Acute myelomonocytic leukemia presenting with gingival enlargement as the only clinical manifestation
A 34-year-old female of Asian Indian origin reported to the Department of Periodontology, Goa Dental College and Hospital on 23rd February, 2011, with the chief complaint of swelling, pain, and bleeding of the maxillary and mandibular gingiva. These symptoms had been present for about 15 days. The patient had been in good health until the last two weeks at which time she began to notice gingival swelling, pain, and bleeding which grew progressively worse, which was why she sought dental treatment.\nOn oral examination, the gingiva appeared enlarged, smooth, shiny, edematous, and lacked stippling [Figure –]. According to the patient, she was also having menstrual irregularities for the past 3 months and experienced excessive tiredness ever since.\nThere was no evidence of lymphadenopathy, hepatospleenomegaly, cutaneous bruising, or petechiae.\nThe patient was not taking any medications. She indicated no family history of hematological disease in her parents or siblings.\nA routine blood investigation revealed a total leukocyte count of 10,000 cells/cmm and Hemoglobin count of 10 mg/dl.\nA provisional diagnosis of ‘Menstrual cycle – associated gingivitis’[] was made. Routine scaling, root planing and pocket irrigation were performed and the patient was referred to the Department of Obstetrics and Gynecology at the Goa Medical College and Hospital for consultation regarding her menstrual irregularities. She was prescribed oral androgenic steroids (Medroxyprogesterone, 30 mg/day to be gradually tapered to 10 mg/day) over a period of 3 weeks.\nAt the 3 week dental recall, her menstruation had regularized but the gingival swelling, bleeding, and pain did not improve; rather the gingival swelling seemed to worsen []. Furthermore, necrosis along the gingival margins of the maxillary and mandibular teeth was noted [Figure and ]. The patient also informed that she had fever of 102°F for the last two days before the follow-up visit.\nMultiple soft and tender lymph nodes ranging from 1.0-1.5 cm in diameter were palpable bilaterally in the neck as well as axillae. A routine blood count revealed leukocytosis white blood cell (WBC) count, 58,000/cmm and anemia (HBG 6 g/dl) suggesting an acute leukemia and the patient were referred to Department of Medicine, Goa Medical College and Hospital. She was subsequently admitted to a ward on 16th March 2011.\nThe laboratory examination the following day included complete blood count and differential count for classification of the WBC. A complete battery of laboratory tests, including glucose tolerance, blood chemistry and urine analysis showed results within normal limits. Her routine blood count at this time revealed leukocytosis, anemia and thrombocytopenia [].\nThe leukocyte differential count displayed 6% neutrophils, 31% monocytoid cells, 3% lymphocytes, 48% blast form, 4% myelocytes, and 8% stabs. The peripheral smear displayed mostly immature monocytes as well as some myeloblasts. A diagnosis of AML - FAB classification M4[] was made. Subsequent bone marrow biopsy revealed 90% hypercellularity.\nDuring the hospital stay, the patient was given symptomatic and supportive treatment, which included chemotherapy, whole blood transfusion and antibiotics. The patient underwent an induction regimen consisting of intravenous administration of cytosine arabinoside (ARA-C, 100/m2/day × 7 days) and idarubicin hydrochloride (Idamycin, 12mg/m2/day × 3 days). The patient tolerated the chemotherapy with minimal complications.\nThe oral hygiene instructions consisted of gentle brushing and mouth rinsing with chlorhexidine 0.2% twice daily.\nThe general condition and primary gingival enlargement of leukemic infiltration were well controlled in that, the enlargement although persistent, was non-progressive, firm and devoid of its necrotic component [Figure –].\nThe patient was discharged with a WBC count of 7,500/cmm and hemoglobin 8 gm/dl.\nRoutine dental treatment included cautious debridement of plaque and food debris followed by chlorhexidine irrigation every fortnight.\nUnfortunately, approximately 4 months after the initial symptoms, a recurrence of the leukemia with sepsis resulted in the patient's death on 5th June 2011.