbreak of mucosal disease in a dairy herd

An outbreak of mucosal disease (MD) was studied in a dairy herd, comprising 12 cows, 9 heifers and 18 calves. During a period of 1 month, six 5 to 8 month-old calves showed typical signs of MD. They all died or were killed in extremis after 2-8 days with progressively worsening clinical signs. Post mortem lesions were examined in one calf. Non-cytopathogenic MD virus was isolated from serum or tissues from 3 clinically affected calves and from 1 healthy heifer. All cows and heifers except for the viremic one possessed neutralizing antibodies against bovine pestivirus. According to the current MD-pathogenesis concept, the affected calves were probably infected transplacentally during the first half of foetal life with pestivirus from the persistently infected heifer in the herd.