Clinical and Radiographic Findings

This patient developed ulcers on the mucosa of the inner lower lip (Figure 1) shortly after Thanksgiving, 2010. About 2 weeks later, he was first evaluated for this at his pediatrician's office. He was given a Benadryl and Maalox rinse. The ulcers and sloughing of the epithelium continued to get worse and spread all over his mouth (Figure 2-4). He complained of throat pain and difficulty eating and drinking. The ulcers were never on the outer lips. He was seen again by his pediatrician and prescribed a course of amoxicillin, which did not have any effect. His symptoms continued to get worse, to the point where he could not eat or drink. He was seen by Dr. Jackson and later by Dr. Martin of the Department of Oral Medicine at the University of Washington. At one point, he went to Seattle Children's Emergency Department for dehydration and was given pain medications, a mouthwash, and was rehydrated. Dr. Martin of Oral Medicine started him on oral prednisolone (15 mg/5 mL) 3 mL p.o. b.i.d., which he took for 3 weeks, as well as dexamethasone mouthwash, which he used 3 times daily. His mouth healed with just two residual ulcers that would not go away. As he continued to have multiple persistent lesions, Dr. Martin recommended stopping the prednisone for 48 hours and do a repeat biopsy, and his sores flared within those 48 hours. ?He resumed oral prednisolone (15 mg/ 5 mL) at 3 mL p.o. twice daily. The results of the second biopsy led to a referral to Children's Hospital, Department of Dermatology for a definitive treatment. While the oral lesions were ongoing, the patient developed sores in his eyes, starting with the left eye and then the right eye.

Figure 1 This is a clinical view of the lesions at the first week of January 2011 demonstrating generalized ulceration of the lower lip. The ulcers are superficial and irregular and are covered by pseudomembrane.

Figure 2 This is a clinical view of the lesions at the first week of January 2011 demonstrating generalized ulceration of the floor of mouth. Like the lower lip, the ulcers are superficial and irregular and are covered by pseudomembrane.

Figure 3 This is a clinical view of the lesions at the first week of January 2011 demonstrating generalized ulceration of the uvula and soft palate area. Like the other areas of the mouth, the ulcers are superficial and irregular and are covered by pseudomembrane.

Figure 4 This is a clinical view of the lesions at the second week of January 2011 demonstrating generalized ulceration of the mandibular vestibule and buccal mucosa. Like the other areas of the mouth, the ulcers are superficial and irregular and are covered by pseudomembrane