Facial edema, oral ulcers, and a cutaneous eruption following a dental procedure utilizing diflunisal and mepivacaine

Abstract

HISTORY OF PRESENT ILLNESS A 48-year-old Asian male was referred to our outpatient allergy clinic after experiencing oral ulcers, angioedema, and a penile skin eruption following tooth extraction and gum irrigation. Less severe reactions had occurred following two prior dental procedures. These reactions consisted of painful buccal blisters developing within 3 hours of each procedure, progressing over the next 3 days to extensive oral ulcerations. Penicillin was given before the first dental procedure in 1990. Ciprofloxacin was given before the second procedure in 1994. He did not receive any antibiotics before the third extraction in 1997. Thirty minutes before all procedures, the patient was pre-medicated with 1000 mg of oral diflunisal. During each procedure, 5.5 mL of the local anesthetic mepivacaine (2%) with the sympathomimetic vasoconstrictor neo-cobefin (1 20,000) was administered by injection. Within 1 hour following the third dental procedure, the patient complained of lip and facial swelling accompanied by burning eyes. Eighty milligrams of triamcinolone and 50 mg of diphenhydramine were given intramuscularly with moderate relief of facial swelling. He was sent home on a regimen of oral dexamethasone 1 mg tid and oral diphenhydramine 50 mg tid. Approximately 3 hours after the procedure, the patient noted the appearance of painful blisters on the buccal mucosa. The blisters progressed to oral ulcers in a manner and time course similar to that following the two prior dental procedures. On the third day post-procedure, the patient complained of severe dysphagia and noted a painful bullous, erythematous penile lesion. Neosporin ointment along with fluocinolone .025% ointment was applied topically to the penile lesion each day. Corticosteroid eye drops were also used daily. The symptoms continued to persist throughout the next 2 months, gradually diminishing in severity, and completely resolving within 3 months.