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ARTICLE
NECROTIZING S I A L O M E TA P L A S I A I N A
H I V P O S I T I V E PAT I E N T
self-limiting, benign, inflammatory dis- who is HIV positive: a case report
ABSTRACT Alessandra Dutra Silva, DDS; * Carolina Amália Barcellos Silva, DDS; Necro
mous cell carcinoma. A case report is
presented of a patient with NS who was
t
Cristiane Furuse, DDS, PhD; Rodrigo Calado Nunes e Souza, DDS, MS;
Mauro Henrique Melo da Costa, DDS; Vera Cavalcanti de Araújo, DDS,
izin
PhD
g
palate. Clinically, the lesion presented Institute and Research Center São Leopoldo Mandic, Campinas, São Paulo, Brazil; Mario Gatti
sialometaplasia in a patient
Necrotizing sialometaplasia (NS) is a
epithelium. The lesion disappeared com- Introduction ease of the minor salivary glands of the
hard palate.
pletely after 2 weeks. Necrotizing sialometaplasia (NS) was first reported by Abrams et The main
al. in 1973, as a self- significance
of the
NS lesion lies
sialometaplasia, HIV event and clinical factors, such as direct local trauma of the in the
type produced by intuba- tion, local anesthesia, violent or induced vomiting as in patients with bulimia, use fact
that it may of ill-fitting dental prosthesis, use of tobacco or cocaine, infectious processes of the
be 1 1
upper respiratory tract, and systemic disease. The ischemic changes could be the
mistaken for mucoepidermoid or squa-
the glandular tissues and their necrosis.
1 2
2
HIV positive; the lesion was located in 1
the minor salivary glands of the hard
1 2
as a deep ulcer with slightly elevated Municipal Hospital, Campinas, São Paulo, Brazil.
irregular borders and a necrotic base in *Corresponding author e-mail: alessandradutrasilva@hotmail.com
the hard palate. Histologically, the tissue
was characterized by squamous meta- Spec Care Dentist 30(4): 160-162, 2010
plasia of ducts and acini, lobular
coagulation necrosis, and pseudoepithe-
liomatous hyperplasia of the overlying
1
limiting, benign, inflammatory disease of the minor salivary glands of the hard palate.
KEY WORDS: necrotizin
g Although the etiology is not clear, it is consid ered to be associated with an ische m ic
1
2 3 4,5
6 6
7 8
result of physical, chemical, and biological blood-vessel injuries leading to infarction of
2
Clinically, NS may appear as an treatment of systemic manifestations of
asymptomatic or painful ulcer or AIDS. The patient had a history of ciga-
swelling, resembling a crater with rette smoking and alcohol consumption.
indurated edges and well-delimited His past medical history included HIV-
shapes, bilateral or unilateral, and com- positive diagnosis and irregular intake of
3

2. The histopathological features are: with the develop m e nt of resistance to
pseu d o e pitheliomatous hyperplasia of th anti-retroviral therap y. His CD4 count
e
3
of ducts and acinis, lobular necrosis with 45,000 copies/ml in 1997, and 297 cells
3
acute or chronic inflammatory infiltrate, The patient was questioned about his
and granulation tissue in or around the lifestyle and sexual behavior in order to
1
treatment within 3 to 12 weeks and transmission was probably by heterosexual
8
habits or using intravenous drugs.
He was hospitalized due to severe
A 50-year-old Caucasian man was fever with an initial diagnosis of neuro-
referred by a private practitioner to the toxoplasm. The patient was treated with
Mario Gatti Municipal Hospital in sulfonamide and pyrimethamine. He had
Campinas, Brazil, for evaluation and weight loss, dysphagia, dehydration,
160 Spec Care Dentist 30(4) 2010 ©2010 Special Care Dentistry Association and Wiley Periodicals, Inc.
doi: 10.1 1 1 1/j.1754-4505.2010.00142.x
monly located in the hard palate
. antiretroviral m e dications
since 1997,
overlying mucosa, squa mo us m etaplasi
a was 130 cells m and viral load
m
was
preservation of the lobular architecture
, mm and 48,851 copies/ml in
2007.
glands. Co m plete healing occurs withou
t clarify disease transmission. He stated tha
recurrent lesions are infrequent
. contact, but denied having
promiscuous
Case repor t headache,
dizziness, and daily cycles of

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N E C R O T I Z I N G S I A L O M E TA P L A S I A I N A H I V P O S I T I V E PAT I E N T
vomiting, and several opportunistic infec-
tions, such as oral and pharyngeal
candidosis, genital herpes, pneu m o nia,
and esophageal ulcers, in addition to the
lesion of the hard palate. The patient
received treatment for the systemic lesions
with fluconazole, sulfonamid e, acyclovir,
pyrimethamine, om eprazol, m etoclo-
pramide, folic acid, and hydrolytic
replacem ent. He was referred to the
Department of Oral and Maxillofacial
Surgery of the Mario Gatti Municipal
Hospital for treatment of the oral candido-
sis and the lesion of the hard palate.
A clinical examination revealed an
irregular ulcer with necrotic debris in the
central region, an indurated border,
m easuring 2.51.0 cm on the hard
palate und erneath the ill-fitting denture,
with slight symptomatology on palpation
present for 1 week (Figure 1A). No cer-
vical lymphadenopathy was noted. The
initial clinical diagnosis was squa m ou s
cell carcinoma. An incisional biopsy was
performed and the material was sent to
the Pathology Laboratory of S ã o
Leopoldo Mandic Institute and Research
Center, Cam pinas.
The pseu d o m e m branous oral candido-
sis was characterized by whitish plaque
that could be rubbed off, and was located Figure 1. (A) Irregular ulcer with necrotic debris in central region, an indurated border measuring
2
2.5 1.0 cm. (B) Histopathological examination revealing a fragment of mucosa exhibiting pseu-
in the oropharynx and bilateral buccal
mucosa (Figure 1 E and 1F). It was associ-
UI, 3 or 4 times daily for 15 days), which ated with burning symptom s and
did not accomplish the expected results. dysphagia. The patient was prescribed a doepitheliomatous hyperplasia (*), squamou s metapla
of salivary gland ducts (arrow), and
Then it was necessary to use a systemic
topical antifungal agent (Nystatin 100,00 0 coagulation necrosis of the acinis in the lower
portion of the speci m e n (HE 40X). (C) Lobular coag-
ulation necrosis of the acinis showing architectural preservation (HE 400X). (D) Squam ou s
m etaplasia of the ducts (HE 400X). (E and F) Bilateral pseu d o m e m branous oral candidosis in the
buccal muco sa, these white plaques could be rubbed off.
therapy with intravenous fluconazole;
plasia, lobular coagulation necrosis with Discussion 2.5 after 3 weeks, the
pseud o m e m branou
s palatal
cm. In the literature, there are mucosa. Two-months after
the the lesion was located
in the minor sali-
candidiasis had disappeared . treatment, the patient died due to com
- vary glands of the hard palate.
The biopsy speci m e n s of thed har plications from AIDS
. The lesion was clinically character-
palate revealed a fragment of mucos a ized as an irregular ulcer with necrotic
exhibiting pseu d o e pitheliomatous hyper
- debris in the central region, m easuring
2,5,8,17
preservation of the lobular architecture, NS is a rare benign, self-healing, reactive reports of patients who present swelling
squamous metaplasia of ducts, and inflammatory process that most fre- without ulcerations, but the most typical
chronic inflammatory infiltrate in or quently affects the minor salivary glands presentation is a deep ulcer, as we found.
1,5,7

4. dence suppor t ed a diagnosis S N of har d and soft pal at e is t he second mos
t (1 men: 1 woman), whit es (4.9 whit es:
.9
(Figur e 1B, 1C, and .1D) common sit e of t his l esion, but ot her lor a 1 bl ack), and middl e- aged adul t s, as
No f urt her sur ger y was perf or med
. sit es may be invol ved, incl uding t h
e ment ioned by sever al pr evious
1,6-8,12,17
3-5,9-11
Silva et al. Spec Care Dentist 30(4) 2010 161
around the glands. The microscopic evi- of the hard palate. The junction of the NS is more frequently
found in men
The lesion disappeared completely after lower lip, retromolar area, tongue, buccal reports. The
patient reported
2 weeks, with complete repair of the mucosa, and others. In our patient, here was a 50-year-
old white man.

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It has been suggested that the patho- early NS, suggesting a possible relationshi
p reports. J Am Dent Asso 1996;127: 1087-
c
genesis of the lesion is a reactive proces s between the two conditions . 92.
necrosis of the glands. This is the most healing time is from 3 to 6 weeks. In 8. Brannon RB, Fowler CB,
Hartmanaccepted theory.
widely KS. NS has been our patient, the lesion disappeared com- Necrotizing sialometaplasia: a
clinicopatho-
described in association with sev- pletely after 2 weeks and follow-up was logic study of sixty-nine
cases and review of
possibly related to trauma. The mai n Once the diagnosis of NS hasn bee 7. Grillon GL, Lally ET. Necrotizing sialometa-
cause of the lesion is the loss ofe th mad e, close follow-up is recom m edn d e plasia: literature review and presentation the
blood suppl leading to infarction an
y, d until healing
Malagon et al. demonstrated is complete. The
an
unusual association of NS with T-cell Conclusion 10. Chen average
cavity. Hum Pathol 1977;8:589-92. f ive cases. J Oral
KT. Necrotizing sialometaplasia of the Surg 1981;39:747-53
13,14
1,2,16
1,2,6,13-15
eral non-neoplastic conditions, such as the procedure of choice. There was no the literature. Oral Surg Oral Med Oral
local trauma, upper respiratory tract recurrence before his death, which Pathol 1991;72:317-25.
infection, induced vomiting in bulimia, occurred 2 months after treatment. 9. Johnston WH. Necrotizing sialometaplasia
cocaine use, and radiation. Dominguez- involving the mucous glands of the nasal
18
lymphoma and reported that vascular It is important for both clinicians and nasal cavity. Am J Otolaryngol 1982;3:444-6.
Scully and Eveson and Solomon who are HIV positive and occlusion by the neoplastic lymphoid
immunocom- 1992;21:280-2.
et al. have suggested that the pathogene- promised would be desirable in order to 14. Walker GK, Fechner RE, Johns ME, Teja
K.
cell pathologists to be aware of the pathogen- 11. Pulse CL, Lebovics RS, Zegarelli DJ.
produces ischemia and
chronic mechanical injury of contributes to
the esis of this
palatine References 15. Prabhakaran VC, Flora RS, Kendall disease, as well as its
clinical Necro
C. tizing sialometaplasia:
report of a case
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In our patient, the lesion could be related different stages of development. Maxillofac Surg 2000;58:1419-21.
to local trauma of the hard palate caused Recognition of the histological spectrum 12. Forney SK, Foley JM, Sugg WE Jr, Oatis GW
by the ill-fitting denture, or persistent and the varied clinical findings, in which Jr. Necrotizing sialometaplasia of the
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minor salivary glands. mens for the treatment of NS in patients sia) of the trachea. Histophatology
5
4
sis of NS is widely believed to be related establish a standard protocol. Necrotizing sialometaplasia of the larynx
to ischemic changes because of vomiting secondary to atheromatous embolization.
induced by bulimia, which could lead to Am J Clin Pathol 1982;77:221-3.
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