A 28-year-old man comes to the office for evaluation of white lesions over the tongue that he recently noticed while brushing his teeth. The lesions are not painful or itchy. Review of systems is negative for dysphagia and positive for both fatigue and unintentional weight loss over the past 4 months. The patient smokes a pack of cigarettes daily and does not drink alcohol. Vital signs are within normal limits. BMI is 22 kg/m². Examination shows bilateral corrugated, adherent plaques located on the lateral tongue surfaces; the lesions cannot be scraped off. Dentition is normal without any caries or decayed tooth. There are multiple enlarged cervical lymph nodes bilaterally that are mobile and nontender. What is the most appropriate next step in management?

Question

Quizplus · Accepted Answer

This patient has multiple painless, white mucosal lesions on the lateral tongue surfaces that cannot be scraped off. In addition, he has systemic symptoms including fatigue, unintentional weight loss, and cervical adenopathy. In a patient his age (ie, young adult), this presentation is suspicious for oral hairy leukoplakia (OHL), a condition that is caused by intense Epstein-Barr virus replication and that is highly associated with HIV infection. OHL classically appears as multiple homogeneous lesions along the lateral tongue surfaces and has a corrugated (ie, folded or wrinkled) appearance that was originally described as "hairy." When this classic appearance is present (as in this patient), OHL can usually be distinguished from other white mucosal lesions without the need for lesional biopsy. Because OHL occurs almost exclusively in patients with significant immunodeficiency, especially HIV, workup should include HIV testing. OHL does not require specific treatment; lesions often resolve with appropriate treatment of the underlying immunodeficiency (eg, antiretroviral treatment). (Choices B and C) Cervical lymph node biopsy and laryngoscopy are frequent components of the workup of mucosal head and neck cancer and would be appropriate if this patient's mucosal lesions were malignant. However, his lesions are classic in appearance for OHL, and his lymphadenopathy is diffuse (multiple, mobile nodes bilaterally). This is more likely related to systemic illness (ie, HIV); therefore, HIV testing should be performed first. If HIV testing is negative, lesional biopsy (vs laryngoscopy or cervical lymph node biopsy) is a reasonable next step. (Choice D) Nystatin is used to treat oral candidiasis (ie, thrush). Although thrush can present with multiple white lesions in the oral cavity, they often have an erythematous base and can be scraped off with gauze or a tongue depressor. (Choice E) Tobacco cessation and close follow-up is appropriate for biopsy-proven benign oral leukoplakia, a potentially premalignant lesion distinct from OHL despite similarities in the name. Leukoplakia is more common in older patients with a long history of tobacco and alcohol use. This patient's young age; systemic symptoms; and classic, corrugated lesions on the lateral tongue surfaces are more consistent with OHL. Educational objective: Oral hairy leukoplakia typically presents as multiple white lesions on the lateral tongue with a distinct corrugated appearance. Because it occurs almost exclusively in patients with significant immunodeficiency, HIV testing should be performed, especially in patients with signs of systemic illness.

A 28-Year-Old Man Comes to the Office for Evaluation of White