hi I'm Jared gardener and I'm here today
with my dramatic pathology ed Fulton and
you guys can thank ed for selecting this
nice case to discuss today it always
picks the esoteric and difficult things
which is good for me because it makes me
continue to learn even in practice mmm
so what we're looking at today is a
biopsy from a white shaggy lesion on the
border of the tongue and it would be
bilateral and and white kind of plaques
that have these vertical lines and it
gives it this kind of shaggy or hairy
appearance so as you may have already
noticed from the clinical history that
this is the the typical history of oral
hairy leukoplakia which is what this
lesion is we're looking at today and
this is a lesion that's caused by
epstein-barr virus and it's usually seen
in the setting of hiv-positive patients
although it can be seen in other types
of immunosuppression or immunodeficiency
and rarely has been reported in healthy
individuals so what we see from
lower-power are a couple things number
one the surface of the mucosa is made of
a thick layer of para keratin the nuclei
are retained here in the keratin and
it's got kind of a slightly shaggy
surface now there's also some purple
bacterial colonies here I'll show you a
closer look in a minute and that's
probably due to secondary biting or
chewing on the lesion that's a term
called Morse Acacio that you can see on
the cheek or the tongue from bite injury
over time that gets colonized by
bacteria and that's probably a secondary
finding here but the thing to pay
attention to is the thick layer of para
keratin and then just beneath it the
keratinocytes of the squamous mucosa let
me turn the light down a little if you
can see they have a pale kind of a pale
cytoplasm and they're kind of enlarged
they have what we call ballooning change
or evacuated ballooning cytoplasm I
think that this feature can be sometimes
difficult to tell apart from actual
normal squamous mucosa in the mouth
because squamous mucosa tends to have a
glycogen ated upper portion of the the
upper layers of the squamous mucosa tend
to have extra glycogen and they look
more pale to begin with so I think
sometimes it can be a little bit hard to
be sure if something's really ballooning
the general
but that's what's described in this
lesion is the thick layer of para
keratin and then a zone or a band of
ballooned pale keratinocytes just
beneath that but the real key to the
diagnosis here is going closer and
looking at the nuclear features so
remember that I just said that what what
causes oral hairy leukoplakia is
epstein-barr virus and if you remember
epstein-barr virus is in the human
herpes virus family and so it has some
similar viral cytopathic effect changes
in the nuclei of the keratinocytes
similar to what you would see in other
forms of herpetic infection the one
particular thing that you will notice
though about epstein-barr virus
infection is it makes the the chromatin
push out to the periphery of the nucleus
and not just condense there like you'd
see in herpes simplex or
varicella-zoster but in fact it makes
not just not just a line around the
peripheral of the nuclear membrane but
little beads little condensed clumps of
chromatin that show up is these little
beaded dots that align around the
surface or I'm excuse me right
underneath the nuclear membrane let me
see if I can get one closer power here
to show you yeah beautiful so this is a
really nice example of that effect this
beaded condensation of okay sorry it's
really hard to move the slide around of
6dx
okay this beaded condensed little clumps
of chromatin that have a tendency to
coalesce around the periphery of the
nucleus just underneath the nuclear
membrane so that's the characteristic
cytologic finding that you'll see it
even on exfoliant of cytology you can
see this same type of viral cytopathic
effect that helps confirm the diagnosis
and again it's always important to make
sure like with anything in in pathology
that it fits with the clinical
impression right if the patient has
shaggy white plaques on the periphery on
the bilateral lateral edges of the
tongue and the patient has HIV or
immunosuppression then that's good
outside of that setting probably talk to
the oral surgeon or the dentist or the
dermatologist to find out if the idea of
oral hairy leukoplakia fits with their
clinical impression so if in doubt it's
all
is good to double-check and make sure
that something fits clinically before
making a diagnosis and again just really
nice example of that beaded condensed
chromatin and as the chromatin gets
pushed out to the periphery it leaves a
kind of glassy slightly eosinophilic
area in the center of the nucleus and
again that's similar to what you see in
other types of herpes virus infections
and that's that Cowdrey type a nuclear
inclusion so you can kind of see it a
little bit here this kind of glassy
homogeneous pale eosinophils central
areas in the nucleus but I think there's
some area on this slide I think that has
it even better let me see if I can find
it sometimes it's hard to show these
subtle nuclear things on video but I'll
try my best I think here I think here
you can kind of see it it's a little
hazy but you can see that the central
the center of the nucleus gets kind of
homogeneous and eosinophils and that's
from a mixture of the viral particles
blending in together with the leftover
DNA in the cell and it makes that kind
of homogenized Zone in the center of the
nucleus so those correspond to the the
viral particles and are kind of a form
of Cowdrey type a nuclear inclusion so
that's oral here a leukoplakia and one
thing that is important to remember also
the term leukoplakia just means a white
plaque like lesion it's a clinical term
but oftentimes leukoplakia implies
underlying swamis dysplasia it doesn't
it doesn't mean that by definition but a
lot of times in people's minds I think
it gives equated with leukoplakia maybe
is atypical maybe dysplastic maybe pre
malignant and I think that that's one
problem with the name oral hairy
leukoplakia is that it makes you think
of other types of leukoplakia that might
be dysplastic or pre malignant and
that's not the case here there's not
cytologic atypia or dysplasia and this
is not a pre malignant lesion it's not
associated with squamous cell carcinoma
development to my knowledge so even
though the name says leukoplakia just
remember that this is a distinct entity
unrelated to other forms of leukoplakia
and also remember that leukoplakia is a
clinical term and by itself it means
it's a white plaque like area on the
Swayne
mucosa in the mouth it doesn't
necessarily mean that there's a pre
malignancy or dysplasia so let's go over
to that one area that shows a little bit
of that biting or chewing effect there
Morse akashi which again is a secondary
phenomenon here and you can see that the
parrot keratosis becomes very ragged and
has this kind of frond like surface and
it's coated with a thick layer of purple
and it's not going to show up real well
on the video unfortunately because
they're so tiny they kind of blur
together on the video screen maybe if I
turn the light up but you can see on a
microscope that this this thick purple
area is composed of numerous tiny coxide
bacteria so these are just layers of
colonization of coxide bacteria on this
damaged ragged surface and this is
called morse Acacio and I think the if I
recall correctly from my oral pathology
rotation back in fellowship Morse Akashi
abou quorum if it's on the inner cheek
morse Acacio ling Gorem if it's on the
tongue and if you find oral pathology
hard you're in good company because i
find it challenging to and i had the
privilege of getting to spend a whole
month with some really excellent oral
pathologists susan mueller and steve
Budnick and kelly magliocca and they
were fantastic people that that taught
me a lot and yet also helped me to
realize just how much there is about
oral pathology that i still do not know
so thick layer of parekura ptosis
underlying band of pale balloons
keratinocytes peripheral margination of
chromatin with these little beaded
appearance and central eosinophils
homogenized nuclear inclusion oral harry
leukoplakia epstein-barr virus
associated and usually in the setting of
HIV so i hope you found that useful and
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