Forum for Clinical and Surgical Oral Pathology

Case BBOPF 13-1

53 Y Caucasian male with a history of DM1, s/p renal and heart transplant (1998) immunosuppressed with mycophenolate mofetil, prednisone, and cyclosporine, s/p b/l LE amputation, s/p CVA, and ESRD with oral erosions since January and scrotal erosion since early May.

Oral erosions came about in January and have remained unchanged since that time. They have not grown or changed. He has never had any partial or complete denture and no mechanical trauma to the area. The scrotal erosion has also remained unchanged since he first noticed it in early May. He has never had any cold sores or genital erosion prior to this episode. The erosions are not painful, but do bleed often and only at night.

He has been seen by ENT and had a biopsy of the hard palate performed on 4/30/13, but this only showed a "polypoid fragment of ulcerated squamous mucosa." On initial visit with dermatology on 6/6/13, biopsies for H&E as well as DIF were performed, which showed "erosion and ulceration with dermal fibrosis." The DIF showed granular C3 at the BMZ, both of which are non-specific. An IIF was negative for autoantibiodies to the BMZ and ELISA was negative for DSG 1 and DSG 3, all making pemphigus unlikely. An HSV NAAT was negative and a routine bacterial culture showed 1+ E. Coli, 1+ Klebsiella pneumoniae, 1+ enterococcus, and 2+ mixed skin flora.

Since that time, he has continued to have bleeding from the oral erosions (not from the scrotal erosion) and has noted blood on the pillow. Most recent CBC showed a hgb of 9.7. The only treatment attempted to date has been vaseline to the scrotum.

My first thought was that these oral lesions are similar to what we see in AIDS patients and might respond to thalidomide. I'd be interested in the collective wisdom on BBOP as to what the lesions represent and how they would treat them. Many thanks.

Denis

Denis P. Lynch, D.D.S., Ph.D.
Professor of Oral and Maxillofacial Pathology
Marquette University School of Dentistry

Images

(Larger images will open in a new window or tab.)

[Click for a larger image] Figure 1	[Click for a larger image] Figure 2
[Click for a larger image] Figure 3	[Click for a larger image] Figure 4
[Click for a larger image] Figure 5

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