Thursday, May 09, 2019

A Young Girl with Ulcerated Lips

A 14-yr-old girl had severe blisters on the lower lip of 5 days duration.  It was painful and developed into superficial painful ulcerations of the lips.  Then she experienced eye discomfort with eye discharge esp in early morning.  There were no red eyes though.  She did not have any fever or any polyarthralgia.  No genital ulcerations. She is a secondary school student and stays with parents with no unusual habits. There was no family history of similar illness.  There was no recent drug history including OTC products, supplements and traditional chinese medicines. 

Examination was unremarkable except superficial ulcerations on the lower lip and to a certain extent on the upper lip too. The ulcerations was covered with yellowish slough and crusts.  Superficial erosions were noted on the inner buccal mucosa. No genital ulcerations.  No blisters elsewhere. 
Rest of exam unremarkable.

Diagnosis
Aphthous ulcerations - severe

Differentials considered were First episode orolabial HSV infection, drug eruptions, pemphigus vulgaris, erythema multiforme.

Blood counts and biochemistry was done as well as ANA serology.  HSV I and II serology was not done due to financial reasons. If she does not improve I think this patient may require a biopsy.

She was treated with oral prednisolone 20mg bd, topical triamcinolone gel bd and oral azithromycin 250mg daily. Your comments on this patient would be highly appreciated.


References:

1. Mucosal erosions as the presenting symptom in erythema multiforme: a case report. Spencer S, Buhary T, Coulson I, Gayed S. Br J Gen Pract. 2016 Mar;66(644):e222-4.  Free Full Text.

Follow up: Good response to treatment with oral prednisolone and azithromycin. Lesions were drying up and clearing.






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3 comments:

  1. The following are three comments from readers:
    Khalifa Sharquie, Baghdad, Iraq: This is oral erythema multiforme without skin manifestation which is not uncommon variant of this disease.The commonest cause is preceding herpes simplex.So I wonder whether there is any history of this herpetic infection.The response to therapy without recurrence is against aphthus ulceration

    Krystal Jones, Boston Children’s Hospital: This looks pretty classic for Mycoplasma Induced Rash and Mucositis. Typically self limited, may involve genital mucosa and eyes. We typically treat with 1mg/kg methyl pred and IVIG if severe. Can recur w additional infections. Would obtain an XRay to rule out atypical pneumonia.

    Rick Sontheimer, Salt Lake City, Utah: I would favour HSV- or Mycoplasma pneumoniae-induced erythema multiforme minor in this case.

    ReplyDelete
  2. Dr. Foong's Reply: Many thanks for the very helpful comments. Her pain and discomfort was much better after 2 days. Since she had improved lot, blood tests for mycoplasma and HSV serology was not done. it would be interesting to find out about her serology results.

    ReplyDelete
  3. Henry FoongMay 22, 2019

    Many thanks for the very helpful comments. Her pain and discomfort was much better after 2 days. Since she had improved lot, blood tests for mycoplasma and HSV serology was not done. it would be interesting to find out about her serology results.

    ReplyDelete

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