Lip Ulcers Research Articles

Quality by Design-Steered Development of Stealth Liposomal Formulation of Everolimus: A Systematic Optimization and Evaluation.

Everolimus is a drug approved for the treatment of breast cancer with HR+ and advanced breast cancer reoccurring in postmenopausal women. The oral administration of EVE has been observed to have low oral bioavailability and severe epithelial cutaneous events that include rashes and lip ulceration followed by mouth ulceration after oral administration. The present research aimed to enhance the bioavailability by loading the EVE into a stealth liposomal formulation (S-EVE-LIPO) intended for intravenous administration. The surface of the liposomes was modified with vitamin E TPGS, which prolongs the systemic circulation of the drug and provides additional benefits like inhibition of the P-gp efflux pump and acting synergistically with EVE. The formulation was prepared using the thin film hydration method and optimized using a D-optimal mixture design. ANOVA suggested the significance of the proposed mathematic model, and the optimized formulation was generated by design expert software. The optimized formulation (S-EVE-LIPO) was observed with nanometric size (99.5 ± 3.70 nm) with higher encapsulation efficacy (81.5 ± 2.86 %). The S-EVELIPO formulation indicated a sustained release profile as 90.22% drug release was observed in 48 h, whereas the formulation without vitamin E TPGS (EVE-LIPO) released only 74.15 drugs in 24 hours. In vitro cytotoxicity study suggested that the presence of vitamin E TPGS lowers the IC50 value (54.2 ± 1.69), increases the cellular uptake of the formulation, also increases the generation of ROS, and shows better hemocompatibility. Vitamin E TPGS could be set as a vital additive to improve therapeutic efficacy and reduce offsite toxicity and dosing frequency.

Rare presentation of drug-induced oral erythema multiforme and its management: a case report

Aim. This case report discusses a rare variant of drug-induced erythema multiforme, focusing on its clinical features, diagnosis, and management. Background. Drug-induced erythema multiforme (DI-EM) is a hypersensitivity reaction occurring due to exposure to certain medications. DI-EM typically presents as erythematous and painful lesions on the oral mucosa, including the lips, tongue, and buccal mucosa. Case description. A 42-year-old male was referred to the Oral Medicine clinic with a chief complaint of painful lip ulceration and eruptions on the body after consuming medications. A detailed history was taken, and after a thorough examination, a perilesional biopsy for histopathological and immunopathological tests was performed. Following the exclusion of all other conditions with a similar presentation, a diagnosis of drug-induced erythema multiforme (DI-EM) was established. Conclusion. DI-EM can pose a diagnostic challenge due to its presentation. However, a diagnosis can be established by excluding other conditions associated with chronic inflammation or the formation of vesicles or bullae. Clinical Significance. DI-EM is a rare variant of EM with a very low prevalence in the general population, making it a challenging condition to diagnose due to its similarity in presentation with other mucocutaneous disorders. A thorough medical history, along with histopathology and immunology tests, coupled with ruling out other diseases and noting a positive history of recent drug consumption, aids in recognizing this condition, given the absence of any confirmatory diagnostic test. Early diagnosis and cessation of causative drugs, along with supportive medications, contribute to the complete resolution of the condition.

Simultaneous Oral Bullous Pemphigoid and Paraneoplastic Pemphigus Following Photoimmunotherapy

Head and neck cancers pose a significant challenge to clinicians to treat the disease while limiting the amount of morbidity to the patient. Given this need, new trials and medications have been explored to provide tissue sparing therapies. One of these methods being trialed at our institution is photoimmunotherapy with the PD1 inhibitor pembrolizumab. A patient with multiple recurrences of squamous cell carcinoma of the oral cavity underwent trial with photoimmunotherapy, but developed severe lip ulceration and swelling that required the patient to discontinue the trial. Biopsy and antibody testing revealed elevated levels of BP180 and BP230 indicating bullous pemphigoid. In addition, elevated Envoplakin was noted confirming a simultaneous paraneoplastic pemphigus diagnosis. Given the growing number of case reports showing an association of paraneoplastic pemphigus and bullous pemphigoid with pembrolizumab and other PD1 inhibitors, further investigation should be undertaken to better understand the incidence of these diseases with photoimmunotherapy.

Fusarium proliferatum-induced chronic lip ulcer: successful treatment with itraconazole: a case report

BackgroundFusarium species are saprophytic fungi with a worldwide distribution. These fungi cause various infections among immunocompromised patients; however, they can also involve immunocompetent individuals.Case presentationWe report a case of a 41-year-old Iranian woman who presented with ulcerative lesions on her lips 10 months ago. She had a long history of anxiety but had no history of classical risk factors such as trauma, cosmetic lip tattoo, burning in her lips, smoking or use of alcohol and opium. A skin biopsy from the lower lip was performed and sent for microbiological examinations. Hyaline septate hyphae were seen on direct microscopy with potassium hydroxide. The clinical specimen was subcultured on sabouraud dextrose agar with chloramphenicol and prepared for antifungal susceptibility testing and molecular identification. Considering the minimum inhibitory concentrations (MIC) for antifungals, itraconazole (100 mg orally twice a day) was started for her, and after 2 months, the lesions were treated. She followed up for 3 months, and no signs of disease recurrence were observed.ConclusionsSelecting an appropriate treatment strategy according to the laboratory assessments is essential in clinical practice and the management of rare infections to prevent related mortality and morbidity of opportunistic fungal infections.

P081 Unravelling SLE in a young male child

Abstract Background Juvenile-onset systemic lupus erythematosus (jSLE)) is a rare but severe multisystem autoimmune, inflammatory disease that can affect any organ system and cause significant morbidity and mortality. The disease onset occurs before the age of 18, however the peak age of onset is between 12 and 14 years and it affects ∼15–20% of all SLE patients. Patients with disease onset before 5 years of age are very uncommon and may be referred to as early-onset SLE. They commonly present with fever and general malaise, rash and arthritis. In addition, cases of jSLE, tend to have more severe organ manifestations and greater damage at the time of diagnosis as well as a higher incidence of renal, cardiovascular and neuropsychiatric involvement. Compared with adult-onset SLE, it is more aggressive, with higher medication burden including corticosteroids and other immunosuppressive drugs. Method and results This case report reviews the journey of a 5-year-old boy, who developed recurrent skin rashes, fever and generalised lymphadenopathy in his second year of life. After multiple hospital admissions and various investigations at different facilities spanning a year, he was admitted to the paediatric emergency unit at a tertiary hospital on account of an acute infection. On presentation, he was pyrexial. There were hypo- and hyperpigmented lesions extending over his scalp, face and upper arms as well as vasculitic lesions in his palms and soles; lip ulcers, sparse brown hair and multiple, non-tender lymph nodes in the cervical, supraclavicular and axillary regions. Respiratory examination revealed a right lobar pneumonia. Heart rate was 112 bpm and heart sounds were normal, however an echocardiogram showed a moderate pericardial effusion with no signs of tamponade. His abdomen was distended with a non-tender hepatomegaly. There was no synovitis. He was lethargic, but had no focal neurological signs. Laboratory results were as follows: normocytic anaemia (8.5 g/dl); ESR (120 mm/h); deranged transaminases; albumin (32 g/dl); Creatinine (12umol/l); urinalysis was normal, positive antinuclear antibody (1:320); positive double-stranded DNA (1:40); positive anti-smith, anti-Ro and anti-RNP antibodies; low C3, C4. A lymph node biopsy showed reactive changes only, with no evidence of haematological malignancy. The diagnosis of jSLE was confirmed at age 3yrs. The acute illness due to pneumonia was treated with antibiotics. Prednisolone 10 mg, Hydroxychloroquine (HCQ) 80 mg daily, Azathioprine 25 mg daily, calcium supplementation and gastric protection were added to manage the jSLE. He made an initial recovery and was managed in the outpatient clinic for months. However, his illness flared up again around age 4 years when he developed generalized seizures, facial and pedal oedema, low urine output, proteinuria 3+, low albumin (25 g/dl), creatinine (252umol/l) and high urine albumin-creatinine ratio (278.62 mg/mmol) reflecting new renal and CNS involvement. A renal biopsy was not available. He received pulse iv methylprednisolone 250 mg daily for 3 days followed by monthly iv cyclophosphamide therapy 500 mg (NIH Regime) which was discontinued after the 5th cycle due to haemorrhagic cystitis. He eventually continued treatment with mycophenolate mofetil 125 mg daily, HCQ 80 mg daily, Prednisolone 10 mg daily, Nifedipine and Enalapril and a year later, has low activity from the cutaneous, renal and CNS manifestations. There is renal damage (creatinine 180 μmol/l) and hypertension, as well as treatment complications from prednisolone causing bilateral cataracts. Conclusion Early diagnosis of jSLE is still a challenge and a high index of suspicion is required especially in the very young. Severe presentation and aggressive clinical course is associated with tissue damage, as in the case presented. Management is complex and we were challenged by the choice and availability of treatment suitable for the severity of his disease, bearing in mind that damage can occur early especially in a male child. In addition, it is important to consider his young age and long-term exposure to drug toxicity and complications.

A necrotic orofacial lesion presenting in an immunocompromised patient in the UK: case review with features of noma

Noma is a gangrenous and destructive orofacial disease. It comes from the Greek word nomein, meaning ‘to devour’. Caused by a rapidly spreading opportunistic infection, noma has a strong affiliation to extreme poverty and is infamously known as the ‘face of poverty’. It is predominantly endemic to children between the ages of two and six who are malnourished, and is incited by disease. However, there is rare precedent of this disease emerging in adulthood in more economically developed countries, with noma-like lesions in the UK doubling since 2015. We report on a 90-year-old patient who initially presented to their general medical practitioner for a necrotic lip ulcer, which was originally thought to be a cold sore. The patient was later admitted to hospital due to reduced mobility and severe anaemia, with underlying features of sepsis, malnutrition, immunosuppression, oral necrosis and progressive ulceration over three weeks. Immediate treatment began following admission, including intravenous antibiotics, oral care and nutritional supplementation, before a definitive clinical diagnosis of noma was made after a biopsy, which ruled out malignancy. The rapid treatment response, albeit before a diagnosis was confirmed, allowed for the disease process to halt. This atypical presentation in a UK hospital highlights the need for periodic review of such lesions, so that current knowledge of their presentation and management is maintained.

The Possible Healing Effect of Aloe Vera versus Silver Nanoparticles on Acid Induced Lip Ulcer in Albino Rats (Histological and Immuno-histochemical Study)

The Possible Healing Effect of Aloe Vera versus Silver Nanoparticles on Acid Induced Lip Ulcer in Albino Rats (Histological and Immuno-histochemical Study)

Interim Results from a Phase 1 Study of ADCT-301 (Camidanlumab Tesirine) Show Promising Activity of a Novel Pyrrolobenzodiazepine-Based Antibody Drug Conjugate in Relapsed/Refractory Hodgkin/Non-Hodgkin Lymphoma

Interim Results from a Phase 1 Study of ADCT-301 (Camidanlumab Tesirine) Show Promising Activity of a Novel Pyrrolobenzodiazepine-Based Antibody Drug Conjugate in Relapsed/Refractory Hodgkin/Non-Hodgkin Lymphoma

P0705 / #733: SUCCESSFUL APPLICATION OF SYNTHETIC AND BIOLOGICAL SKIN SUBSTITUTE TO A CHILD WITH TOXIC EPIDERMAL NECROLYSIS

Aims & Objectives: Report the successful application of synthetic and biological skin substitute to a child with toxic epidermal necrolysis Methods: Descriptive case report Results: A 2 years old female with a two days history of fever, reduced oral intake and loose stool, she was treated with multiple drugs (antibiotics, antiviral, acetaminophen, antihistamines, dexpanthenol, zinc acetate) with no improvement. Five days later, she developed progressing reddish rash with symmetrical exfoliation affecting face, scalp, neck, trunk, both upper limbs and both lower limbs. As the rash worsened, the child developed oral and lip ulcers, hemorrhagic lesions of the oral mucous membrane, purulent conjunctivitis. Her general condition deteriorated and she was therefore transferred to a Intensive Care and Pediatric Burn Unit. Intravenous fluid resuscitation was initiated with commencement of nasogastric feeding and adequate opioid analgesia. She received a single dose of intravenous immunoglobulin as well as a three day course of steroids. On day 2 the affected areas were debrided. A synthetic copolymer based on DL-lactide, Trimethylenecarbonate and e-caprolactone (Suprathel) was applied to the entire left arm, right arm, left leg, right leg, trunk circumferentially, then covered with paraffin gauze (Adaptic) and dry dressings. The face area was covered with an extracellular matrix graft (OASIS Wound Matrix) a porcine derived collagen scaffold. All areas were completely healed at 6 days, no longer required dressings. Discharged after 1 week with follow-up at outpatient consultation.Conclusions: In conclusion wound coverage using synthetic and biological skin substitute enables easier application, less exudation with fewer dressing changes, reduced pain and earlier re-epithelialization.

Abstract PS11-11: Targeted safety events from a phase I/Ib study evaluating GDC-0077 alone and in combination with endocrine therapy (ET) ± palbociclib (palbo) in patients (pts) with PIK3CA-mutant (mut), hormone receptor-positive/HER2-negative metastatic breast cancer (HR+/HER2- mBC)

Abstract Background Activating mutations in PIK3CA, encoding the p110α subunit of phosphatidylinositol 3-kinase (PI3K) occur in ~40% of HR+/HER2- BCs. GDC-0077, a PI3Kα-selective inhibitor and mutant PI3Kα degrader, is being developed as an anticancer agent. A phase I/Ib study of GDC-0077 alone and combined with other therapies is ongoing in pts with locally advanced or metastatic PIK3CAmut, HR+/HER2- mBC (NCT03006172). Targeted safety events are presented here. Methods Safety was assessed via NCI-CTCAE v4 for GDC-0077 administered alone (Arm A), with letrozole and palbo (Arm B), with letrozole (Arm C), with fulvestrant (Arm D), or with fulvestrant and palbo (Arm E, plus metformin in Arm F for pts with body mass index ≥ 30 and/or HbA1c ≥ 5.7%), in 28-day cycles until intolerable toxicity or disease progression. GDC-0077 was administered orally daily at 3, 6, 9, or 12 mg; letrozole, at 2.5 mg orally daily; palbo, at 125 mg orally 21/28 days; and fulvestrant, at 500 mg intramuscularly every 4 weeks. Targeted adverse events (AEs) included hyperglycemia, diarrhea, stomatitis (includes stomatitis, mucosal inflammation, mouth ulceration, glossitis, lip ulceration, palatal ulcer, and tongue ulceration), rash (includes rash, maculopapular rash, dermatitis acneiform, erythema, and erythematous rash), neutropenia (includes neutropenia and neutrophil count decreased), thrombocytopenia, and pneumonitis. Results As of clinical data cutoff (03/20/2020), 157 pts were enrolled and treated (Arm A: 20; Arm B: 33; Arm C: 37; Arm D: 39; Arm E: 13; Arm F: 15). Median cumulative dose intensity was 97.2% for GDC-0077, 90.6% for palbo, 99.9% for letrozole, and 100% for fulvestrant. Pneumonitis was reported in 2 pts, both in palbo-containing arms (grade 1 in Arm B; grade 2 in Arm F). Hyperglycemia required antihyperglycemic treatment in 69 pts (44%), and the most frequent agents used were metformin (39%; except Arm F where this was required as part of study treatment), empagliflozin (16%), and sitagliptin (15%). Fifteen pts (10%) required GDC-0077 dose reductions due to hyperglycemia. Stomatitis treatment was administered in 51 pts (32%), with dexamethasone mouthwash used most frequently (22%). Neutropenia and thrombocytopenia were managed with palbo dose reduction in 13 pts (21%) and 1 pt (2%), respectively. Overall, treatment-related AEs led to GDC-0077 discontinuation in 2 pts (1%) (grade 3 hyperglycemia in Arm B; grade 2 panniculitis in Arm F). Conclusion Targeted safety events with GDC-0077 alone and in combination ET ± palbo were manageable and required minimal GDC-0077 dose modifications or discontinuations. No unexpected safety events were reported in combination with palbo. A phase III study of GDC-0077 in combination with palbo and fulvestrant is enrolling currently (NCT04191499). Pts, n (%)Treatment-related AEsTreatment-related grade ≥ 3 AEsAll arms;All arms;N = 157N = 157Hyperglycemia98 (62)36 (23)Stomatitis (grouped terms)69 (44)2 (1)Diarrhea68 (43)0Rash (grouped terms)19 (12)1 (1)Palbo arms (B/E/F);Palbo arms (B/E/F);N = 61N = 61Neutropenia45 (74)36 (59)Stomatitis (grouped terms)41 (66)2 (3)Thrombocytopenia19 (31)4 (7) Citation Format: Mafalda Olivera, Komal Jhaveri, Dejan Juric, Philippe L Bedard, Andrés Cervantes, Valentina Gambardella, Erika Hamilton, Antoine Italiano, Kevin Kalinsky, Ian E Krop, Peter Schmid, Nicolas Turner, Andrea Varga, Guiyuan Lei, Stephanie Royer-Joo, Piia Thomas, Jennifer L Schutzman, Cristina Saura. Targeted safety events from a phase I/Ib study evaluating GDC-0077 alone and in combination with endocrine therapy (ET) ± palbociclib (palbo) in patients (pts) with PIK3CA-mutant (mut), hormone receptor-positive/HER2-negative metastatic breast cancer (HR+/HER2- mBC) [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS11-11.

KERATINIZED SQUAMOUS CELL CARCINOMA CLINICALLY PRESENTING AS ACTINIC CHEILITIS

Actinic cheilitis (AC) is a potentially malignant disorder of the lip caused by exposure to solar radiation and warrants special attention because its malignant transformation rate varies from 10% to 20%. A 59-year-old male patient sought out a stomatology service with a lip wound. He reported being a smoker and alcoholic and working under sun exposure. Extrabuccal examination revealed dryness of the lower lip and leucoerythroblastic and ulcer lesions measuring 1.3 × 0.6 cm in total area. The clinical diagnosis of actinic cheilitis and differential leukoerythroplasia. There were no lesions in the mouth. An incisional biopsy was performed, and the histopathologic result was keratinized squamous cell carcinoma. The patient was referred for surgical treatment. This report is relevant because it shows how early diagnosis can optimize treatment and substantially improve the patient’s life.

ONCOLOGIC PATIENT WITH JAW LESION: A POSSIBLE METASTASIS?

An 82-year-old female patient presented as main complaint burning teeth, gums, and lips. In the anamnesis, we reported the diagnosis of clear cell carcinoma in the right kidney and metastasis in the lungs. Intraoral oral examination revealed lesions of pseudomembranous candidiasis in the jugal mucosa, palate, vestibule, and oropharynx, as well as lower lip ulcers. On return, she reported pain in the lower alveolar ridge, on the left side, with slight erythematous swelling. Panoramic radiography was requested, and later computed tomography scan. Bone cortical rupture and pathologic fracture of the mandible were observed, with a diagnostic hypothesis of neoplasia. Biopsy of the region was indicated; however, the patient was too weak. During hospital visit, we observed increased rash swelling and persistence of pain. Total improvement in the lesions of candida was verified. The oral cavity was cleaned and we realized the photographic record. Patient died 1 month after the last visit. An 82-year-old female patient presented as main complaint burning teeth, gums, and lips. In the anamnesis, we reported the diagnosis of clear cell carcinoma in the right kidney and metastasis in the lungs. Intraoral oral examination revealed lesions of pseudomembranous candidiasis in the jugal mucosa, palate, vestibule, and oropharynx, as well as lower lip ulcers. On return, she reported pain in the lower alveolar ridge, on the left side, with slight erythematous swelling. Panoramic radiography was requested, and later computed tomography scan. Bone cortical rupture and pathologic fracture of the mandible were observed, with a diagnostic hypothesis of neoplasia. Biopsy of the region was indicated; however, the patient was too weak. During hospital visit, we observed increased rash swelling and persistence of pain. Total improvement in the lesions of candida was verified. The oral cavity was cleaned and we realized the photographic record. Patient died 1 month after the last visit.

Effectiveness of gold sea cucumber (Stichopus hermanii) extracts in accelerating the healing process of oral traumatic ulcer in rats

Introduction: Gold sea cucumber (Stichopus hermanii) is a marine organism that contains omega-3 and glycosaminoglycan for enhancing collagen needed in the healing process. This study was aimed to determine the effectiveness of gold sea cucumber extracts in accelerating the healing process of oral traumatic ulcer in Wistar rats, in terms of the correlation between collagen type I expression, ulcer diameter, and body weight loss. Methods: Twenty Wistar rats (Rattus norvegicus) was divided into four groups and treated with gold sea cucumber extracts with the concentration of 80%, 40%, and 20% in the form of 0.1 ml gel daily. The negative control group received no treatment. Ulceration of the lower lip of labial mucosa was induced by a burnisher. The animals were observed for 7 days, during which they were weighed and the ulcers diameter was measured. The rats were then sacrificed after 7 days of treatment. Histometric analysis of collagen type I expression was also performed. Data obtained were analysed for differences between the group with one-way ANOVA test and the correlation was analysed with the Pearson test. Results: The significant differences (p < 0.05) between treatment groups was found in the ulcer diameters and the collagen type I expression. The most decreased ulcer diameter and the highest collagen type I expression detected in the group of treatment with a concentration of 80% — no significant differences found in the weight loss between-groups (p > 0.05). Strong correlation was also found between the expression of collagen type I and diameter of ulcer (Pearson correlation = 0.599, p = 0.05), however, no correlation found between weight loss with the expression of collagen type I (Pearson correlation = -0.102, p = 0.66), and the ulcer diameter (Pearson correlation = 0.022, p = 0.92). Conclusion: Gold sea cucumber had a potential benefit to be used as a traumatic ulcer healing medicament. Water extract of gold sea cucumber able to accelerate traumatic ulcer healing by enhancing the production of collagen type I and reduce the diameter of ulcer. There is a strong correlation between collagen type 1 expression and diameter of ulcer, and a weak correlation found between body weight loss and collagen type I expression, also with reducing ulcer diameter.Keywords: Gold sea cucumber, Stichopus hermanii, healing process, traumatic ulcer.

Does Orthodontic Treatment induce Erythema Multiforme

Oral erythema multiforme (EM) is considered as a third category of EM other than EM minor and major. Patients present with oral and lip ulcerations typical of EM but without any skin target lesions. It has been reported that primary attacks of oral EM is confined to the oral mucosa but the subsequent attacks can produce more severe forms of EM involving the skin. Hence, it is important to identify and distinguish them from other ulcerative disorders involving oral cavity for early management. This article reports a case of oral EM that presented with oral and lip ulcerations typical of EM without any skin lesions during first phase of orthodontic treatment and highlights the importance of early diagnosis and proper management.

Feline dental implants: new paradigm shift in maxillary alveolar osteitis treatment planning with osseodensification

Background Felines are obligate carnivores and use their teeth for prehending as well as tearing and dissecting their food. Mastication is the first step of digestion, aiding in the lubrication of the food and the formation of a bolus. Mastication also increases the surface area of the food to be initially digested by salivary enzymes before being more easily swallowed. The teeth are specialized structures which play an important role in mastication, grooming, supporting the lips and the tongue, as well as being used as weapons for hunting and for self-defense. Although some mammals can still survive with few or no teeth at all, cats included, losing teeth can influence the types of foods that can be eaten, and will affect the ability to masticate and processing of the food prior to swallowing. Dental implants have become an option for replacement of lost canines in these animals. Although cats appear to manage well after a canine extraction, complications such as lip entrapment can occur, especially after maxillary canine tooth extraction. Even cats with a complicated crown fracture of the maxillary canine tooth that have had root canal therapy to preserve the tooth, can still suffer from lip entrapment. This can lead to painful lip ulcers and the need for further dental treatment. Today, canine tooth replacement with a dental implant/crown is a predictable option that can be offered to clients who would like to replace a lost canine tooth. Case report Two long term cases and follow up of lost maxillary canines caused by alveolar osteitis and replacement by dental implants, to restore normal function in feline subjects are reported. Conclusion Dental implants proved to be a viable long-term treatment option in the 2 cats described.Immediate implant placement at the time of extraction helps to maintain the surrounding bone structures and prevent collapse of the labial buccal plate. So far, the authors have placed 30 implants in 15 feline subjects up to a 3-year follow-up and no integration failures have been observed to date.

The management of herpes labialis, oral thrush and angular cheilitis in cases of oral diabetes

Background: As reported in several studies, prolonged or uncontrolled cases of diabetes mellitus (DM) may induce a more extreme inflammatory response. Mucosal lesions can be observed in patients who present this systemic condition. Purpose: The purpose of this study was to elaborate the management of herpes labialis, oral thrush and angular cheilitis as oral manifestations of diabetes. Case: A 49-year-old male complained of having experienced painful lip ulceration for the preceding seven days. The anamnesis of the patient revealed that, prior to lip ulceration, he had experienced high fever and malaise in addition to frequent urination at night and a tingling sensation in the toes and fingertips on waking. Case management: The patient was referred to undergo blood count, fasting blood glucose and oral glucose tolerance tests. The blood test result confirmed the patient to be suffering from DM and anemia. The immunocompromised condition of the patient prompted the occurrence of herpes labialis, oral thrush and angular cheilitis. Conclusion: Multidisciplinary treatment for herpes labialis resulting in oral candidiasis in DM patients is indispensable. Concurrent infection with HSV and candidiasis necessitates a more prolonged healing process. Consequently, it is a essential to treat the hyperglycemia which induces an immunocompromised state in diabetic patients.

Safety of herbal medicine for elderly patients with chronic disease in the Republic of Korea

IntroductionElderly patients with chronic diseases may experience unintended adverse events (AEs) related to medication. This study investigated the detection of drug safety signals associated with herbal medicine by analyzing spontaneous AE reports in this patient group to generate new safety information. MethodsThe “Korea Institute of Drug Safety and Risk Management Korea Adverse Event Reporting System database (KIDS-KD)” was used to investigate patients over 65 years old with chronic disease from 2013 to 2016. The target of analysis is seven herbal medicines such as ginkgo leaf extracts, ivy leaf extracts, herbal cough suppressants and expectorants. AEs associated with herbal medicine were considered a signal if they accounted for greater than 0 of the 95% lower confidence interval of the Information Component (IC025). The relevance of unexpected Adverse Drug Reactions (ADRs) was determined based on a review of the KIDS-KD and then derived as safety information. ResultsAmong 113 types of herbal medicine-AE combinations, 56 drug-event combinations (DECs) in elderly patients with chronic disease were detected as signals. Of those, 12 types of DECs were investigated as unexpected ADR and finally 9 types were assessed as necessitating reporting of safety information: ginkgo leaf extracts (depression, thrombocytopenia), ivy leaf extracts (bullous eruption, muscle weakness, nocturia, lip ulceration, neuropathy peripheral, anxiety, malaise). ConclusionsThe elderly have a high prevalence of chronic diseases, resulting in polypharmacy, and potentially creating a high risk of ADRs. Establishing a pharmacovigilance system for herbal medicine is of great importance.

The effect of adhesive tape versus endotracheal tube fastener in critically ill adults: the endotracheal tube securement (ETTS) randomized controlled trial

BackgroundThe optimal securement method of endotracheal tubes is unknown but should prevent dislodgement while minimizing complications. The use of an endotracheal tube fastener might reduce complications among critically ill adults undergoing endotracheal intubation.MethodsIn this pragmatic, single-center, randomized trial, critically ill adults admitted to the medical intensive care unit (MICU) and expected to require invasive mechanical ventilation for greater than 24 h were randomized to adhesive tape or endotracheal tube fastener at the time of intubation. The primary endpoint was a composite of any of the following: presence of lip ulcer, endotracheal tube dislodgement (defined as moving at least 2 cm), ventilator-associated pneumonia, or facial skin tears anytime between randomization and the earlier of death or 48 h after extubation. Secondary endpoints included duration of mechanical ventilation and ICU and in-hospital mortality.ResultsOf 500 patients randomized over a 12-month period, 162 had a duration of mechanical ventilation less than 24 h and 40 had missing outcome data, leaving 153 evaluable patients randomized to tube fastener and 145 evaluable patients randomized to adhesive tape. Baseline characteristics were similar between the groups. The primary endpoint occurred 13 times in 12 (7.8%) patients in the tube fastener group and 30 times in 25 (17.2%) patients in the adhesive tape group (p = 0.014) for an overall incidence of 22.0 versus 52.6 per 1000 ventilator days, respectively (p = 0.020). Lip ulcers occurred in 4 (2.6%) versus 11 (7.3%) patients, or an incidence rate of 6.5 versus 19.5 per 1000 patient ventilator days (p = 0.053) in the fastener and tape groups, respectively. The endotracheal tube was dislodged 7 times in 6 (3.9%) patients in the tube fastener group and 16 times in 15 (10.3%) patients in the tape group (p = 0.03), reflecting incidences of 11.9 and 28.1 per 1000 ventilator days, respectively. Facial skin tears were similar between the groups. Mechanical ventilation duration and ICU and hospital mortality did not differ.ConclusionThe use of the endotracheal tube fastener to secure the endotracheal tubes reduces the rate of a composite outcome that included lip ulcers, facial skin tears, or endotracheal tube dislodgement compared to adhesive tape.Trial registrationClinicalTrials.gov NCT03760510. Retrospectively registered on November 30, 2018

Oral Manifestation of Stevens-Johnson Syndrome: a Case Report

Stevens-Johnson syndrome (SJS), a rare dermatological condition, affects the skin and mucosa, and is usually triggered by medications and rarely by infections. A 17-year-old boy presented with oral and ocular mucosal pain. Clinical examination revealed erosive areas with epithelial detachment in the oral cavity, lip ulceration, conjunctival hyperemia, and fever. The patient reported tetracycline use for 30 days to treat acne. The diagnostic hypotheses were SJS, Behçet's disease, and viral infection. The clinical condition of the patient worsened, despite the tetracycline suspension, with maculopapular lesions in the thorax, dorsum, and upper limbs, and an increase of the previous injuries. Serological tests were negative for hepatitis, HIV, toxoplasmosis, CMV, herpes, and syphilis. An incisional biopsy of the arm lesion and histopathological examination showed vacuolar interface dermatitis with subtotal epidermal necrosis. Treatment included systemic hydrocortisone and prednisone, local hygiene care, and low-level laser therapy of the oral lesions; all the lesions exhibited remission.

A case report on Actinic cheilitis: a rarer entity among Sri Lankans

Actinic keratosis (AK) is a dermatological condition commonly found among fair-skinned populations and considered as a potentially malignant disorder usually appearing on sun-exposed areas such as the scalp, face and forearms. It is an uncommon disorder among Asians. Therefore, Actinic Keratosis in Asians has not been thoroughly investigated. AK is clinically termed as“Actinic chelitis” when lesions present in the lips. This case report is about a 42-year-old male who presented at the Oral Medicine Clinic of the University Dental Hospital, Peradeniya, with a complaint of burning sensation of the mouth which aggravates with spicy foods for about three months. Been working in a farm from the age of 12 years and exposure to sunlight for about 9 to 10 hours a day, he has had an extreme exposure to sunlight. Examination revealed an erythematous, non-indurated ulceration of the lower lip. Histopathological sections showed ulcerated mucosa covered by orthokeratinized stratified squamous epithelium with regenerative atypia towards the ulcer bed. Degenerative changes of collagen were evident in the upper corium. The patient was educated about the disease and a protective local covering agent was prescribed to apply on the affected area. This case report emphasizes the possibility of acquiring AK among dark-skinned people due to extreme exposure to sunlight and the importance of knowledge about this disease entity for clinicians when diagnosing as it may have been misdiagnosed.