Gingival enlargement as an early diagnostic indicator in therapy-related acute myeloid leukemia: A rare case report and review of literature
A 28-year-old female patient at her 8th month of gestation, reported to the Department of Periodontology, on 21st June 2011, with a chief complaint of swelling and dull aching pain in her gums since 10 days. The patient first noticed the swelling 2 months back, prior to which she was asymptomatic. The swelling was accompanied with pain and bleeding on brushing. The patient did not give any significant past medical history and her routine blood investigations for pregnancy were normal. Extra-oral examination revealed mild, slightly tender, bilateral submandibular lymphadenopathy. On intraoral examination, there was generalized papillary and marginal gingival enlargement in both her jaws. The gingiva was inflamed with moderate deposits of plaque and calculus with localized bleeding on probing. The patient appeared very fatigued and weak, and hence the decision to perform gingival biopsy was postponed. Given the history and oral findings, a provisional diagnosis of pregnancy gingival enlargement was made. The patient requested for an appointment after a week as she had prior engagements. Hence, a treatment plan was formulated which included oral prophylaxis and the patient was advised chlorhexidine mouthwash (0.2%) twice daily, for a period of 2 weeks.\nOn 27th June 2011, the patient reported with increased gingival pain and swelling accompanied with fever. On examination, there was severe generalized gingival overgrowth with localized necrosis and sloughing involving the interdental papilla in relation to tooth #3. Interdental and marginal gingiva in relation to teeth #10 and 11 revealed the first instance of an abnormal color change and had become more erythematous, boggy, and cyanotic []. Routine blood investigations were advised. The hematological findings are presented in . Peripheral blood smear revealed 90% myeloblasts with large round nucleus, coarse chromatin and ill-defined nucleoli with moderately pale blue cytoplasm [Figures and ]. Hematology clinic diagnosed the case as AML M4/M5 (French-American-British Classification, 2000). After observing the hematological report, the patient was further probed for her past medical history, on which she disclosed that she had taken systemic CT for HL 4 years back. Considering her medical status (8th month of pregnancy), she was referred to her consulting obstetrician and oncologist for any required immediate needful treatment. The oncologist informed us that the patient was diagnosed for Malignant HL 4 years back in May 2007, for which she had received CT with six cycles of ABVD and RT (40 Grays) for 1 month. Co-relating the past medical history with present findings, the case was diagnosed as therapy-related AML (t-AML). The clinical photographs from the day the necrotic areas were observed till the delivery of the baby showed classical gingival changes [Figures and ].\nFurther on supervision with her obstetrician, on 21st July 2011, the patient delivered a healthy baby without any complications. After few days of delivery, the patient was put on CT with vincristine, daunorubicin and cytarabine for AML. However, the patient did not respond well to the treatment and died 3 months later.