History of Present Illness
Len is a 54-year-old white male who reports to your office in great distress. For the past 4 days he has been suffering from painful, widespread ulcerations affecting his mouth. He states is unable to eat and has been drinking nutritional protein shakes to get by. He woke up with mouth sores 4 days ago. He denies any constitutional signs and symptoms such as fever, malaise or fatigue. He denies having any rashes or ulcers affecting his skin or any other mucosal sites such as his eyes and genitalia. He does note a recent medication change for his osteoarthritis management from ibuprofen to naproxen about 2 weeks ago.
Extraoral examination reveals normal TMJ function, no facial muscle tenderness, and no cervical lymphadenopathy. The labial mucosa exhibits a serohemorrhagic weep with crusting (Figures 1-2). Intraoral examination reveals wide-spread areas of bullae with mucosal sloughing affecting virtually all nonkeratinized tissues and palate (Figures 2-6). An incisional biopsy was performed on the right commissural area and the specimen was submitted for histologic assessment.
The biopsy shows inflamed oral mucosa consisting of reactive stratified squamous surface epithelium with subjacent fibrovascular connective tissue. The interface to perivascular inflammatory infiltrate consists predominantly of lymphocytes with admixed neutrophils and eosinophils. There is superficial stromal edema with areas of subepithelial and intraepithelial vesiculation. The basal portion of the epithelium displays scattered necrotic keratinocytes.