Forum for Clinical and Surgical Oral Pathology

Case BBOPF 21-2

Dr. Patricia Brooks (Princess Margaret Cancer Centre, Toronto, Canada) would like to get input on the following case BBOP 21-2. The case will be posted until April 4, 2021. A summary of the responses will ensue shortly after.

History

25 year old Lebanese female

Ten year history of raised and ragged ulcerations of the keratinized and non-keratinized oral mucosa. Ulcers tend to resolve in about 4 weeks, but new ones occur. Generally accompanied by lower lip swelling. No palpable cervical lymphadenopathy. No eye, skin, or genital lesions.
Ulcers respond slightly to topical corticosteroids.
Otherwise, healthy, no medications. No recurrent fevers/infections, no joint swelling/pain, no GI symptoms, no difficulties breathing.
Never smoker, rare alcohol use. No known drug or environmental allergies. No one else in her family experiences oral ulcers.

Investigations:
Oral biopsies (taken at time of attached clinical images):
Right buccal/labial mucosa - parakeratinized stratified squamous epithelium and ulcer covering inflamed fibrous connective tissue. Inflammatory infiltrate consists primarily of lymphocytes, plasma cells, and scattered neutrophils extending into the deeper submucosal tissue around neurovascular structures. Definitive evidence of granulomatous inflammation is not seen. GMS, PASD, and Warthin Starry stains are interpreted to be negative.
Left hard palate - parakeratinized stratified squamous epithelium and ulcer covering minimal fibrous connective tissue showing subacute mucositis.

Slightly elevated ESR and CRP when the ulcerations are particularly prominent. Otherwise, all other values have been normal. ANA negative 2x over 4 years.
Chest x-ray normal.
Recent colonoscopy and endoscopy, no abnormalities detected. Biopsy results all within the range of normal. Nothing suggestive of Crohn’s or Celiac disease. Allergy testing for standard environmental allergens and food was negative.

Images

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