Clinical pathologic conference case 3: multiple deep oral ulcers

• Published in: Oral surgery, oral medicine, oral pathology and oral radiology oral medicine, oral pathology and oral radiology, 2021-01, Vol.131 (1), p.e29-e33
• Main Authors: Bernstein, Mark L., Wetzel, Stephanie L.
• Format: Article
• Language: English
• ISSN: 2212-4403; 2212-4411
• DOI: 10.1016/j.oooo.2020.09.016

Clinical Presentation: An 87-year-old woman reported a history of “canker sores” so painful she was unable to eat. Large ulcerations were present on the right buccal mucosa, left ventral tongue (Figure 1A and B), left hard palate, and right soft palate. Recently she developed 3 lesions on her scalp (Figure 2). The patient's medications include levothyroxine (Synthroid), pantoprazole (Protonix), furosemide (Lasix), and sucralfate (Carafate). Differential Diagnosis: Close examination of the patient's medications and clinical history was essential to developing a working diagnosis. For example, levothyroxine is primarily used to treat hypothyroidism. Possible side effects include swelling of face and tongue, as well as candidiasis. Furthermore, gastroesophageal reflux disease is often treated with pantoprazole. The use of this medication can cause a deficiency in B12, which can lead to oral ulcerations, mucositis, and candidiasis along with other oral symptoms. Sucralfate can be used to treat pain associated with oral aphthae, which may also cause a decrease in vitamin absorption and lead to vitamin deficiencies. Although some of these medications have oral side effects, a thorough search of the literature did not provide examples of these drugs causing large necrotic ulcerations. Therefore the possibility of necrotic ulcerations secondary to medication use was eliminated. Other causative factors include autoimmune or inflammatory conditions, infectious organisms, neoplastic processes, factitial or traumatic ulcerations, vasculitis, and postradiation or chemotherapy-related necrosis. However, neoplasms usually occur as solitary lesions. In addition, some of the lesions in this case were present at sites, such as the soft palate, that would be difficult to traumatize. Therefore these possibilities were also eliminated. Autoimmune and inflammatory conditions that can cause necrotic ulcerations in the oral cavity include neutropenia and paraneoplastic pemphigus. Patients with less than 1500/mm3 circulating neutrophils are considered neutropenic. Causes of neutropenia include use of certain medications, and infectious agents, as well as immunosuppression. Clinical features include ulcerations with or without abscesses and lacking an erythematous border.2 These features are not seen in the photographs from the present example. However, oral lesions are identified in almost all cases of paraneoplastic pemphigus. Lesions present as diffuse and painful erosions occur