Forum for Clinical and Surgical Oral Pathology

Case BBOPF 03-10

Dr. John Lovas is requesting your comments on the following case. Please send your comments in the window located below the clinical image. This case will be posted from December 22, 2003 to January 5, 2004. A summary of the responses will be posted in BBOP.

Clinical History

This 28yo white male has had this, initially painful, now asymptomatic, ulcer of the anterior dorsum of tongue, for 20 months, despite initially increasing his prednisone from 2.5mg alternate days to 5mg/day x3 months.

Crohn's disease was diagnosed 4yrs ago, takes 5-ASA, omeprazole & prednisone (2.5mg alt days) - stress / fatigue causes mouth to flare - always same site anterior dorsum of tongue (6 times) ± few tiny "cankers" on lateral borders - only sore for 2 days by upping prednisone to 5mg/day for 3days. He's had asthma x20yrs - has used budesonide "for years" but never gargles afterwards - I advised him to do so to avoid Candidal overgrowth; he also uses formoteral fumarate dihydrate & salbutamol; has used fluticasone x3yrs; has never used tobacco; works in the insurance industry.

Examination revealed no regional lymphadenopathy; anterior dorsum of tongue, just left of midline (over a year ago, showed an) 8x3mm nonindurated gray pseudomembrane-covered shallow ulcer c/w oral manifestation of Crohn's vs erosive LP ± Candidiasis. His right posterior inferior buccal vestibule had a 2x1cm area of multiple tiny white papules, left & right ventral tongue / floor of mouth each >3cm diameter areas thin white striae, none of which wiped off with gauze, the right tongue lesion included a 2mm shallow ulcer c/w erosive LP. Incidental findings: posterior dorsum of tongue showed multiple lesions of geographic tongue

He was given a prescription for topical steroids & antifungals.

On recall 3 weeks later, his left mandibular vestibule showed "epulis fissuratum without dentures" type linear ulcer with raised margins c/w oral manifestation of Crohn's disease. He had discontinued fluconazole after 4 days "killed my guts." Topical clobetasol helped while he used it (few days) but then went camping & "decreased" its use (ie left it at home); also lack of sleep exacerbated his Crohn's & thus his anterior dorsum flared. I gave him a pep talk on following instructions regarding treatment.

Two months later, his mandibular vestibules were asymptomatic with healing of the linear ulcers. His anterior dorsum looked the same as initially. He discontinued prednisone 6wks ago, still on steroid inhalers but now gargles, I prescribed nystatin susp.

Two months later, he did not think nystin helped (again did not comply fully), his dorsum ulcer (ILLUSTRATED BELOW) now has a 1-2cm wide fleshy-looking barely elevated dusky margin. He was again not gargling religiously after using his steroid inhalers and as a result, his soft palate shows acute pseudomembranous Candidiasis - I again prescribed nystatin susp.

Two days ago, I performed an incisional wedge biopsy of the right margin & ulcer rim of the lesion, strongly suspecting Crohn's but wanting to rule out TB, deep Candidal or odd fungal infection or even parasitic infection. His soft palate was clinically free of Candidiasis.

His biopsy shows evidence of both lichen planus and Crohn's. There's no evidence of carcinoma / epithelial dysplasia, Candidiasis, syphillis, parasitic infection, or Herpes. PAS, ZN, B&B Gram, and GMS were all negative.

WHAT treatment would you recommend for this tongue lesion, which has shown resistance to treatment with topical clobetasol? I doubt that he'd agree to yet another (I didn't prescribe the previous ones) short course of prednisone.

Images

Case prepared by Dr. Alfredo Aguirre (BBOP Manager) and Daniel Emmer (Web Administrator, University at Buffalo School of Dental Medicine).