In September 2006, a 17-year-old patient, student, referred by the Hematology Service, came to the Dento-Maxyl-Facial Service of the Clinical Hospital of the University of Chile for presenting whitish mucosa.
The patient had a history of severe anemia diagnosed in 2005, which was attributed to a phenothiazine derivative and therefore underwent allogeneic bone marrow transplantation (BMT).
The first manifestations were acute cutaneous manifestations due to tacrolimus, with predominant cutaneous involvement on day +42, manifested as maculo-erythematous papule-mapular lesion and extremities with biopsy compatible with cyclosporine predianisone 20 mg.
The lesions of the oral mucosa appeared later and its first description appears in the course of the day +310.
At the time of the clinical examination, the oral lesions compromised almost the entire mucosa, but manifested mostly on the inner side of the lips, inner cheek face and ventral side of the tongue.
The lesions were whitish-colored, reticular and non-scratched.
The patient reported no associated symptoms.
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With the diagnostic hypothesis of oral mucosa involvement due to graft-versus-host disease, an incisional biopsy of the mucosa of the internal face of the lower lip was performed, where the lesions were manifested.
Histopathological report was compatible with IVHS.
A hyperparakeratinized multistratified flat lining epithelium with agusiform hyperplasia was described.
A basal stratum with cellular disorganization and in the immediately underlying corion lymphocytic infiltration together with neoformation vessels and fibro proliferation.
Mild periductal lymphocytic infiltrate was also described in neighboring minor salivary gland.
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Local measures were indicated to reduce the risk of infections and maintain adequate humectation of the oral environment; 0.12% chlorhexidine twice a day, saliva subject for daily use, and oral hygiene instruction.
Six months later, the patient was controlled showing pain in some areas of the oral mucosa, with erosive lesions appearing on clinical examination.
It was decided to incorporate in the local treatment scheme, the use of 0.1% betamethasone in plastibase, reinforcing oral hygiene measures.
However, the lesions remained and the pain increased, so it was changed to tacrolimus 0.1% in topical application 3 times a day, adding topical miconazole 2% (Daktarin Gel 3 times a day) of application.
Chlorhexidine was also suspected to be 0.12% at a lower concentration 0.05%, as the patient used to tolerate the former because it caused burning when using it.
After one week the lesions disappeared and the patient had no pain or feeding difficulties.
