ODAY, the importance in the diagnosis of oral lesions has justly asswneti a role of its own. Xrytlicma esudatirum mult,iforme, of the oral l;vpe, is one of t,he many diseases whiclr t,hc dental practitioner Inay hc called npon to differcntiat,e from the more c’ommon oral diseases. A~I al tempt is made in Ihis paper to present a clear I)icture of this disease ;IS ai1 aitl to t,he practitioner in diagnosis.
Etiology The causal factors in this disease remain unknown. Many clinicians a~ltl aut,liorities have advanced theories as to its etiology, Ijut they are still unlxove(l. Those 1)ostiilations have x~r-ic?tl from lrric~oor~anisms: drugs, inczluding 1.11~ of a toxic sulfa group, hemol~tic Skaph?llococ,~lts ~~~I~P~I,s,Vincc~nl.‘s angina,’ Systemic resist ante ma)- also plnp origin, allergy to foods, and VV(VI pcvlicillin. of these patient,s seem 11) 1~~ in ;I ill1 important role in this cwtity. its sonic TI~P~c art’ OIL LYTO~ SOII~C CM~S OC erythema dehilitatcd physical state. esndativum multiforme following s(‘vci*o l~lits of pnc~nmonia. All these factors seem to distinguish that, this disease aplxcars to he ii manifestal ion of’ somo systemic disorders, rather than having an underlying specific causativt, agent. hart> a ()rmsl)y:’ feels that during thca spring and antnmn months patients (‘limair has a hearing, for it has predilection or susceptibility to i hc tliSWW. hccn noted that the chanpin, 0‘ of rt~sidrncc l’ronl one locxlc t,o another makes a The outbreak is occasionally associated with patient more prone to the discasc. rheumatic pains and swelling of the joints.‘*
Symptoms ‘l’hc onset of t,hc disease is penally sudden, with mild malaise. SOW throat, and rheumatic pains. Along wit.11 t,hesc symptoms there are the accompanying dermal lesions which usually present thrmselves more freqnently on the feet. legs, forearm, and dorsum 01’ thv hands. 5’rtquentl~-, the lesions maniftsb
themselves as ulcerative eruptions on the mucous membrane of the e,ws, nose, mouth, upper respiratory tract, esophagus, anus, and genitalia. At times, onl!~ the lesions of the mucous membrane are seen with the absence of the dvrmal lesions. During the acute symptoms the pativiit nia~- bc bedridden 01’ may lw ambulal ory. Elevated temperature, which is l)rcsenf, may or may not lw of contributory significance, but in tht: literatnrc temlwratuws of 10-l” to IOY have been no&l. Generally these patients: especially 1how with I he ora I manifest ations, show signs of an nndernourishcd stale wit 11poor oral 11ygi.ictlc~. The disease usually lasts from two to five weeks alIt has th(b itntlcnc*y IO IWIW. Complications from this disease because of its wide tlistrihnt ion ran Iw watlil~~ appreciated. The greatest damage is that wsnlting on tlrcb c’yw. The overlaymanifestations consist of cornea1 scarring wit Ii tlccrwscd visilal iIcilii\-, c~lrronic~ conjunct iritis, and damage to t,he cbpelids.
Lesions The dcrmal lesions of er,vthcma cxlldativtlnl mnltiformc ii re nlow ])ronotulcwl and discernible than t,hose of the mucous nIc11Il)ranc. In appeat~anw the lesions arc lwticarial-like eruptions which take> up varying c~onfi~nl,;ltions. The>- arc’ usually bilateral and erythcmatons, consisting of light pink to bluishred papllles which later dcrclop into vesicles with a sulwrfic+~llg c~rodtvl wntcr. The lesions map 1~ confluent., but one ringlikc lesion ~~rcdol~lir~;lt(~s. lIemo~~rhage is prrwnt in t,hc older lesion. I)rlt is not prol’l~st~. The gross otwptiotl wusts, heals, and 1he pigment,ation which may follow soon tlisa~ppcars? Orally” the lesion has an affinity- for the lilts, tongucb. and c~l1c~4~. 7’11(, gingiva is not a frcqncnt site for the disease. Tn gr~t~c~ral,the lesions arc less The t ong11(~cishil)i f s cliwretc, being inoi*c c~onlesceiit alit1 nierging logethrr. loss of tlicl papillae with regeneration as the discaw lrssens. T’wticnts with oral c>rythema exudatirnm mult iformc suffer wq- acnt (1l.v alIt foot1 intake is \-cI~~~ difficult. Their nervous apprchcnsion, dr~e to this fact. causrs them great alart-II, Increasecl sialorrhea is present. Microscopic examination of sect ions of the lesion ot’tcn aids in the diagnosis. Early lesions appear edematous with no wandering wlls ; how~vcr. in thn oldrl lesions the squamous cells appear swollen, and the inlcrepithclial l,vmph spares arc cnlarged.7 The surfucc cpithelium, whcrc thr trouhlc first begins? is underrnined by several vcsirles which may hrcomc enc. Blood wssrls arc dilated in the subpapillary layer, where hemorrhage varies from a Ccw cells to estravasations. During the later stage w‘c find that the infiltrate around t,he wssels is predominantly made up of pal-llzorphorlnrle:Iv Icncocytes which o~~tnnmbcr tht, lymphocytes. The most striking features are thr dilat.ctl vrssrls ant1 alwwcc OI The plasma or round ~11s. In the syphilitic lesions wr fintl that 1’rvrwc is tmrt. collagen stains poorly. In the lesion of lichen l)lanus tlicrti is less ~sudate 1hat that seen in cryt.hcma exudat ivllm multiformc.
Diagnosis Erythema cxudativum multiforme ma>- lw nrisconstrwd as orw of m;ln~diagnosis difficult. The oral variation diseases, which makes its differential with absence of other sympt,oms makes t,he diagnosis almost impossible, It
Case History \vilh a 51-year-old
\vhitr ll~all ill fail* hralth when had never suffered from ally tb-I)e of skiu 0~’ mouth lesion until cbtle yfwl* ago when he suddenly develop4 t.iny blisters in t,lre buccal area, which b+ reniailietl so for forfv or five C’illllf! ulcerated and painful ii1 il short tilllf~, I)uring this tiltle he had 110 lesions 011 Illra twl. lveeks, aud then grew better. anal itlabilit,y to eat solit foo(I. of his body, no fever, soli~v \vciglit loss. gollr. rc~llli~illill~ and Throughout this past year t h(w symptonls have c:ome Several l)hJ.sicaians hatI for three or four weeks atIt1 regressing tcmporarilq-. various nletlications wit,liu1lt rrlirf. Owasionally, a I~mpll lio(ltB pwscrilwd at the left angle of the jaw bc~artle IitI*ge ;lt~tl I~II(~PI*. ‘I’hert~ 11:~~~berlr IIO other symptoms referabI(> 10 ;IIIJ- systemic, tliseflsc~ clscdrpt )~II ifIt~f(‘l< 01 ‘ ’ arthritis ’ ’ (gout).
noncontributory. Physical examination w;as (lone by t,he hospital i1lteru mtcl was essentially negative, cswpt COYthe q~, now, throat, and nlout 21. ‘I‘llfU pupils were pinpoint in size and did not react to light; the left side of the nasal mucosa showed supchrficial nlcrratioir and bleeding points ; the lips, buwal ~uucous membrane. aud tongue showetl areas of’ cryt,hema. Itl(deratiotl, and they were painful to touc*li. arid tlrsquamatitnl with easy blertlillg, (Figs. 1, 2: and 3.)
and were also esblood counts, serology, alld nrinal,vsis were tlm~e sentially normal. Three (lays after admission the patient suffered an attac*k of gout. and uric acid tests it, the blood chemistry examinat,ion wew elevatetl. Klood cultures were negative and bacateriologic esanliuations rt~\~caIrtl itlcareased normal flora of the mouth. 13ioI)sy report of a typical mout,h lesion indic*atrd the following: an infiltrate composed of monocytes, sniall lymphocytes, and polyniorphonuclear lrucoc~tw. The infiltrate is perivascular and is most heavy and very dense itI the upper cutis. The findings are consistent, with eryt,hema lnult,iforrnc. Routine
Medication---The paCent received penicillin ilk oil, 300,OOU units daily, ZTigli vitamin to combat t,he secondary infection ljresent in the mouth. therapy was given; Unical) vitamins three times didy ; fruit juices at bedside; Brewer’s yeast 6 gr. three times daily after meals; liver extract ; high caloric diet. Bland mouthwashrs were used to cleanse the Inouth and to reduce infection locally. Summary,-The patient was discharged in seven days (Aug. 25, 1948’) The lesions ha(I almost disappeared and his in a very improved condition. mouth had taken on a normal appraranw. References I. Hazen, H. FL: Diseases of Skin. ed. 2, St. Louis, 1922, The C. V. Mosby 2. Wright, D. 0, Gold, Edwin M., and .Jennings, (korge: Stevens-Johnsons ;2rch. Int. Med. 79: 510-517. 1947.