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A 71-year-old man with a history of rheumatoid arthritis and type 2 diabetes presented to the otolaryngology team with 6 weeks’ history of pain and ulcers in the pharynx. He also complained of nasal regurgitation. He denied having any systemic symptoms. He took linagliptin, valsartan, and 15 mg of methotrexate weekly. He was a nonsmoker and consumed very little alcohol.
Clinical examination including flexible nasendoscopy revealed multiple shallow ulcers on the posterior wall of the nasopharynx. There was a large defect involving the entire soft palate on the left. There was no obvious mass or any exophytic lesion. The edges of the soft palate defect were smooth and clean (Figure 1). There were no cranial nerve palsies. There was no cervical, axillary, or inguinal lymphadenopathy. Findings of the remaining head and neck examinations were normal.
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D. EBV-positive mucocutaneous ulcer
Histologic findings from the biopsy showed stratified squamous mucosa and respiratory-type mucosa with large areas of surface ulceration. There were dense underlying lymphoid infiltrates composed of lymphocytes, transformed lymphoid cells, and plasma cells. The transformed cells resembled atypical immunoblastic or Hodgkin and Reed-Sternberg–like cells (Figure 2A) dispersed between lymphocytes with no evidence of palisaded lymphocytes around those. These cells showed strong positivity for CD20, Pax5, MUM1, CD30, and CD15 on immunohistochemical staining (Figure 2B). More than 90% of the cells’ nuclear expression also showed EBV positivity on EBV-encoded RNA testing, but the results of B-cell clonality analysis using polymerase chain reaction were negative for any monoclonal B-cell population. No lymphoepithelial lesion, dysplasia, or epithelial malignant neoplasm was seen.
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Corresponding Author: Billy L. K. Wong, MBBS, Department of Otolaryngology–Head and Neck Surgery, Broomfield Hospital, CM1 7ET, Essex, United Kingdom (firstname.lastname@example.org).
Published Online: August 12, 2021. doi:10.1001/jamaoto.2021.1927
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank the patient for granting permission to publish this information.
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