Specially with immunocompromised patients ,complications might occur as eye infection keratitis or encephalitis ,in addition to its psychosocial impact for all patients 22, It is essential to maintain hydration, especially for children in addition to topical and systemic antibiotics as a part of symptomatic treatment of the patient A 27 years old Pakistani male, his chef Complaint was pain and mouth sores, in ability to eat and drink.
The onset was noticed about 2 weeks prior to his seeking for treatment. The patient stated sores were present to both his lips and intra-orally with bleeding and pain noted. In addition to dysphagia. He went to the hospital, Acyclovir and myconozle were prescribed to him, with no improvement in signs and symptoms. Past medical history revealed that the patient had no systemic illness, not taking and medication before the appearance of the oral lesion, but he gave history of flue before the eruption of the oral lesion.
The family history was unremarkable. The patient is not a smoker. The patient had been hospitalized this time and routine laboratory investigations done to him figure The result of the investigations revealed normal results except for C-reactive protein fig.
Click here to View figure. Along the past seven years the patient experienced the same attach five times before, always he had been diagnosed as having Herpes Simplex Viral infection, Acyclovir was given without any improvement in signs and symptoms.
The patient denied exposure to medications, food, or allergens that may have precipitated his symptoms. On clinical examination the patient looked fatigued with, afebrile. There were no target lesions on his hands or arms but remnant of target lesion is there. Nikolsky sign was negative. During the last attach last year the patient mentioned that he had target lesions on skin. On intra oral examination: Marked halitosis when patient opened his mouth.
Generalized erythema with multiple huge sized, irregular in shape ulcers, with un covered surface no necrotic pseudo-membrane. Sloughed mucosal tissue present all over the oral mucosa, all the oral mucosa is tender Figure The tongue mucosa was markedly erythematous, ulcerated with involvement of all tongue surfaces, sloughed tissue presents on ulceration borders Figure There were large sized ulcerations present in both the hard and soft palate on erythematous bases, these ulcers were very painful and prevented her from carrying out her daily routines and even eating, drinking and speaking.
Contrary to acute EM, treatment with systemic corticosteroids and prednisone has been recommended [ 12 ], although controlled studies are missing. In cases with a high suspicion of drug-induced EM, the first measure is to stop the drug or exposure to drugs with a potential for crossreactivity due to similar chemical structures [ 2 ].
In patients with recurrent episodes, especially with a history of HSV infection, antiviral therapy is recommended and may be beneficial in preventing recurrences. Tatnall et al. The study showed significant superiority of acyclovir compared to placebo treatment with regard to the prevention of further EM episodes. Furthermore, after discontinuation of acyclovir, a fraction of patients remained in clinical remission, whereas all patients treated with placebo showed recurrence [ 2 ]. Due to its typical clinical and histological features, its frequent association with HSV, and its potentially recurrent course, EM represents a distinct entity [ 2 ].
As there remain no specific diagnostic tests, early clinical recognition of disease remains essential to promptly initiate appropriate treatment [ 14 ] and improve life quality. Thus, in the above case, prompt diagnosis and immediate treatment given to the patient not only cured him but also prevented any recurrence, thereby saving the patient from major discomfort and pain [ 15 ].
This is an open access article distributed under the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Article of the Year Award: Outstanding research contributions of , as selected by our Chief Editors.
Read the winning articles. Journal overview. Academic Editor: Alberto Delbem. Received 19 Dec Revised 18 Feb Accepted 02 May Published 11 May Abstract Erythema multiforme is an acute mucocutaneous hypersensitivity reaction with various etiological factors, including herpes simplex virus, medications, autoimmune diseases, and malignancies, but the most common cause is infection by herpes simplex virus.
Introduction Erythema multiforme EM is a reactive mucocutaneous disorder that is characterized by acute cutaneous and mucous bullous lesions. Case Report A year-old male patient was referred from the internal medicine department to the dental surgery unit of University Hospital Farhat Hached, Tunisia. Figure 1. Figure 2. Histopathology of EM minor. A dermal inflammatory infiltrate consisting of lymphocytes, histiocytes, and necrotic epidermal cells.
Figure 3. Oral lesions of oral erythema multiforme. The oral lesions involve a the gingival, b labial, and c buccal mucosae and vermilion of the lips. Figure 4. Clinical presentation of EM: a target lesions on the right arm and left thumb; b target lesions on the back; c crusty blister. References P. Farthing, J. However, most agree that all three are distinct entities [ 9 , 10 , 11 , 12 ]. EM minor is a mild recurrent condition that clears without sequelae and is associated with infection, including infection with Mycoplasma pneumoniae , vaccinia or varicella-zoster virus VZV [ 13 , 14 ], Patient history, clinical observations and prospective studies indicate that most cases of EM minor follow infection with herpes simplex virus HSV.
EM major , a broader category, is caused by drug administration. Acrosyringeal concentration of necrotic keratinocytes is a potential clue to drug etiology [ 17 ]. Most often it is central rather than acral. Pruritus may be common. The treatment of EM depends on the severity of the disease manifestation, the causes, and its acute or chronic course. In most cases, EM is minor and regresses spontaneously in 2 to 4 weeks. Therapy is similar for EM minor and major with the addition of oral care for oral EM.
When the manifestations are not severe, only symptomatic, conservative care is usually indicated. This may include topical analgesics and oral care which consist mainly of soothing mouth rinses, like viscous lidocaine rinse; topical anesthetics, such as gel benzocaine in Orabase Bland or lidocaine gel; soft liquid diet; and avoidance of spicy and acidic food. Adequate nutrition with high-calorie and high-protein diet is essential. Systemic treatment may also be used such as systemic analgesics, as well as antibiotic treatment if the lesions are secondarily infected.
Some authors believe that the use of systemic glucocorticoids is unnecessary [ 10 ] in this case, and it may worsen the condition [ 8 ]. Contrary to acute EM, treatment with systemic corticosteroids and prednisone has been recommended [ 12 ], although controlled studies are missing.
In cases with a high suspicion of drug-induced EM, the first measure is to stop the drug or exposure to drugs with a potential for crossreactivity due to similar chemical structures [ 2 ]. In patients with recurrent episodes, especially with a history of HSV infection, antiviral therapy is recommended and may be beneficial in preventing recurrences.
Tatnall et al. The study showed significant superiority of acyclovir compared to placebo treatment with regard to the prevention of further EM episodes.
Furthermore, after discontinuation of acyclovir, a fraction of patients remained in clinical remission, whereas all patients treated with placebo showed recurrence [ 2 ]. Due to its typical clinical and histological features, its frequent association with HSV, and its potentially recurrent course, EM represents a distinct entity [ 2 ]. As there remain no specific diagnostic tests, early clinical recognition of disease remains essential to promptly initiate appropriate treatment [ 14 ] and improve life quality.
Thus, in the above case, prompt diagnosis and immediate treatment given to the patient not only cured him but also prevented any recurrence, thereby saving the patient from major discomfort and pain [ 15 ]. National Center for Biotechnology Information , U. Journal List Case Rep Dent v. Case Rep Dent. Published online May Author information Article notes Copyright and License information Disclaimer.
Corresponding author. Aya Mtiri: moc. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Erythema multiforme is an acute mucocutaneous hypersensitivity reaction with various etiological factors, including herpes simplex virus, medications, autoimmune diseases, and malignancies, but the most common cause is infection by herpes simplex virus.
Introduction Erythema multiforme EM is a reactive mucocutaneous disorder that is characterized by acute cutaneous and mucous bullous lesions. Case Report A year-old male patient was referred from the internal medicine department to the dental surgery unit of University Hospital Farhat Hached, Tunisia.
Open in a separate window. Figure 1. Figure 2. Figure 3.
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