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Case Report

Oral manifestations leading to the diagnosis of

acute lymphoblastic leukemia in a young girl
Silva BA, Siqueira CRB1, Castro PHS,
Arajo SS, Volpato LER1

Abstract
Background: oral complications may be leukemias first
presentation. Aim: to present a case of a young girl with
a swelling on the face that led to the diagnosis of acute
lymphoblastic leukemia is reported. Results: a 10-year old
anemic girl was referred for evaluation and treatment of a
swelling at the left-nasolabial region. Symptoms reported
(tiredness, poor appetite, fever, lethargy, and musculoskeletal
pain) and clinical findings (enlargement at the presternal
region and brownish stain in the lumbar region) led to the
suspicion of a hematopoietic malignancy. The diagnosis of
lymphoblastic leukemia was attained after specific examination
conducted by the pediatric oncologist and hematologist.
Conclusion: dentists must be able to clearly recognize oral
physiological characteristics, and, when identifying changes
of normalcy, to fully investigate it requesting additional tests
or referring the patient to specialized professionals.

Key words
Acute, diagnosis, leukemia, leukemia, lymphoblastic,
lymphoid, oral manifestations

Department of Dentistry, Mato Grosso Cancer Hospital,

1
Master's Program in Integrated Dental Sciences, University of
Cuiab, Cuiab, MT, Brazil
Correspondence:
Prof. Luiz Evaristo Ricci Volpato, Hospital de Cncer de Mato
Grosso Departamento de Odontologia, Av. Historiador Rubens
de Mendona, 5500, Bairro Morada da Serra, CEP: 78055-500
Cuiab, MT, Brazil. E-mail: odontologiavolpato@uol.com.br
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DOI:
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that lead to the diagnosis of acute lymphoblastic

leukemia.

Case Report
Introduction
Leukemia represents one-third of all childhood cancers.
Seventy five percent of those pediatric patients suffer
from acute lymphoblastic leukemia (ALL),[1] which may
be of B or T cell origin.[1,2]
Oral complications occur frequently in leukemia and
may, indeed, be the presenting feature of the disease[3]
or of its relapse.[1] Oral manifestations usually arise
from an underlying thrombocytopenia, neutropenia,
or impaired granulocyte function, or may result from
direct leukemic infiltration.[1]
This paper describes the case of a young girl with occult
hematological malignancy referred for dental evaluation
166

A 10-year-old girl was referred to the Municipal

Emergency Hospital of Cuiab for treatment of
anemia. The responsible physician requested the oral
and maxillofacial surgeon to evaluate a swelling in the
left-nasolabial region of the patient. The surgeon then
referred her to the Department of Dentistry at the
Mato Grosso Cancer Hospital to speed up the evaluation
and consequent treatment.
The symptoms reported by the patient during the
interview were: tiredness, poor appetite, fever, lethargy,
and musculoskeletal pain.
At the physical extra-oral examination, it was observed
pale skin, facial asymmetry with swelling on the leftnasolabial region [Figure 1a]. Another volumetric

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Silva, et al.: Oral manifestations of ALL in a young girl

enlargement was observed at the presternal region,

hard and painless to palpation, with approximately 30
mm at its largest diameter [Figure 1b]. A brownish
stain confined to about 20 mm in the lumbar region
was also perceived [Figure 1c].
The intraoral examination showed a discrete swelling
of fibrous consistency, painless to palpation, measuring
approximately 30 mm, involving the area between
the upper-right central incisor to the left canine with
undefined limits leading to the relaxation of the
gingival-labial sulcus [Figure 2].
Requested laboratory exams included blood and
coagulation tests, which showed a hematological
picture of anemia and neutrocytic leukopenia.
Imaging tests did not show any significant changes
[Figure 3].
Given the signs and symptoms, it was suspected that
the patient could present a hematopoietic malignancy.
She was then referred for evaluation by the pediatric
oncologist and hematologist, who requested specific

tests such as myelogram, bone marrow biopsy, and

immunophenotyping.
The morphology and immunohistochemistry led
to the diagnosis of lymphoblastic leukemia of
precursor cells with T-cell phenotype and proliferation
rate of 30%.

Comment
Acute lymphoblastic leukemia is the most common
leukemia of childhood. It is a malignancy characterized
by the uncontrolled clonal proliferation of a transformed
lymphoblast with overgrowth and displacement of
normal bone marrow precursors.[3] The etiology of
leukemia remains speculative, although a number of
factors have been implicated, including: exposure to
ionizing radiation or electromagnetic fields, treatment
with cytotoxic drugs, and viral infections.[1] Its initial
presentation is nonspecific and may reflect various
non-neoplastic and neoplastic processes such as
idiopathic thrombocytopenic purpura, Epstein-Barr
virus infection, juvenile rheumatoid arthritis, aplastic

Figure 1: (a) Volumetric enlargement in the left nasolabial region. (b) Hard tumor in the presternal region. (c) Brownish stain in lumbar region

Figure 2: Discrete swelling from the upper right central incisor to the
upper left canine

Figure 3: Occlusal radiograph with no sign of abnormality

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Silva, et al.: Oral manifestations of ALL in a young girl

anemia, and hypereosinophilic syndrome to name a

few.[3] As the disease progresses, anemia, neutropenia,
and thrombocytopenia from failed hematopoiesis
dominates the hematologic picture. [1-3] These are
related to the co-abrupt onset of clinical symptoms
such as fatigue, fever, petechia, ecchymosis, epistaxis,
and bleeding.[3] Osseous changes, in association
with the initial onset of leukemia, have been well
documented.[1,4] Other symptoms include aseptic
bone necrosis, lymphadenopathy, hepatosplenomegaly,
respiratory discomfort, visual disturbances, and
central nervous system manifestations (i.e., headache,
vomiting, and nerve palsy).[2]

that the diseases are of local origin. Initial laboratory

tests may be quite normal or show subtle changes that do
not target for cancer. It is essential for the professional
to be able to clearly recognize oral physiological
characteristics, and, when identifying a change of
normalcy, to fully investigate it requesting additional
tests or referring the patient to specialized professionals.

Oral manifestations usually arise from an underlying

thrombocytopenia, neutropenia, or impaired function. It
has been described a number of leukemic-induced oral
changes including: pain, gingival swelling (especially if
platelet counts are below 10 000 to 20,000/mm3), ulcers,
bleeding, ulceration, bony changes, and infections.[1-3,5]
Another manifestation is the infiltration of leukemic
cells in an area of the oral mucosa (chloroma).[2,3]

References

The complete blood count may be normal in early

stages, or possibly reveal normochromic normocytic
anemia and thrombocytopenia, needing to repeat
the blood test to detect early changes suggestive of
leukemia.[1] White blood cell count is occasionally very
high, but often normal or decreased.
The dentist, and mainly the pediatric dentist, plays a
fundamental role in the early diagnosis of leukemia.
Frequently the first signs of the disease occur in the
mouth, and patients usually seek dental care believing

168

Acknowledgement
The work was carried out at the Department of Dentistry
and Department of Pediatric Oncology - Mato Grosso
Cancer Hospital.

1. Benson RE, Rodd HD, North S, Loescher AR, Farthing PM,

Payne M. Leukaemic infiltration of the mandible in a young
girl. Int J Paediatr Dent 2007;17:145-50.
2. Burke VP, Startzell JM. The leukemias. Oral Maxillofacial Surg
Clin N Am 2008;20:597-608.
3. Aronovich S, Connolly TW. Pericoronitis as an initial
manifestation of Acute Lymphoblastic Leukaemia: A Case
Report. J Oral Maxillofac Surg 2008;66:804-8.
4. Prognostic factors in children and adolescents with Acute
Lymphoblastic Leukaemia. Rev Bras Sade Matern Infant
2007;7:413-21.
5. Fatahzadeh M, Krakow AM. Manifestation of acute monocytic
leukaemia in the oral cavity: A case report. Spec Care Dentist
2008;28:190-4.
How to cite this article: Silva BA, Siqueira C, Castro P, Arajo
SS, Volpato L. Oral manifestations leading to the diagnosis of
acute lymphoblastic leukemia in a young girl. J Indian Soc Pedod
Prev Dent 2012;30:166-8.
Source of Support: Nil, Conflict of Interest: None declared.

JOURNAL OF INDIAN SOCIETY OF PEDODONTICS AND PREVENTIVE DENTISTRY | Apr - Jun 2012 | Issue 2 | Vol 30 |