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pISSN 2360-2406; eISSN 2502-0285

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1. INTRODUCTION

Sarcomas are a rare mesenchymal cancer that grows

in dierent types of connective tissue [1]. Kaposi

sarcoma (KS) is one type of sarcoma that develops

from the cells lining lymphatic or blood vessels [1]. It

is classied as an intermediate neoplasm because it

lacks the conventional features of a true malignancy

[2]. Caused by human herpes virus-8 (HHV-8), KS is

present in 1%–5% of the general population globally,

but its seroprevalence is greater (20%–77%) among

men who have sex with other men, particularly those

diagnosed with human immunodeciency virus (HIV)

and acquired immunodeciency syndrome (AIDS)

[3]. Because HHV-8 is considered an opportunistic

infection, it is often transmitted between individuals

through saliva, sexual activity, blood, or organ

transplant. However, it can also remain latent until

the individual experiences an immunosuppression

reaction, at which point the virus becomes

associated with additional pathologies, such as KS

or lymphomas. Therefore, it is crucial to understand

these transmission routes and latency mechanisms

for eective prevention and management strategies

in susceptible populations.

OPEN ACCESS This is an Open Access article under the CC BY-NC 4.0 license.

Peer-Reviewed Article

Citation: Haribabu PK, Verma M, Vij A, Singer SR. Kaposi Sarcoma disguised as pericoronitis: a deferred diagnosis due to COVID-19 pandemic.

Stoma Edu J. 2024;11(1-2):73-77

Received: July 23, 2024; Revised: August 06, 2024; Accepted: August 15, 2024; Published: August 29, 2024.

*Corresponding author: Assoc. Prof. Prashanth K. Haribabu, DDS, BDS, MDS, MSD, FICD, Director, Specialty Care Unit – Oral & Maxillofacial Surgery,

Missouri School of Dentistry & Oral Health, A.T. Still University of Health Sciences, 1500 Park Ave, Saint Louis, MO 63104, USA; Tel.: 660.626.2121;

Fax: 660.626.2121;

e-mail: prashanthharibabu@atsu.edu

ORAL PATHOLOGY

KAPOSI SARCOMA DISGUISED AS PERICORONITIS:

A DEFERRED DIAGNOSIS DUE TO COVID-19 PANDEMIC

Prashanth Konatham Haribabu

1a*

, Minaal Verma

, Akshay Vij

, Steven R. Singer

Specialty Care Unit - Oral & Maxillofacial Surgery, Missouri School of Dentistry & Oral Health, A.T. Still University of Health Sciences, Saint Louis, USA

Dental Materials Section, Department of Prosthodontics & Endodontics, School of Dental Medicine, Southern Illinois University, Alton, USA

Specialty Care Unit - Esthetic & Digital Dentistry, Missouri School of Dentistry & Oral Health A.T. Still University of Health Sciences, Saint Louis, USA

Division of Oral & Maxillofacial Radiology, Department of Diagnostic Sciences, Rutgers School of Dental Medicine, Rutgers, The State University of New

Jersey, Newark, USA

DDS, BDS, MDS, MSD, FICD, Associate Professor and Director; e-mail: prashanthharibabu@atsu.edu; ORCIDiD: https://orcid.org/0000-0002-0470-1467

DDS, BDS, MDS, FICD, Assistant Professor and Head; e-mail: mverma@siue.edu; ORCIDiD: https://orcid.org/0009-0006-2390-4223

BDS, ACT, FAGD, FICD, Associate Professor and Director; e-mail: akshayvij@atsu.edu; ORCIDiD: https://orcid.org/0000-0002-6342-8755

DDS, Professor and Chair, Interim Director; e-mail: steven.singer@rutgers.edu; ORCIDiD: https://orcid.org/0000-0003-2549-955X

ABSTRACT

Aim The current case report describes an uncommon presentation and subsequent diagnosis of Kaposi

sarcoma caused by acquired immunodeciency syndrome (AIDS).

Summary The COVID-19 pandemic led to global disruptions in healthcare services, sometimes resulting

in postponed diagnoses of infectious diseases. Kaposi sarcoma (KS) is a malignant soft-tissue neoplasm

commonly associated with human immunodeciency virus (HIV) and AIDS, but it also occurs in other

immune-compromised individuals. The oral manifestations of KS play a crucial role in its early diagnosis

and may be a predictor of disease progression from HIV to AIDS. The current case report describes an

unusual case involving a young male who presented to a dental clinic with persistent postoperative pain

and delayed wound healing following extraction of his lower third molar. Clinical examination indicated a

proliferative mucosal lesion with reddish-purple coloration in the vicinity of the surgical site that extended

to the left retromolar pad, and cone-beam computed tomography scans showed marked osseous changes.

Histopathological analysis conrmed a diagnosis of AIDS-related KS and an additional diagnosis of metastatic

pulmonary KS.

Key learning points

1. The COVID-19 pandemic caused numerous disruptions in healthcare systems and services, which led to

delayed healthcare visits.

2. Kaposi sarcoma is a malignant soft-tissue neoplasm commonly associated with HIV and AIDS.

3. Kaposi sarcoma may also occur in other immune-compromised individuals.

4. The oral manifestations of KS may play a crucial role in diagnosis of AIDS.

5. Kaposi sarcoma may present in uncommon ways, such as persistent postoperative pain and delayed

wound healing.

https://doi.org/10.25241/stomaeduj.2024.11(1-2).art.7

KEYWORDS

Kaposi Sarcoma; Postoperative Pain; Delayed Wound Healing; Human Immunodeciency Virus; Acquired Immune

Deciency Syndrome.

Case Report

73-77

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73-77

Original Articles

Haribabu PK, et al.

Oral KS occurs in approximately 22% of individuals

diagnosed with HIV and is typically the rst sign of

undiagnosed HIV infection [4]. The most common sites

of occurrence in the oral cavity are the hard palate,

gingiva, and dorsum of the tongue [5,6]. Clinically, oral

KS can present as solitary, multifocal, or multicentric

macular patches, plaques, or nodules of varying

dimension; colors can range from deep red to purplish

blue [7,8]. Multifocal lesions may also coalesce into

solitary exophytic masses. Oral KS can cause local

tissue destruction, pain, spontaneous bleeding,

masticatory difficulty, and interference with the

wearing of oral prostheses. Although severe alveolar

bone destruction and unexplained tooth mobility with

underlying oral KS has been documented [9], oral KS

presenting as a source of persistent dentoalveolar pain

is uncommon. Therefore, the aim of the current case

report was to describe an uncommon presentation

and subsequent diagnosis of KS caused by AIDS.

2. CASE PRESENTATION

A 29-year-old White male presented to our Oral

& Maxillofacial Surgery clinic with pain with

accompanying intraoral swelling that emanated from

the region around his lower left third molar. The only

relevant medical history that the patient divulged is

that he had been previously been diagnosed with

HIV but had not followed with his physician for

management and treatment. Patient did not provide

any previous medical records or blood work. Clinical

examination revealed erythematous, hyperplastic

soft tissue partially covering the lower left third molar

(tooth #17) and tenderness on palpation. A diagnosis

of acute pericoronitis was established based on the

clinical and radiological ndings. Due to the acute

nature of this event, a clinical decision to proceed

with treatment was made. The tooth was considered

to be not salvageable and was extracted. The socket

was subsequently curetted to remove remnants of

granulation tissue. The residual pericoronal tissue was

rather prominent and noticeable.

The patient was instructed to return for evaluation

of the surgical site if his pain persisted or there was

no resolution of the redundant pericoronal tissue.

However, the patient did not follow up as instructed,

likely because of the COVID-19 pandemic. His

treatment coincided with increased public health

restrictions designed to mitigate the eects of the

pandemic, which meant that follow-up oral care

services were severely limited.

Four months later, the patient returned to the clinic

with complaints of bleeding and constant, low-grade

pain emanating from the surgical site. He reported

that the bleeding started two weeks before and that

his pain had intensied (5 of 10 on a numeric pain

scale), leading him to seek care. At the time of this visit,

his HIV disease was poorly controlled (CD4+ < 200

cells/mm3, viral load = 67,229 copies/mL), and he had

stopped taking the highly active antiretroviral therapy

over the past few months. He reported generalized

weakness, insomnia, poor appetite, and weight loss

during the past month.

Extraoral examination was significant for a non-

tender, nonmobile left submandibular lymph

node that measured approximately 1 × 1 cm.

Intraoral examination revealed a 3 × 3 cm bluish-

purple proliferative lesion that originated from the

extraction socket site of tooth #17, extended to the

left retromolar pad, and involved the lingual gingiva

and buccal vestibule (Fig. 1).

A less intense, reddish-purple mucosal discoloration

was also visible in the left maxillary tuberosity (Fig. 2).

Palpation of the clinical sites elicited intense pain,

which the patient indicated was the primary reason

he returned for follow-up (Fig. 3).

Figure 1. Irregular proliferative lesion at the healing surgical site of tooth

#17 that extended toward the lingual and buccal gingiva and toward the

faucial pillars of the oropharynx.

Figure 2. Reddish-purple hyperplastic discoloration (arrows) that

extended superiorly around the attached palatal gingiva of tooth #16.

Figure 3. Reddish-purple coloration of palatal gingiva at tooth #16 and

near the left maxillary tuberosity.

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Case Report

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At this visit, a panoramic radiograph was obtained and

indicated a well-healed extraction socket for tooth

#17 and intact cortical borders of the mandible (Fig.

4). The shadow of a dome-shaped soft tissue growth

of approximately 9-mm wide × 3-mm high at the crest

of the ridge posterior to tooth #18 was evident and

likely represented the lesion.

Next, an incisional biopsy of the lesion growing

from the extraction site of tooth #17 was performed.

Histopathological examination with hematoxylin-

eosin conrmed the presence of AIDS-associated

oral KS. Low resolution (Fig. 5) and medium resolution

(Fig. 6) photomicrographs showed a polypoid

lesion composed of vascular connective tissue

and pleomorphic spindle cells compressing the

extravasations of erythrocytes.

Advanced imaging was then performed to determine

whether there was any osseous change in the site

of the lesion. Large volume cone-beam computed

tomography scans revealed an irregularly shaped

osseous defect in the left posterior mandible that

extended from the ramus anteriorly to the second

molar area (Fig. 7). Although the buccal cortical plate

was intact, the lingual cortical plate and the alveolar

crest showed signs of resorption. There was a furcation

defect in tooth #18 and loss of the lamina dura, which

likely represented the most anterior extent of the

lesion. The lesion extended inferiorly to the level of the

inferior alveolar nerve canal, perforating the cortical

shelf of that canal (Fig. 8). Inltration of the inferior

alveolar nerve canal explained the patient’s reported

episodes of sharp pain in conjunction with persistent

low-grade pain.

The patient was informed of the diagnosis and

promptly referred to his infectious disease specialist

for further evaluation and management. Diagnostic

workup conrmed the presence of pulmonary KS, and

he was again started on highly active antiretroviral

therapy that helped resolve the oral and systemic

manifestations of KS throughout his body.

3. DISCUSSION

Manifestation of oral KS as pericoronitis or in

conjunction with pain often serves as a warning sign

Figure 4. Panoramic radiograph showing intact cortical alveolar borders

in the healed extraction socket (region of tooth #17), but marked alveolar

bone loss around tooth #16.

Figure 5. Low resolution histopathological photomicrograph showing

a polypoid lesion composed of vascular connective tissue partially covered

by stratified squamous (hematoxylin-eosin, magnification ×40).

Figure 6. Medium resolution histopathological photomicrograph

showing poorly differentiated vascular slits and fascicles of pleomorphic

spindle cells compressing the extravasated erythrocytes (hematoxylin-

eosin, magnification ×40).

Figure 7. Cone-beam computed tomography scan showing irregularly

shaped osseous defect in the left posterior mandible that extended from

the ramus anteriorly to the second molar area.

Figure 8. Large volume cone-beam computed tomography scan slices

showing an irregular alveolar defect on the lingual cortex of the mandible

that extended inferiorly to the level of the inferior alveolar nerve canal.

Kaposi Sarcoma disguised as pericoronitis

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Haribabu PK, et al.

Case Report

73-77

for any form of injury sustained by the human body.

In the current case report, persistent postextraction

pain was the main reason the patient pursued follow-

up evaluation. Although oral KS can occur at any

intraoral site, it has a predilection for the hard palate

and gingiva. Cases of oral KS resembling pericoronitis

or local soft tissue inammation with constant low-

intensity pain have been rare. For patients living with

HIV, unrelieved pain has been reported as a major

problem. For example, patients with CD4+ T cell counts

less than 200/mm3 often have pain as a common,

persistent symptom [10]. Given the outcomes of the

current case, clinicians should consider HIV, AIDS, and

their associated manifestations, such as oral KS, as

potential sources of persistent postoperative pain.

Therefore, clinicians should routinely examine oral soft

tissues for potential pathology in immunosuppressed

patients. Certainly, the detection of oral KS in this case

led to the discovery of pulmonary involvement and

was critical for eective and successful treatment of

the patient.

The disruption of healthcare services during and after

the COVID-19 pandemic had a major eect on patient

care and increased the number of complications for

oral infectious diseases. Several studies reported

that COVID-19 accelerated the incidence of KS in

extraoral areas, especially the skin of the extremities.

This increase was associated with reactivation of the

HHV-8 virus, which was likely due to exposure to the

SARS-CoV-2 virus. This type of surge in carcinomas was

also observed in other oral malignancies that were not

caused by HIV [28].

4. CONCLUSIONS

Manifestations of KS in the oral cavity can be an early

sign of additional pathology in immunosuppressed

individuals. Therefore, dental practitioners should

purposefully investigate the origin of preoperative

and postoperative intraoral pain in patients with HIV

disease and eectively communicate any ndings to

medical providers to expedite systemic care of these

patients. During the current post-pandemic period,

dental practitioners should include an additional layer

of screening during standard patient examinations for

early detection of oral malignancies, such as oral KS.

AUTHOR CONTRIBUTIONS

PKH, SRS contributed to the concept, protocol, case documentation,

data gathering and interpretation and making critical edits

to the manuscript. AV, MV contributed to the protocol, case

documentation, data gathering and interpretation and making

critical edits to the manuscript.

ACKNOWLEDGMENTS

We would like to acknowledge and thank Late Dr. Harold V.

Cohen, DDS – Professor of Diagnostic Sciences, Rutgers School of

Dental Medicine, Newark NJ for his expertise and counsel towards

interprofessional care involving infectious diseases medical and

dental care.

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Stoma Edu J. 2024;11(1-2):

pISSN 2360-2406; eISSN 2502-0285

www.stomaeduj.com

Kaposi Sarcoma disguised as pericoronitis

Case Report

73-77

Dr. Prashanth K. Haribabu, DDS, MDS, MSD, is the Director of Oral and Maxillofacial Surgery and Assistant Professor at A.T. Still

University-Missouri School of Dentistry & Oral Health (ATSU-MOSDOH). A dedicated educator, he emphasizes continuous learning

to maintain excellence in patient care and train future healthcare providers. Dr. Haribabu also chaired a scientic surgical session

and was awarded the prestigious Master Implant Fellow Certication by the World Congress of Oral Implantology (WCOI).

Prashanth Konatham HARIBABU

DDS, BDS, MDS, MSD, FICD

Associate Professor and Director

Specialty Care Unit – Oral & Maxillofacial Surgery Missouri School of Dentistry & Oral Health

A.T. Still University of Health Sciences

Saint Louis, MO 63104, USA

Questions

1. What is the primary cause of Kaposi Sarcoma (KS)?

qa. Human Papillomavirus (HPV);

qb. Epstein-Barr Virus (EBV);

qc. Human Herpesvirus-8 (HHV-8);

qd. Cytomegalovirus (CMV).

2. What was the initial diagnosis for the 29-year-old male in the case report?

qa. Kaposi Sarcoma;

qb. Acute Pericoronitis;

qc. Osteomyelitis,

qd. Oral Lichen Planus.

3. What delayed the follow-up care of the patient in the case report?

qa. Personal negligence,

qb. Financial constraints,

qc. The COVID-19 pandemic,

qd. Lack of transportation.

4. What was a signiﬁcant clinical ﬁnding during the patient’s follow-up visit?

qa. A painless intraoral lesion,

qb. A bluish-purple proliferative lesion,

qc. Normal healing of the extraction site,

qd. Discoloration limited to the hard palate.

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