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.

-->