Open Journal of Stomatology, 2013, 3, 507-509 OJST Published Online December 2013 (
Oral ulcerations as the first manifestations of acute
leukemia: A case report
Somayeh Alirezaei1, Mahin Bakhshi2, Jamileh -Bigom Taheri2, Ahmad R. Mafi3*, Omid Moghaddas4
1Department of Oral and Maxillofacial Medicine, Dental School, Islamic Azad University, Tehran, Iran
2Department of Oral and Maxillofacial Medicine, Dental School, Shahid Beheshti University of Medical Sciences, Tehran, Iran
3Jorjani Cancer Center, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
4Department of Periodontology, Dental School, Islamic Azad University, Tehran, Iran
Email: *
Received 20 November 2013; revised 21 December 2013; accepted 31 December 2013
Copyright © 2013 Somayeh Alirezaei et al. This is an open access article distributed under the Creative Commons Attribution Li-
cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Acute myeloblastic leukemia (AML) is a highly fatal
malignant bone marrow disease. Physicians, dentists
and all other healthcare professionals should be
aware of sinister oral signs and symptoms in order to
early diagnosis and referral of patients. Here we re-
port a case of AML who presented with oral ulcers.
Ulcers developed after a parrot bite, which initially
misled the physicians. Unfortunately our patient did
not survive, but early diagnosis and prompt investi-
gation and treatment can be life-saving in many other
similar cases.
Keywords: Acute Leukemia; Oral Ulcers
A 48-year-old female presented to the General Dental
Clinic of our hospital with chief complaint of painful
ulcers in gingiva and tongue that had developed three
weeks before. The lesion had started as a small ulcer in
her tongue, but gradually enlarged and after a couple of
days gingival ulcers developed.
On history taking, she gave a history of lethargy, mild
fever and slight weight loss. She also mentioned that she
kept a parrot in her house and she often fed the bird
mouth to mouth, and remarked that the lesion first started
when the parrot accidentally bit her tongue a couple of
weeks before. Furthermore, she remarked that her sister
also fed the parrot mouth to mouth, and she had devel-
oped similar ulcers that had healed spontaneously. The
rest of past medical history was unremarkable.
Based on this history, with the primary diagnosis of a
zoonotic disease, the patient was referred to oral medi-
cine department for consultation with an oral medicine
On arrival to our department, it could be seen that she
was pale and ill. Extra-oral examination revealed swell-
ing and tenderness to palpitation of the face.
Intra-orally, bilateral palatal and lingual gingiva ap-
peared to be mildly swollen, glazed, devoid of stippling
and spongy in consistency. The color of the marginal and
papillary gingiva was dark red. Several ulcers were ob-
served on gingival and buccal mucosa. Ulcers were cov-
ered by a necrotic slough and surrounded by an erythe-
matous margin. A necrotic ulcer was also seen on left
lateral border of tongue (Figures 1 and 2).
As part of departmental routine, first we started inves-
tigating the disease with a systemic approach, and lab
tests were ordered as a part of this approach.
Haematology results revealed anemia (Hgb = 10.2
g/dL), thrombocytopenia (Plt = 49,000/mm3), and mark-
ed leukocytosis (WBC = 133,000/mm3). ESR was also
grossly elevated. Examination of the blood smear re-
vealed large cells with large nucleus with distinct nucle-
oli. Bone marrow biopsy revealed the diagnosis of acute
myelomonocytic leukemia (AML-M4).
The patient was referred to the hematology department.
Chemotherapy started, which was not successful. She
went to coma after the second cycle of chemotherapy and
passed away a couple of days later.
There are several etiologies for oral lesions and ulcers.
The majority of these lesions and ulcers are benign and
often self-limiting; therefore, the art of a physician is to
diagnose those sinister lesions that can be life-threaten-
ing. Lesions of different etiologies have different char-
acteristics, and proper knowledge of these characteristics
*Corresponding author.
S. Alirezaei et al. / Open Journal of Stomatology 3 (2013) 507-509
Figure 1. Lesion in left lateral border of tongue.
Figure 2. Lesion in right upper gingival.
is essential for health care professionals who are in-
volved in treating oral lesions. For example, while ge-
netically induced gingival overgrowth is normal colored
and firm, gingival overgrowth due to blood dyscrasias
are edematous, soft, tender to touch and show tendency
to bleed [1,2].
Oral lesions are relatively common in leukemias, as a
part of a widespread disease. However, oral ulcers and
lesions could be the first presentation of the disease [2,3].
Leukemia is a broad term covering a spectrum of dis-
eases. Clinically and pathologically, leukemia is subdi-
vided into chronic and acute forms. Chronic leukemias
involve relatively well differentiated leukocytes, are slow
in onset and typically take months or years to progress.
Hence, immediate treatment sometimes is not necessary,
and patients can be monitored for some time before
treatment to ensure maximum effectiveness of therapy
On the other hand, acute leukemias are characterized
by a rapid and uncontrolled proliferation of poorly dif-
ferentiated blast cells, for which immediate treatment is
required. They are abrupt in onset, and are aggressive
and rapidly fatal if left untreated. Oral manifestations are
more common in acute leukemias [5].
One of the sinister and fatal etiologies of oral ulcers
and lesions, is Acute Myeloid leukemia (AML), mainly
acute monocytic (M5) acute myelomonocytic (M4), and
acute myelocytic (M1, M2) leukemias. Oral lesions may
be the presenting feature of acute leukemias and are
therefore important diagnostic indicators of the disease
Most signs and symptoms of AML are caused by the
replacement of normal blood cells with leukemic cells.
They usually present with signs and symptoms of bone
marrow failure, including anemia, infection, and bleed-
ing. At first, symptoms are non-specific; such as bone
pain, joint pain, or other flu-like symptoms, and patients
usually seek medical help because of these constitutional
symptoms that have lasted more than usual. Oral cavity
usually is involved as part of a widespread disease;
however, oral ulcers can be the first presentation of the
disease which can lead physicians to make exact diagno-
sis [5].
Most of the time, the patients with an oral lesion first
consult their dentist, who—with proper knowledge and
awareness of potentially fatal etiologies—can play a vital
role in early diagnosis of the disease.
According to various reports, the most common presenta-
tion of AML in the oral cavity include gingival enlarge-
ment, local abnormal color orgingival hemorrhage, pete-
chiae, ecchymoses, mucosal ulceration and oral infec-
tions [3,6].
The fact that oral lesions are sometimes the first mani-
festation of life-threatening diseases implies that dental
professionals must be familiar with the clinical manifes-
tations of systemic diseases [1,5].
In our case, the history of feeding the bird and pres-
ence of similar oral ulcers in patient’s sister was quite
misleading and drew all attentions to a zootonic disease
as a possible cause of the disease. Unfortunately, our
patient did not survive, as the overall prognosis of AML
is poor, however, in case of a potentially curable disease,
early diagnosis of an oral lesion can be life-saving.
This case (and other similar cases) underlies the impor-
tance of oral signs and symptoms as indicators of a sys-
temic disease. Apart from physicians who generally di-
agnose acute leukemias based on systemic manifesta-
tions, dentists also can play an important role in diag-
nosing the disease, especially in patients who present
with an oral lesion as the first manifestation of the dis-
ease. Although our patient had a poor prognosis anyway,
early diagnosis and referral could be life-saving for many
other similar cases.
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