THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS SIGNED AFTER TAKING HIS SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
[15-04-2025 20:44] PPM 1: @~PPM 3 please share his history events and clinical images (oral ulcerations etc) with post hospitalization data on the tests done and interventions offered
[15-04-2025 21:14] PPM 3: A 70 yr old male pt,10 days back patient was having fever and loose stools for 3 days, he was taken to the local hospital where he was treated and was discharged.
Then later on 19/04/25
he has been admitted for Rt inguinal hernia and phimosis.Then surgery doctor found his deranged RFT, thrombocytopenia and referred to Gen Medicine.He was dehydrated and there were oral ulcerations started and progressed .
[15-04-2025 21:17] PPM 1: Share the clinical images
[15-04-2025 21:18] PPM 3: Yes sir.
[15-04-2025 21:35] +91 6302 536 191: Slit done for phimosis.
[15-04-2025 21:37] +91 6302 536 191: Today's(15/04/25)
[15-04-2025 21:48] PPM 3: On 09th ecg
[15-04-2025 21:50] PPM 3: Todays sir
[16-04-2025 06:22] PPM 1: Thanks @~PPM 3 for sharing.
Please collect his signed informed consent form today with date, age gender, diagnosis and full address with the signature of his kin today asap so that @CR can prepare his case report
[16-04-2025 07:24] PPM 3: Ok sir
[16-04-2025 07:55] PPM 1: Please share his BP and interventions chart since admission along with other vitals
[16-04-2025 08:38] PPM 3: Ok sir.
[16-04-2025 15.40] PPM 1: Hospital course of events
[16-04-2025 15:41] PPM 1: Mistook his age both in the fever chart as well as consent form!
[17-04-2025 14.49] PPM 1: @PPM 3 today's updates?
[17-04-2025 15:26] PPM 1: Today's Update: Fever spikes persistent. For those who joined late this patient had fever and diarrhoea and vomiting 5 days prior to admission on 9/4/25
Subsequently found to have atrial fibrillation and was put on oral metoprolol and then developed hypotension.
[17-04-2025 15:47] PPM 1: @Meta AI What are clinical parameters to suspect oral pemphigus over other causes of severe oral ulcerations?
[17-04-2025 15:47] Meta AI: To suspect oral pemphigus over other causes of severe oral ulcerations, consider the following clinical parameters:
- Lesion Characteristics:
- Deep crater-like lesions: Oral pemphigus often presents with deep ulcers.
- Erosions with lichenoid hue: Lesions may have a distinctive appearance.
- Location: Lesions on the retromolar trigone and occlusion line of buccal mucosa are common and often refractory to treatment.
- Disease Severity:
- Number of mucosae involved: More than one mucosal surface involved, such as ocular, nasal, oral, genital, or anal mucosa.
- Number of sites involved in the oral cavity: Multiple sites, including hard palate, soft palate, oropharynx, tongue, floor of the mouth, and buccal mucosa.
- Size and depth of erosions: Larger and deeper erosions indicate more severe disease.
- Symptoms:
- Difficulty in eating: Patients may experience pain or discomfort while eating due to oral lesions.
- Difficulty in speaking: Oral lesions can cause discomfort or pain while speaking.
- Difficulty in swallowing: Large or deep lesions can cause discomfort or pain while swallowing.
- Disease Course:
- Persistence of oral lesions: Oral lesions may persist longer than cutaneous lesions.
- Relapse: Patients may experience recurrent episodes of oral lesions.
These clinical parameters can help differentiate oral pemphigus from other causes of severe oral ulcerations. A definitive diagnosis requires a combination of clinical findings, Tzanck smear, histopathology, and direct immunofluorescence of oral mucosal biopsy.¹
[17-04-2025 15:48] Meta AI: https://www.frontiersin.org/journals/medicine/articles/10.3389/fmed.2020.00449/full
[17-04-2025 22:13] PPM 4: The image shows the oral cavity of a patient with several notable findings suggestive of significant pathology:
1. Ulcerative Lesions: The ventral surface of the tongue and floor of the mouth display irregular, ulcerative lesions with a yellowish base and erythematous (reddened) margins. These lesions appear necrotic and possibly infected.
2. Fibrotic and Indurated Tissue: The surrounding tissue, especially at the floor of the mouth and the lower lip, appears indurated, fibrotic, and scarred—suggesting chronic inflammation or malignancy.
3. Mucosal Sloughing: There appears to be sloughing or pseudomembrane formation, particularly on the tongue.
4. Excess Salivation or Mucopurulent Discharge: There is a visible string of viscous fluid (possibly saliva or purulent exudate), which may indicate infection or impaired oral clearance.
5. Perioral Skin Changes: The perioral area has signs of excoriation, crusting, and possible secondary infection. The skin is discolored and there appears to be tissue damage extending beyond the vermilion border.
6. Trismus or Restricted Mouth Opening: The image is taken with effortful retraction of the lower lip, possibly indicating pain or fibrosis restricting normal mouth opening.
Differential Diagnosis: Oral squamous cell carcinoma (most likely, especially given the necrosis, induration, and chronicity).
Necrotizing ulcerative stomatitis or Noma (cancrum oris) in immunocompromised or malnourished patients.
Deep fungal infections like mucormycosis (though not classic).
Severe aphthous ulceration or HSV superinfection in immunosuppressed patients.
Autoimmune mucosal disease like pemphigus vulgaris (less likely).
Recommendation: Urgent referral for biopsy and imaging (CT/MRI) to assess for malignancy and extent of tissue invasion. Culture swabs and blood tests for infection/immunosuppression may also be indicated.
Would you like help drafting a referral or diagnostic workup plan for this case?
[17-04-2025 22:16] PPM 4: Thanks for the additional context—very helpful.
Given this patient's recent febrile illness, gastrointestinal symptoms, new-onset atrial fibrillation, metoprolol-induced hypotension, and now the severe oral lesions, a few additional thoughts come to mind:
Possible Diagnoses to Consider:
1. Stevens-Johnson Syndrome (SJS)/Toxic Epidermal Necrolysis (TEN):
Oral ulcerations with mucosal sloughing and necrosis fit.
Could be drug-induced (possibly metoprolol or another medication introduced recently).
Check for skin involvement on trunk/extremities.
2. Severe Mucositis secondary to Sepsis or Drug Reaction:
Hypotension might suggest septic or drug-induced shock.
Immune compromise (either primary or secondary) could predispose to mucosal breakdown.
3. Nutritional Deficiency + Sepsis:
If malnourished or alcohol-dependent, could develop mucosal lesions with a superadded infection.
Atrial fibrillation and hypotension might be part of a broader systemic inflammatory response.
4. Oral Mucormycosis:
If immunocompromised or in diabetic ketoacidosis (DKA) setting—necrotic oral lesions could be fungal.
Needs urgent biopsy and debridement if suspected.
Would you like to go through a workup plan (labs, imaging, biopsies) or a differential prioritization based on most urgent possibilities?
[17-04-2025 22:17] PPM 4: To me, this is a case of Steven-Johnson syndrome
[17-04-2025 22:19] PPM 1: Agree!
Only unable to pin point the drug probably due to limitations in our history taking
[17-04-2025 22:28] PPM 4: The treatment of Stevens-Johnson syndrome (SJS) and its more severe form, toxic epidermal necrolysis (TEN), involves a multidisciplinary approach focused on halting disease progression, managing complications, and supporting recovery. Below is a detailed synthesis of treatment strategies based on current guidelines and research:
---
### *1. Immediate Interventions*
- *Discontinuation of Causative Agents*: The first critical step is identifying and stopping any suspected medication, as drug reactions cause most cases. Common culprits include antibiotics (e.g., sulfonamides), anticonvulsants (e.g., lamotrigine), NSAIDs, and allopurinol . Symptoms typically develop 1–3 weeks after drug initiation .
- *Hospitalization*: Patients are often admitted to intensive care units (ICUs) or burn centers for specialized care, particularly if >10% of the body surface area is affected .
---
### *2. Supportive Care*
- *Fluid and Electrolyte Management*: IV fluids are administered to counteract fluid loss from skin detachment. Electrolyte imbalances (e.g., hypophosphatemia) are corrected .
- *Wound Care*:
- Non-adhesive dressings, biologic membranes (e.g., porcine xenografts, amniotic membranes), or antimicrobial agents (e.g., silver nitrate) protect denuded skin .
- Avoidance of silver sulfadiazine (due to sulfa allergy risk) is recommended .
- *Nutritional Support*: High-calorie intake via nasogastric tubes is often necessary to promote healing .---
### *3. Infection Control*
- *Sterile Handling*: Reverse-isolation techniques reduce infection risk. Prophylactic antibiotics are generally avoided, but systemic antibiotics are used if sepsis is suspected .
- *Monitoring*: Regular cultures of skin, blood, and catheters help detect early infections .
---
### *4. Immunomodulatory Therapies* (Controversial)
- *Intravenous Immunoglobulin (IVIG)*: High-dose IVIG may block Fas-mediated apoptosis, potentially reducing mortality if administered early. However, studies show mixed efficacy .
- *Cyclosporine*: Inhibits T-cell activity and granulysin, accelerating re-epithelialization. Doses of 3–5 mg/kg/day are often used .
- *Corticosteroids*: Controversial due to infection risks. Some guidelines recommend short-term, high-dose IV steroids (e.g., methylprednisolone) early in the disease, while others, particularly for HIV patients, advise against them .
---
### *5. Management of Mucosal Involvement*
- *Ocular Care*: Lubricating drops, topical steroids, and amniotic membrane grafts prevent corneal scarring and vision loss. Ophthalmology consultation is critical .
- *Oral/Genital Care*: Mouthwashes (e.g., lidocaine) and topical anesthetics alleviate pain. Urinary catheters may be needed for genital erosions .
---
## *6. Prognostic Tools and Complications*
- *SCORTEN*: A severity score (age, heart rate, epidermal detachment, etc.) predicts mortality risk. For example, a SCORTEN ≥3 correlates with >35% mortality .
- *Complications*: Sepsis, respiratory failure, and multi-organ dysfunction are leading causes of death. Long-term sequelae include chronic dry eyes, skin discoloration, and pulmonary issues .
---
### *7. Long-Term Management*
- *Avoidance of Triggers*: Patients must permanently avoid the causative drug and related medications. Medical alert bracelets are recommended .
- *Rehabilitation*: Physical therapy and psychological support address fatigue, scarring, and emotional trauma .
---
### *Controversies and Gaps*
- The role of systemic steroids and IVIG remains debated, with no consensus due to limited randomized trials.
- Biomarkers (e.g., granulysin) and genetic testing (e.g., HLA-B*15:02 for carbamazepine risk) are emerging but not universally adopted .
For detailed protocols, refer to guidelines from dermatology and burn care specialists . Early intervention and specialized care significantly improve outcomes.
[17-04-2025 22:33] PPM 4: Hyaluronic acid (HA) oral gel has emerged as a potential adjunct therapy for managing oral ulceration in conditions like Stevens-Johnson syndrome (SJS), though its role is *supportive* rather than curative. Below is a detailed breakdown of its proposed benefits, evidence, and limitations:
---
### *Mechanisms of Action*
1. *Mucosal Protection*:
HA forms a bioadhesive barrier over ulcers, shielding exposed nerve endings and reducing pain.
2. *Hydration*:
Its high water-binding capacity maintains a moist environment, critical for wound healing.
3. *Anti-inflammatory Effects*:
HA modulates inflammatory cytokines (e.g., IL-6, TNF-α) and promotes tissue repair by stimulating fibroblast activity.
4. *Epithelial Regeneration*:
Enhances re-epithelialization by binding to CD44 receptors on mucosal cells.
---
### *Evidence in Oral Ulceration*
- *General Oral Mucositis*:
HA gel is well-studied in chemotherapy/radiation-induced mucositis, showing reduced pain, faster healing, and improved quality of life in randomized trials.
- *SJS/TEN-Specific Data*:
Evidence is limited to small case reports and observational studies. For example:
- A 2020 case series reported accelerated healing of oral ulcers in SJS patients using HA gel alongside standard care.
- Anecdotal reports highlight reduced pain and improved oral intake.
- *Guidelines*:
Not yet included in major SJS management guidelines (e.g., UpToDate, UK guidelines), but some experts recommend it as an adjunct based on mechanistic plausibility and mucositis data.
---
### *Practical Use in SJS*
1. *Application*:
- Apply 0.2% HA gel directly to ulcers 3–4 times daily.
- Often combined with *topical anesthetics* (e.g., lidocaine) or *steroid mouthwashes* (e.g., dexamethasone).
2. *Advantages*:
- Minimal side effects (non-irritating, non-allergenic).
- Safe for use in children and adults.
3. *Limitations*:
- Does not replace systemic therapies (e.g., immunomodulators) or wound care.
- Limited data on severe SJS/TEN cases.
---
### *Comparison to Other Topical Therapies*
| *Therapy* | *Pros* | *Cons* |
|-----------------------|-----------------------------------|---------------------------------------|
| *Hyaluronic acid* | Promotes healing, minimal risk | Limited SJS-specific evidence |
| *Topical steroids* | Reduces inflammation | Risk of thrush, delayed healing |
| *Lidocaine gel* | Immediate pain relief | Short duration, no healing benefits |
| *Sucralfate* | Forms protective barrier | Chalky texture, less adherence |
---
### *Key Considerations*
- HA gel is *not a standalone treatment* but may complement:
- *Systemic therapies* (e.g., cyclosporine, IVIG).
- *Oral hygiene* (e.g., saline rinses, chlorhexidine).
- *Nutritional support* (soft diets, protein supplements).
- Larger clinical trials are needed to confirm efficacy in SJS.
---
### *Conclusion*
Hyaluronic acid oral gel is a promising, low-risk option for alleviating pain and promoting healing of oral ulcers in SJS. While robust evidence specific to SJS is lacking, its mechanistic benefits and success in other mucositis contexts justify its use as part of a multidisciplinary oral care regimen. Always prioritize discontinuation of causative drugs and systemic therapies first.
[18-04-2025 12:17] PPM 1: Promising but currently limited evidence
[18-04-2025 12:18] PPM 1: Even immunomodulatory therapies don't have good RCT evidence. Our patient hasn't been put on any by our currently minimalist team although we do have a lot more maximalists in our team and very very few minimalists
[18-04-2025 12:29] PPM 4: I am using it very frequently in almost all oral ulcerations over the last a couple of years and I found a very promising local healing power regardless of the underlying pathogenesis.
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