Severe Oral Lesions Research Articles

Spotting the owl: surreptitious cytomegalovirus disease in a renal transplant recipient

Cytomegalovirus (CMV) is a known cause of ulcerative oral lesions among HIV-infected patients, but such ulcers have not been previously reported in recipients of solid organ transplants. We describe a case of a renal transplant recipient who developed severe CMV-associated oral lesions despite prophylaxis with valganciclovir, and in the absence of detectable CMV viremia. The diagnosis was made only after multiple biopsies of the lesions. The patient recovered upon reducing immunosuppression. Potential pitfalls in making a prompt diagnosis are reviewed. The differential diagnosis of a large oral ulceration in a transplant recipient is broad, but should include CMV infection.

Ligneous conjunctivitis secondary to a congenital plasminogen deficiency in a dog

A 7-month-old 16.6-kg (36.5-lb) sexually intact female Golden Retriever was evaluated because of progressive severe bilateral membranous conjunctivitis, oral lesions, nasal discharge, and cough. Histologic examination of conjunctival biopsy specimens revealed findings consistent with ligneous conjunctivitis. Circulating plasminogen activity was repeatedly low, and congenital plasminogen deficiency was identified as the underlying cause of the ocular, oral, and respiratory lesions. Topical and subconjunctival administrations of fresh frozen plasma (FFP), topical administration of cyclosporine, and oral administration of azathioprine had no effect on the conjunctival membranes. Excision of the membranes followed by intensive treatment with topical applications of heparin, tissue plasminogen activator, corticosteroid, and FFP and IV administration of FFP prevented membrane regrowth. Intravenous administration of FFP increased plasma plasminogen activity to within reference limits, improved respiratory and oral lesions, and resulted in weight gain; discontinuation of this treatment resulted in weight loss, signs of depression, and worsening of lesions. After euthanasia because of disease progression, necropsy findings included mild hydrocephalus; multifocal intestinal hemorrhages; and fibrinous plaques in the oral cavity, nasopharynx, trachea, esophagus, and pericardium. Microscopically, the plaques were composed of fibrin and poorly organized granulation tissue. Fibrin thrombi were present within vessels in the lungs, oral cavity, and trachea. In dogs, congenital plasminogen deficiency can occur and may be the underlying cause of ligneous conjunctivitis. A combination of surgical and medical treatments may improve conjunctival membranes, and administration of FFP IV appears to be effective in treating nonocular signs of plasminogen deficiency.

Syndrome de Stevens-Johnson à la lymécycline (Tétralysal ®)

Reports of severe drug-induced bullous reactions to tetracyclines are rare. A case of Stevens-Johnson syndrome in a patient treated with lymecycline is reported herein. A 22 year-old woman with acne was referred for Stevens-Johnson syndrome occurring ten days after starting lymecycline. The patient was initially treated with high doses of corticosteroid. She presented with severe oral and vulvar erosions and erosive cutaneous lesions involving 5 to 7% of the body surface area. Erosive cutaneous lesions progressively extended to 20-30% of the body surface area for a 27-day period. Histological analysis of a skin biopsy showed epidermal necrolysis typical of toxic epidermal necrolysis. Epithelialization of mucosal and cutaneous lesions was achieved 34 days after lymecycline withdrawal. Stevens-Johnson syndrome is an extremely rare reaction to lymecycline. The prolonged development of skin lesions seen here after lymecycline withdrawal despite the short half life of the drug is surprising. It could have been due to use of strong systemic corticosteroids, as described in certain other case reports.

Severe tongue necrosis associated with pine processionary moth ( Thaumetopoea wilkinsoni) ingestion in three dogs

The pine processionary moth ( Thaumetopoea wilkinsoni) is an insect of medical significance in the eastern Mediterranean. This report describes three exposure cases in dogs due to ingestion of this moth's caterpillars in Israel. All three dogs were observed in direct contact with caterpillars or pinecones in infested gardens. The disease course and progression of signs were acute in all three cases, and included vomiting and severe tongue swelling. Physical examination findings included hyperthermia, tachypnoea, respiratory distress, cyanosis and tongue oedema, labial angioedema, ptyalism, bilateral submandibular lymphadenomegaly and conjunctivitis. Severe tongue necrosis and sloughing of its distal portion occurred 2–5 days after admission to the hospital. All dogs recovered and were discharged within 2–7 days of admission. Two staff members, attending one of the dogs, experienced an itchy rash and wheals on their arms, wrists and necks. To the best of our knowledge, this should be the first report of severe oral lesions and tongue necrosis due to contact with T. wilkinsoni caterpillars.

In reply:

I have carefully read the comments of Drs Thami and Bhalla on the crushing or chewing of 1-mg tablets of betamethasone for the topical corticosteroid treatment of oral erosive lesions. Betamethasone is a corticosteroid of lower potency than clobetasol propionate. 1 Cornell R Stoughton R. The use of topical steroid in psoriasis. Dermatol Clin. 1984; 2: 397-409 Google Scholar My personal experience with treating severe oral erosive lesions with intermediate-potency corticosteroids has not been promising. I believe that the low efficacy of intermediate-potency corticosteroids in severe oral erosive lesions justifies the use by many clinicians of corticosteroids of greater potency to treat these diseases, which cause such distress in patients. Moreover, besides the potency of the corticoid, the vehicle for its application is critical to the success of the treatment. The idea of using the saliva of patients as the aqueous vehicle is brilliant. Nevertheless, there may be some drawbacks to the procedure. We cannot be certain that the tablet is completely dissolved and thus cannot be sure of the concentration of corticosteroid applied, another important factor. Furthermore, this method cannot be used in patients with dry mouth, a frequent condition in altered emotional states associated with oral lichen planus. Finally, it would be of great interest to be able to read a detailed study of a series of patients treated with the proposed chew-and-spit method.

Graft-versus-host disease: Case report and discussion

The graft-versus-host disease reaction is an immunologic consequence resulting from the grafting of immunocompetent cells from one individual to an immunocompromised host. The oral manifestations of this disease process include severe oral pain, xerostemia, ulcerative lesions, and mucositis. With appropriate history and diagnostic testing, these lesions can be differentiated from other oral diseases having similar clinical appearance.

Rhinocerebral mucormycosis with severe oral lesions: A case report

Rhinocerebral mucormycosis with severe oral lesions: A case report

Epidermolysis Bullosa Simplex Associated With Muscular Dystrophy: A New Case

We report an infant with a rare form of epidermolysis bullosa simplex characterized by an autosomal recessive pattern of inheritance, severe cutaneous involvement, oral and nail lesions, associated with muscular dystrophy, and a poor prognosis, due to extracutaneous disease. In addition to the usual presentation of this disease, our patient had severe anemia, with immature circulating white cells, and bone marrow histology suggestive of a pre-leukemic state, a finding which has not before been reported in the literature.

Chronic oral infections of cats and their relationship to persistent oral carriage of feline calici-, immunodeficiency, or leukemia viruses

Two hundred and twenty-six cats from the Veterinary Medical Teaching Hospital (VMTH), a cat shelter, and a purebred cattery were tested for chronic feline calicivirus (FCV), feline leukemia virus (FeLV) and feline immunodeficiency virus (FIV) infections. Chronic oral carriage of FCV was present in about one-fifth of the cats in each of the groups. FIV infection was not present in the purebred cattery, was moderately prevalent (8%) in the pet population of cats examined at the VMTH for various complaints and was rampant in the cat shelter (21%). Unexpectedly high FeLV infection rates were found in the hospital cat population (28%) and in the purebred cattery (36%), but not in the cat shelter (1.4%). FCV and FeLV infections tended to occur early in life, whereas FIV infections tended to occur in older animals. From 43 to 100% of the cats in these environments had oral cavity disease ranging from mild gingivitis (23–46%), proliferative gingivitis (18–20%), periodontitis (3–32%) and periodontitis with involvement of extra-gingival tissues (7–27%). Cats infected solely with FCV did not have a greater likelihood of oral lesions, or more severe oral disease, than cats that were totally virus free. This was also true for cats infected solely with FeLV, or for cats dually infected with FeLV and FCV. Cats infected solely with FIV appeared to have a greater prevalence of oral cavity infections and their oral cavity disease tended to be more severe than cats without FIV infection. FIV-infected cats that were coinfected with either FCV, or with FCV and FeLV, had the highest prevalence of oral cavity infections and the most severe oral lesions.

129 GRANULOCYTE/MACROPHAGE COLONY STIMULATING FACTOR (GM-CSF) FOR TREATMENT IN GLYCOGEN STORAGE DISEASE TYPE IB

Type Ib glycogen storage disease is caused by a defect in the glucose-6-phosphatase translocase of the microsomal glucose-6-phosphatase system. In addition to metabolic problems patients exhibit a predisposition for infections which is related to neutropenia. Various degrees of impairment of the neutrophil function have been observed including reduced chemotaxis and superoxide (O2−) production. In vitro, GM-CSF stimulates growth of myeloic progenitor cells and improves functions of mature neutrophils such as formation of oxygen radicals and chemotaxis. In clinical trials, GM-CSF has been shown to increase the neutrophil count in a dose-dependent manner.A 13 year old girl with type Ib glycogen storage disease, inflammatory bowel disease (resembling Crohn's disease), and obstinate neutropenia (neutrophil counts below 500/μl) sufferd from severe oral mucosal lesions. The girl was treated with human recombinant GM-CSF at a daily dose of 250 μg/m2 subcutaneously during a 2 week course with the parents' informed consent. From the third day of treatment the neutrophil count increased continuously from 216/μl to 6052/μl at day 14. At the same time, normal superoxide production was measured in the isolated granulocytes activated by PMA or zymosan. Oral ulcers resolved completely. Except for some painful hyperemic areas at the sites of injections no side effects appeared. After GM-CSF administration was discontinued leucocyte counts decreased to pre-treatment levels within 7 days.From the results of this limited clinical trial we conclude that GM-CSF can increase the neutrophil count and normalize specific granulocyte functions in glycogen storage disease Ib. GM-CSF might be of clinical benefit in managing severe inflammatory complications in neutropenic patients with this disorder.

Psittacine Pox Virus: Virus Isolation and Identification, Transmission, and Cross-Challenge Studies in Parrots and Chickens

An avian pox virus was isolated from Amazon parrots dying with severe diphtheritic oral, esophageal, and crop lesions. The virus was propagated on chorioallantoic membranes (CAM) of 10-day-old chicken embryos, and a homogenate of the infected CAM was rubbed vigorously onto the conjunctiva, oral mucosa, and defeathered follicles of two healthy Amazon parrots and three conures. All experimental birds developed cutaneous and ocular pox lesions, and one parrot developed oral pox lesions. Specific-pathogen-free chicks inoculated with the virus isolate developed skin lesions identical to those of the parrots. Chickens vaccinated with fowl and pigeon pox vaccines and inoculated with the psittacine isolate developed lesions typical of avian pox. Chickens vaccinated with the psittacine virus were susceptible to fowl and pigeon pox virus infection. This pox virus isolate may thus be regarded as a potential pathogen for chickens.

Egg production, shell thickness, and other physiological parameters of laying hens affected by T-2 toxin.

T-2 toxin has been reported to cause severe oral lesions and neural disturbances in young broiler chickens. T-2 toxin, when added at a level of 20 mug per g of feed, caused oral lesions but no abnormal neural disturbances in young broiler chickens. T-2 toxin, when added at a level of 20 mug per g of feed, caused oral lesions but no abnormal neural symptoms in laying hens. T-2 toxin had no effect on either hemoglobin, hematocrit values, erythrocyte count, plasma glucose, prothrombin times, or the sizes of the liver, spleen, pancreas, and heart. Lipid content of the liver was not altered. Feed consumption, however, was reduced, as were the total plasma protein and lipid concentrations and the total leukocyte count. Most important economically was the lowered egg production and a thinner egg shell. The timing and severity of the symptoms suggest that T-2 toxin causes primary oral lesions that reduce feed consumption with a consequent reduction in serum proteins and lipids, which culminate in decreased egg production. The leucopenia and thinner egg shell may be independent systemic effects of T-2 toxin in laying hens.

Egg Production, Shell Thickness, and Other Physiological Parameters of Laying Hens Affected by T-2 Toxin1

T-2 toxin has been reported to cause severe oral lesions and neural disturbances in young broiler chickens. T-2 toxin, when added at a level of 20 mug per g of feed, caused oral lesions but no abnormal neural disturbances in young broiler chickens. T-2 toxin, when added at a level of 20 mug per g of feed, caused oral lesions but no abnormal neural symptoms in laying hens. T-2 toxin had no effect on either hemoglobin, hematocrit values, erythrocyte count, plasma glucose, prothrombin times, or the sizes of the liver, spleen, pancreas, and heart. Lipid content of the liver was not altered. Feed consumption, however, was reduced, as were the total plasma protein and lipid concentrations and the total leukocyte count. Most important economically was the lowered egg production and a thinner egg shell. The timing and severity of the symptoms suggest that T-2 toxin causes primary oral lesions that reduce feed consumption with a consequent reduction in serum proteins and lipids, which culminate in decreased egg production. The leucopenia and thinner egg shell may be independent systemic effects of T-2 toxin in laying hens.

Some findings in patients with uraemic stomatitis

Uraemic stomatitis may occur in patients with advanced renal failure. Thirteen patients with severe oral lesions due to their uraemic state are discussed. The stomatitis became manifest after a few days of severe renal failure (blood urea level was at least 20 mnol./1) and persisted for 2-3 weeks even when the urea concentration had decreased.

The Effects of T-2 Toxin in Broiler Chickens

T-2 toxin is a mycotoxin produced by several species of Fusarium and small concentrations have been reported earlier to cause severe oral lesions in chickens. Graded concentrations (0, 1, 2, 4, 8, and 16 μg./g.) of dietary T-2 toxin were given to groups of 40 broiler chickens. A total of 240 chicks were used in these experiments. The growth rate was reduced significantly (P < 0.05) by concentrations of 4, 8, and 16 μg./g. but not by lower concentrations while the feed conversion ratios were unaffected by any concentration. The relative weight of the spleen was decreased and the relative weight of the pancreas was increased by the growth inhibitory concentrations. The bursa of Fabricius was reduced in relative weight by concentrations of 8 and 16 μg./g. while the relative weight of the crop was increased. The relative weight of the liver was unaffected as was its lipid content and its percent of dry matter; however, there was a dose-related increase in liver hematomas. The hemoglobin, serum proteins, serum cholesterol, serum total lipids, plasma glucose, and plasma uric acid were unaffected as were the capillary fragility, lateral shear strength of breast muscle, and liver acid phosphatase which is a marker enzyme of lysosomes. These data suggest that severe oral lesions which impair their ability to eat are the primary effect of T-2 toxin in chickens. Secondarily with greater concentrations, T-2 toxin exerts its systemic effects on the chickens.

Severe oral lesions in chickens caused by ingestion of dietary fusariotoxin T-2.

Fusariotoxin T-2 is a mycotoxin produced by Fusarium tricinctum which was implicated in moldy corn toxicosis of farm animals. Graded concentrations of dietary fusariotoxin T-2 (0, 1, 2, 4, 8, and 16 mug/g, respectively) were given to groups of 40 chickens. Raised yellowish-white lesions on the mouth parts were produced by all concentrations, and the size of the lesions was dose-related. The growth rate was reduced significantly (P < 0.05) by concentrations of 4, 8, and 16 mug/g. The mouth fluid of the affected birds contained greatly increased numbers of bacteria, including Staphylococcus epidermidis and Escherichia coli, which proved avirulent when inoculated into scarified tissue of control birds. Microscopy examinations of the lesions revealed a fibrinous surface layer, intermediate layers containing invaginations filled with rods and cocci, and a heavy infiltration of the underlying tissues with granular leukocytes. These data suggest that the role of fusariotoxin T-2 in field cases of moldy corn toxicosis should be reinvestigated since oral lesions were not mentioned in the original descriptions of the disease. However, the lesions bear some features of those characteristic of the third or septic angina stage of alimentary toxic aleukia, a nutritional toxicosis of humans produced by eating grains infested with F. tricinctum.

Severe Oral Lesions in Chickens Caused by Ingestion of Dietary Fusariotoxin T-21

Fusariotoxin T-2 is a mycotoxin produced by Fusarium tricinctum which was implicated in moldy corn toxicosis of farm animals. Graded concentrations of dietary fusariotoxin T-2 (0, 1, 2, 4, 8, and 16 mug/g, respectively) were given to groups of 40 chickens. Raised yellowish-white lesions on the mouth parts were produced by all concentrations, and the size of the lesions was dose-related. The growth rate was reduced significantly (P < 0.05) by concentrations of 4, 8, and 16 mug/g. The mouth fluid of the affected birds contained greatly increased numbers of bacteria, including Staphylococcus epidermidis and Escherichia coli, which proved avirulent when inoculated into scarified tissue of control birds. Microscopy examinations of the lesions revealed a fibrinous surface layer, intermediate layers containing invaginations filled with rods and cocci, and a heavy infiltration of the underlying tissues with granular leukocytes. These data suggest that the role of fusariotoxin T-2 in field cases of moldy corn toxicosis should be reinvestigated since oral lesions were not mentioned in the original descriptions of the disease. However, the lesions bear some features of those characteristic of the third or septic angina stage of alimentary toxic aleukia, a nutritional toxicosis of humans produced by eating grains infested with F. tricinctum.

Development and clinical investigation of a new oral surface anesthetic for acute and chronic oral lesions

Various solutions of antihistamines and dyclonine hydrochloride were compared with lidocaine hydrochloride as topical applications for relief of pain in patients with severe oral lesions. Preliminary screening indicated that dyclonine hydrochloride and lidocaine hydrochloride demonstrated excellent anesthetic qualities and that solutions of diphenhydramine hydrochloride produced mild anesthesia of prolonged duration. The combination of dyclonine hydrochloride and diphenhydramine hydrochloride in saline solution produced effective anesthesia in the lowest concentrations under study. Anesthesia persisted for periods of one to two hours in forty-four patients studied for periods ranging from seven to 540 days. One allergic reaction to 0.5 per cent dyclonine hydrochloride—0.5 per cent diphenhydramine hydrochloride solution was described. Self-administered, either applied with cotton-tipped applicators directly to the mucosal lesion or used as a mouthwash, a 0.5 per cent dyclonine hydrochloride—0.5 per cent diphenhydramine hydrochloride solution gave adequate to excellent relief from pain in most of the patients studied.

Treatment of Pellagra by Means of Parenteral Liver Extract

Goldberger and Sebrell1 found that liver extract fed to dogs in large amounts either prevented or retarded the development of blacktongue (a disease which they consider analogous to pellagra of human beings). Boggs and Padgett2 stressed the curative value of liver (not liver extract) in pellagra and Smith and Ruffin3 stated that large amounts of liver extract by mouth were efficacious in treating the disease. Ramsdell and Magness4 in a preliminary study on the effects of intramuscular liver extract on the course of pellagrins, gave small daily doses and at the same time allowed the patients a highly nutritious diet. They felt that the intramuscular administration of liver extract resulted in clinical improvement but stated the patients were not given a basic diet. Since many pellagrins have severe oral lesions and refuse to eat, it seemed worthwhile to determine the therapeutic efficacy of intravenous liver extract under controlled experimental conditions.Six patients with the classical skin and oral lesi...