COM July 2005

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Multiple Oral Ulcerations and Skin Rash

Dolphine Oda, BDS, MSc
doda@u.washington.edu

Contributed by
Mae Chin and Dr. Dena Fischer
DECOD clinic, Department of Oral Medicine, University of Washington

Case Summary and Diagnostic Information

This is a 48-year-old white female who presented to the University of Washington School of Dentistry DECOD Clinic complaining mainly of soreness under her upper partial denture, which was constructed three months prior to this episode.

Diagnostic Information Available

History of present Illness

This is a 48-year-old white female who presented to the University of Washington School of Dentistry DECOD Clinic complaining mainly of soreness under her upper partial denture, which was constructed three months prior to this episode. The clinical examination revealed multiple non-specific ulcerations of the
maxillary (Fig 1) and mandibular edentulous alveolar ridges, and the posterior hard palate. The ulcers had been present for four days and were getting progressively worse. The skin manifestation was in the form of rashes on her extremities, chest (Fig 2), back and face. Within a week, she developed extensive skin lesions, for which she was hospitalized. There was skin peeling on the hands that lasted for five weeks (Fig 3). After seven weeks, the skin lesions healed, but the oral ulcers were still present, though less prominent.

Fig 1. This clinical photograph is taken at week 1. It illustrates multiple irregular ulcers on the edentulous maxillary alveolar ridge and a small ulcer involving the mucosa covering a small torus palatinus.

Fig 2. This clinical photograph is taken at week 1. It illustrates extensive skin rash involving the chest, upper extremities, neck and shoulders.

Fig 3. This clinical photograph is taken at week three. It illustrates continued sloughing of the hand skin.

Medical History

The patient has a history of coronary artery disease which required surgical intervention with a coronary artery bypass surgery in March 04. She also has a history of hyperlipidemia, myopia, psoriatic arthropathy, and familial spastic paraplegia. She was admitted to the Mount Saint Vincent nursing home for rehabilitation after the cardiac surgery. A week prior to the skin and oral lesions she was treated with Bacterim for a urinary tract infection. She is on the following medications: Lanoxin, Trazodone, Megestrol, Neurontin, Lovastatin, Desinide cream, Fosamax, Metoprolol and, most recently, Bacterim. She is allergic to Tizanidine, Acyclovir, PCN and sulfa drugs.

Clinical and Radiographic Findings

The patient developed a generalized erythematous rash and papular urticarial eruption on the extremities, hand, feet, trunk, back, chest (Fig 2), face and lips. She developed sloughing epithelium, especially of the hands (Fig 3). The oral cavity showed multiple ulcers of 1-2 mm in size on the upper and lower alveolar ridges and palate (Fig 1). The oral ulcers were symptomatic; the patient had difficulty eating and drinking hot food and beverages and spicy food.

Fig 1. This clinical photograph is taken at week 1. It illustrates multiple irregular ulcers on the edentulous maxillary alveolar ridge and a small ulcer involving the mucosa covering a small torus palatinus.

Fig 2. This clinical photograph is taken at week 1. It illustrates extensive skin rash involving the chest, upper extremities, neck and shoulders.

Excisional Biopsy

No need for a biopsy. The diagnosis is made on the clinical presentation.

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