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J Am Coll Emerg Physicians Open
J Am Coll Emerg Physicians Open
10.1002/(ISSN)2688-1152
EMP2
Journal of the American College of Emergency Physicians Open
2688-1152
John Wiley and Sons Inc. Hoboken

10.1002/emp2.13261
EMP213261
Images in Emergency Medicine
Images in Emergency Medicine
An adult male presenting with left buccal mass
LIIMATTA and ADAMS
Liimatta Anthony DO 1 anthonyliimatta@gmail.com

Adams J. Taylor DO 2
1 Department of Emergency Medicine Brooke Army Medical Center Fort Sam Houston Texas USA
2 Department of Radiology Brooke Army Medical Center Fort Sam Houston Texas USA
* Correspondence
Anthony Liimatta, Department of Emergency Medicine, Brooke Army Medical Center, 3551 Roger Brooke Dr, Fort Sam Houston, TX, USA.
Email: anthonyliimatta@gmail.com

11 9 2024
10 2024
5 5 10.1002/emp2.v5.5 e1326111 7 2024
17 7 2024
© 2024 The Author(s). Journal of the American College of Emergency Physicians Open published by Wiley Periodicals LLC on behalf of American College of Emergency Physicians.
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.

abscess
AIDS
buccal mass
HIV
Kaposi sarcoma
osteomyelitis
source-schema-version-number2.0
cover-dateOctober 2024
details-of-publishers-convertorConverter:WILEY_ML3GV2_TO_JATSPMC version:6.4.8 mode:remove_FC converted:11.09.2024
Liimatta A , Adams JT . An adult male presenting with left buccal mass. JACEP Open. 2024;5 :e13261. 10.1002/emp2.13261
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pmc1 CASE PRESENTATION

The patient is a 52‐year‐old male with a 30‐year history of human immunodeficiency virus (HIV), not compliant with antiretroviral therapy (although his last viral load was undetectable 1 year prior), presenting with 3 months of worsening left facial mass (Figures 1, 2, 3, 4, 5), generalized weakness, and a 30‐pound weight loss. He came into the emergency department (ED) because the mass started causing changes in his speech.

FIGURE 1 Patient presenting with left facial swelling.

FIGURE 2 Oral examination revealing the buccal lesion.

FIGURE 3 CT of the face (coronal view, soft tissue [left]; bone window [right]): Large complicated fluid collection in the left maxillary sinus extending into the left masticator soft tissue spaces and left inferior orbit. Bone window shows cortical erosion and breakthrough of the superior, lateral and inferior left maxillary walls, including peripical lucencies of the 1st and 2nd left maxillary molars (arrow points toward left inferior orbital wall/superior maxillary sinus). Abbreviation: CT, computed tomography.

FIGURE 4 MR of the face (coronal view T1 pre‐contrast): T1 hyperintense complex collection seen in the same distribution as CT images. Additional mild T1 hyperintense signal within the left inferior and lateral rectus muscles suggesting early muscular involvement. Abbreviations: MR, magnetic resonance; CT, computed tomography.

FIGURE 5 MR of the face (coronal view T1 post‐contrast with fast saturation): Enhancing mucosa of the left frontal, maxillary and ethmoid sinuses. Extensive soft tissue cellulitis and myositis involving the left temporalis muscle and left temporal fossa. Abbrevation: MR, magnetic resonance.

2 DIAGNOSIS

2.1 Kaposi sarcoma complicated by an abscess with osteomyelitis of the left maxilla

The patient was admitted to the hospital. The osteomyelitis source was found to be polymicrobial bacteria and Candida albicans was treated with ampicillin/sulbactam and fluconazole. Osteomyelitis in the maxilla is rare and typically seen in immunocompromised patients. 1 As seen with this patient, oral lesions are highly predictive markers of immunosuppression, occurring in up to 50% of HIV‐infected patients and in up to 80% of patients with acquired immunodeficiency syndrome (AIDS). 2 His initial CD4 cell count found to be 4 and his viral load was 108,000 copies/mL revealing his progression from HIV to AIDS. His infection was found to be originating from a Kaposi sarcoma lesion. During the hospital course, he underwent surgical debridement, continued antimicrobial therapy, and he was restarted on bictegravir, emtricitabine, and tenofovir alafenamide. Treatment for Kaposi sarcoma is the prompt initiation of antiretroviral therapy, which helps to increase CD4 count and suppress human herpesvirus‐8. 3 The parotid is the only salivary gland with substantial lymphoid tissue, which is the suspected origin of this patient's lesion. 4 This explains why most cases of Kaposi sarcoma stem from intra‐parotid lymph nodes. 4

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.
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REFERENCES

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2 Lomelí‐Martínez SM , González‐Hernández LA , Ruiz‐Anaya AJ , et al. Oral manifestations associated with HIV/AIDS patients. Medicina (Kaunas). 2022;58 (9 ):1214. doi:10.3390/medicina58091214 36143891
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