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Multiple Intraoral Ulcerations

Case Challenge Number: 65

Diagnostic Information

History of Present Illness Mrs. Cabello is a 68-year-old Hispanic female who presents to your office for a new patient examination. She states that she last visited a dentist approximately four years ago. She relates no acute dental problems but complains of significant pain of several months duration involving multiple areas of her mouth. Medical History - Adverse drug effects: none

- Medications: flecainide, Pravachol, vitamin D, Centrum silver

- Pertinent medical history: paroxysmal supraventricular tachycardia, hypercholesterolemia, osteopenia

- Pertinent family history: mother and father - deceased

- Social history: previous history of tobacco use - discontinued 30 years ago; does not drink alcohol; denies recreational drug use Clinical Findings Extraoral examination is within normal limits. No skin lesions are noted. Intraoral examination reveals multiple irregularly shaped ulcerations involving the left side of the lower labial mucosa, the left and right lateral tongue, and the ventral tongue (Figures 1-2). An incisional biopsy from the right lateral tongue is performed and the tissue submitted for histopathologic examination.

Figure 1. Irregular ulceration on left side of lower labial mucosa and an area of hemorrhage on the right side of the lower labial mucosa.

Figure 2. Multiple irregular ulcerations on the right lateral and ventral tongue.

Histopathologic Findings An incisional biopsy reveals acantholysis in the lower levels of the epithelium. The basal epithelial cells are attached to the underlying connective tissue (Figure 3). Individual squamous epithelial cells (Tzanck cells) are noted in the intraepithelial blister (Figure 4). Direct immunofluorescence reveals the deposition of IgG and C3 in a netlike pattern around individual squamous epithelial cells.

Figure 3. High power histologic image of a mucosal soft tissue fragment consisting of stratified squamous surface epithelium exhibiting acantholysis. Basal epithelial cells are attached to the underlying connective tissue.

Figure 4. High power histologic image showing acantholysis and Tzanck cells.