ulcerative conditions associated with immunlogic dysfunctions

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    ULCERATIVE CONDITIONS

    CONDITIONS ASSOCIATED WITH IMMUNLOGIC DYSFUNCTIONS

    APHTHOUS ULCERS

    The most common of all types of non-traumatic ulceration that affects themucous membranes

    Incidence ranges from 20-60%

    Prevalence tends to be higher in professional persons and those in uppersocio-economic groups

    Also known as canker sores & recurrent aphthous stomatitis

    APHTHOUS ULCERS

    etiology & pathogenesis

    Cause is unknown

    Etiologic factors:

    Immunologic factors

    Microbiologic factors

    Nutritional factors

    Other factors: hormonal alterations, stress, trauma & food allergies

    APHTHOUS ULCERSetiologic factors: immunologic

    The most promising avenue of investigation

    Aphthous ulcers result from a focal immune dysfunction in which Tlymphocytes play a significant role

    Causative agent

    Endogenous antigen autoimmune

    Exogenous antigen hyperimmune

    APHTHOUS ULCERSetiologic factors: microbiologic

    After several studies, this theory has been discarded

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    APHTHOUS ULCERSetiologic factors: nutritional

    Deficiencies of vitamin B12, folic acid & iron

    Correction of the above deficiencies has produced improvement or cures

    APHTHOUS ULCERSetiologic factors: others

    Hormonal alterations

    Stress

    Trauma

    Food allergies: nuts, chocolate & gluten

    None of these is seriously regarded as being important in the primarycausation

    But can have triggering role

    APHTHOUS ULCERSclinical features

    Three forms of aphthous ulcers

    Minor aphthous ulcers

    Major aphthous ulcers

    Herpetiform aphthous ulcers

    All are believed to be part of the same disease spectrum with a commonetiology

    Differences are essentially clinical & correspond to degree of severity

    APHTHOUS ULCERS

    clinical features

    All forms present as painful recurrent ulcers

    Occasionally, patient have prodromal symptoms: tingling or burning prior tothe appearance of the lesions

    Ulcers are not preceded by vesicles

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    Rarely appear: gingiva & hard palate

    APHTHOUS ULCERSclinical features

    Appear on :

    Vestibular & buccal mucosa

    Tongue

    Soft palate

    Fauces

    Floor of the mouth

    MINOR APHTHOUS ULCERSclinical features

    Most commonly encountered form

    Appear as single, painful, oval ulcers

    Less than 0.5 cm in size

    Covered by a yellow fibrinous membrane

    Surrounded by an erythematous halo

    Lesion lasts 7-10 days

    MINOR APHTHOUS ULCERSclinical features

    Heals without scar formation

    When the lateral or ventral surfaces of the tongue are affected, pain tends tobe out of proportion to the size of the lesion

    Multiple oral aphthae may occasionally be seenRecurrences vary from one person to another

    Periods of freedom from this disease may range from a matter of weeks to aslong as years

    MINOR APHTHOUS ULCERS

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    MINOR APHTHOUS ULCER

    MINOR APHTHOUS ULCER

    MAJOR APHTHOUS ULCERSclinical features

    Was referred to as periadenitis mucosa necrotica recurrens (PMNR) orSuttons disease

    Regarded as the most severe expression of aphthous stomatitis

    Lesions are larger & more painful

    Persist longer than minor aphthae

    MAJOR APHTHOUS ULCERS

    clinical features

    Appear crateriform because of the depth of inflammation

    Heal with scar

    Lesions may take as long as 6 weeks to heal

    as soon as one lesion disappears, another one starts

    MAJOR APHTHOUS ULCERSclinical features

    In patients who experience an unremitting course with significant pain anddiscomfort, systemic health may be compromised because of difficulty ineating and psychologic stress

    MAJOR APHTHOUS ULCERS

    MAJOR APHTHOUS ULCER

    HERPETIFORM APHTHOUS ULCERS- clinical features

    Unlike herpetic infection, this form are not preceded by vesicles

    Exhibit no virus-infected cells

    HERPETIFORM APHTHOUS ULCERS-clinical features

    clinically presents as recurrent crops of small ulcers

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    Although movable mucosa is predominantly affected, palate & gingiva maybe involved

    Pain may be considerable

    Healing occurs in 1-2 weeks

    HERPETIFORM APHTHOUS ULCERS

    HERPETIFORM APHTHOUS ULCER

    APHTHOUS ULCERShistopathology

    It is generally accepted that important clues to the etiology and pathogenesismay be found during the early stages , therefore biopsies are unnecessaryand rarely done

    APHTHOUS ULCERSdifferential diagnosis

    Diagnosis is generally based on history & clinical appearance

    Secondary recurrent oral herpes is often confused with aphthous ulcers butcan be distinguished from it, because the latter is not precede by a vesicle

    APHTHOUS ULCERStreatment

    In patients with occasional or few minor aphthous ulcers usually no treatmentis needed because of minor discomfort

    For patients who are affected severely, some form of treatment can providesignificant control but not necessarily cure

    Because of its immunologic defect related factor, treatment includes drugsthat can regulate the immune response

    APHTHOUS ULCERStreatment

    Chemotherapeutic agents used:

    Systemic steroids

    Topical steroids

    antibiotics

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    Other drugs

    APHTHOUS ULCERStreatment / systemic steroids

    Appropriate for severe disease

    Should not be use unless the clinician as experience in this treatment area/working with a knowledgeable consultant

    Should know the effects & side effects of systemic steroids therapy

    APHTHOUS ULCERStreatment / systemic steroids

    Effects:

    Anti-inflammation

    Immunosuppression

    Gluconeogenesis from protein & fat

    Altered fat metabolism

    Fluid retention from Na resorption & K excretion

    Potentiation of vasopressors

    Increased gastric secretions

    Suppression of pituitary-adrenal axis

    CNS effects

    Ocular effects

    Side effects:

    Therapeutic

    Aggravation of Tb & other infections, delayed wound healing

    Aggravation of diabetes, muscle weakness & osteoporosis

    Buffalo hump, hyperlipidemia

    Moon face, weight gain

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    Blood pressure elevation, aggravation of congestion, heart failure

    Aggravation of peptic ulcer

    Adrenal atrophy

    Psychologic changes

    Cataracts, glaucoma

    APHTHOUS ULCERStreatment / systemic steroids

    For immediate control of severe case, a lo to moderate dose of prednisoneover a short period of time is recommended

    A typical regimen:

    20-40 mg daily for 1 week

    Followed by another week at half the initial dose

    Prednisone should be taken in one bolus in the morning

    APHTHOUS ULCERStreatment / systemic steroids

    A slow steroid taper is not necessary if the treatment lasts for less than 4weeks

    In patients requiring higher dosage prolonged, or maintenance therapy,

    an alternate-day regimen may be used after initial daily therapy

    APHTHOUS ULCERStreatment / topical steroids

    If used judiciously, can be effective and safe in mild to moderate condition

    Creams & gels: Orabase

    APHTHOUS ULCERStreatment / topical steroids

    Side effects :

    Systemic

    Suppression of pituitary-adrenal axis

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    Iatrogenic Cushings syndrome

    Local (skin)

    Striae

    Atrophy

    Hypopigmentation

    Telangiectasia

    Induced acne

    Folliculitis

    candidiasis

    APHTHOUS ULCERStreatment / antibiotics

    Tetracycline oral suspension

    Used to eliminate secondary bacterial infection of the ulcers

    Combination of tetracycline oral suspension, nystatin oral suspensionanddephenhydramine hydrchloride ( Benadryl) provides more clinical benefits

    Oral rinse containing chlorhexidine gluconate .12% ( Peridex, Orahex)

    APHTHOUS ULCERStreatment / other drugs

    Vitamin A derivatives

    Anti-inflammatory drugs

    Sulfones sulfonamides

    BEHCETS SYNDROME

    A multisystem disease in which recurrent oral aphthae are a consistentfeature

    System involve are: GIT, cardiovascular, ocular, CNS, articular, pulmonary,dermal

    Oral manifestations are relatively minor, involvement of other sites , esp. theeyes & CNS can be quite serious

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    BEHCETS SYNDROMEetiology

    Cause is basically unknown

    Underlying disease mechanism may likely be immuno-dysfunction in whichvasculitis has a part

    Genetic predisposition to the frequent presence of HLA-B15 within the group

    BEHCETS SYNDROMEclinical features

    Typically affect the oral cavity, eyes & genitalia

    Recurrent arthritis of the wrists, ankles and knees

    Cardiovascular manifestations results fro vasculitis and thrombosis

    CNS manifestations are in the form of headaches, but infarcts have beenreported

    BEHCETS SYNDROMEclinical features

    Presence of pustular erythema nodosum-like skin lesions

    Relapsing polychondritis ( e.g. auricular cartilage & nasal cartilage) in

    association with Bechets stigmataBehcets stigmata known as MAGIC syndrome Mouth & genital ulcers withInflamed Cartilage

    BEHCETS SYNDROMEclinical features

    Oral manifestations are identical to the ulcers of aphthous stomatitis, minor,and with the same distribution

    Ocular changes such as uveitis, conunctivitis and retinitis

    Genital lesions are ulcerative in nature & may cause significant pain &discomfort

    BEHCETS SYNDROMEclinical features

    Painful ulcerative lesions may also occur around the anus

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    Inflammatory bowel disease & neurological problems

    BEHCETS SYNDROMEhistopathology

    T-lymphocytes are very prominent

    Infiltration of neutrophils appear within the vessel representingleukocytoclastic vasculitis

    BEHCETS SYNDROMEdiagnosis

    Diagnosis is based on clinical signs & symptoms described above

    Biopsy & laboratory tests will produce non-specific results

    BEHCETS SYNDROMEtreatment

    Systemic steroids

    Immunosuppressive drugs

    Chlorambucil

    Azathioprine

    Dapsone, cyclosporine & interferon

    REITERS SYNDROMEetiology

    Cause is unknown

    Abnormal immune response to microbial antigen regarded as a likelymechanism for the multiple manifestations of this syndrome

    REITERS SYNDROMEclinical features

    Major components are:

    Arthritis

    Non-gonococcal urethritis

    Conjuctivitis or uveitis

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    Urethritis precedes the appearance of other lesions

    REITERS SYNDROMEclinical features

    Mucocutaneous lesions seen in 50% of patients with this syndrome

    Maculopapular lesions may occur on the genitalia

    Oral lesions are relatively painless aphthous-like ulcers occurring anywhere inthe oral cavity

    Tongue lesions is similar to that of georaphic tongue

    REITERS SYNDROMEclinical features

    Occur predominantly in white males in their third decade

    Duration of the disease varies from weeks to months

    Recurrences are not uncommon

    REITERS SYNDROMEdiagnosis

    Upon the recognition of various signs and symptoms

    No specific laboratory tests

    REITERS SYNDROMEtreatment

    Non-steroidal anti-inflammatory agents

    Antibiotics can be added to the treatment regimen

    ERYTHEMA MULTIFORMEetiology & pathogenesis

    Basic cause is unknown

    Hypersensitivity reaction is suspected

    Evidence shows that the disease mechanism may be related to antigen-antibody complexes that are targeted for small vessels of the upper dermis &submucosa

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    ERYTHEMA MULTIFORMEetiology & pathogenesis

    Precipitating factors can be identified in 50% of the cases

    Infections

    drugs

    Other factors which trigger EM

    Malignancy

    Vaccination

    Autoimmune disease

    Radiotherapy

    ERYTHEMA MULTIFORMEetiology & pathogenesis

    Infections frequently reported include

    Herpes simples ( HSV types I & II)

    TB

    Histoplasmosis

    Various types of drugs that precipitate EM:

    Barbiturates

    sulfonamides

    ERYTHEMA MULTIFORMEclinical features

    Usually an acute self-limiting process that affects the skin &/or mucous

    membranes25-50% of the patients with cutaneous EM will have oral manifestations

    May be chronic in nature or recurrent acute type

    In recurrent cases, prodromal symptoms are experienced prior to anyeruptions

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    ERYTHEMA MULTIFORMEclinical features

    Young adults are mostly affected

    Often develop in the spring or fall & may have recurrence seasonally

    Include multiple & varied clinical appearances that are associated withcutaneous manifestations ( multiforme)

    ERYTHEMA MULTIFORMEclinical features

    Target or iris lesion is the classic skin lesion of EM

    It is consists of concentric erythematous rings separated by rings of near-normal color

    The skin in the center of these lesions may be erythematous or tan,representing resolution

    ERYTHEMA MULTIFORMEtarget or iris lesion in the skin

    ERYTHEMA MULTIFORMEtarget lesion on the palmar skin

    ERYTHEMA MULTIFORME

    clinical features

    Typically, the extremities are involved

    Usually in symmetric distribution

    Other types of skin manifestations include:

    Macules

    Papules

    Vesicles

    Bullae

    Urticarial plaques

    ERYTHEMA MULTIFORMEclinical features

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    Orally, EM characteristically presents as an ulcerative disease

    Varying from a few aphthous-type lesions to multiple, superficial, widespreadulcers

    Areas involved are the lips, buccal mucosa, palate & tongue

    ERYTHEMA MULTIFORMEon the lower lip

    ERYTHEMA MULTIFORMEoral lesions: lower lip

    ERYTHEMA MULTIFORMEoral lesions: gingiva

    ERYTHEMA MULTIFORMEclinical features

    Recurrent oral lesions may appear as multiple painful ulcers similar to theinitial episode

    As less asymptomatic erythematous patches with limited ulceration

    Symptoms range from mild discomfort to severe pain

    ERYTHEMA MULTIFORMEclinical features

    Patient experience considerable apprehension because of occasionalexplotive onset

    Systemic signs & symptoms are:

    Headache

    Slightly elevated temperature

    lymphadenopathy

    ERYTHEMA MULTIFORMEclinical features

    Stevens-Johnson syndrome- a major variant of EM

    Intense involvement of the mouth, eyes, skin, genitalia & occasionally theesophagus & respiratory tract may be seen

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    Systemic signs & symptoms are more pronounced

    Cutaneous & mucosal lesions are more extensive

    ERYTHEMA MULTIFORMEclinical features: stevens-johnson

    Lips my become encrusted

    Oral lesions may cause exquisite pain

    Superficial ulceration, often preceded by a bullae is common to all affectedsites

    Ocular inflammation ( conjunctivitis & uveitis) may lead to scarring &blindness in some patients

    ERYTHEMA MULTIFORMEocular lesion

    ERYTHEMA MULTIFORMEhistopathology

    No specific or consistent microscopic pattern

    Dermal vessels shown to have IgM complement and fibrin in their walls- thissupport an immune-complex vasculitis cause of EM

    ERYTHEMA MULTIFORMEdifferential diagnosis

    Target or iris skin lesion is present, clinical diagnosis is straightforward

    If skin lesion is absent, it has to be compared with primary HSV infections,aphthous ulcers, pemphigus vulgaris, bullous pemphigoid & erosive lichenplanus

    ERYTHEMA MULTIFORMEdiagnosis

    To diagnose EM, the ff. should be present:

    General lack of systemic symptoms

    Favored oral location of lips, buccal mucosa, tongue, & palate

    Larger sized ulcers- not precede by vesicles

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    Presence of target skin lesions

    History of recent drug ingestion or infection

    ERYTHEMA MULTIFORMEtreatment

    Symptomatic treatment for mild affected patients

    Topical corticosteroids with anti-fungals

    In severe cases, moderate dose of systemic corticosteroids may be used toshorten the course of the disease & abort recurrences or reduce its intensity

    ERYTHEMA MULTIFORMEtreatment

    Supportive measures to provide patients with substantial benefits:

    Oral irrigation

    Adequate fluid intake

    Use of antipyretics

    LUPUS ERYTHEMATOSUS

    Encompasses three (3) recognized subsets:

    Systemic (acute) LE

    Subacute cutaneous LE

    Discoid (chronic) LE- which may have oral manifestations

    LUPUS ERYTHEMATOSUS

    Systemic lupus erythematosus (SLE) is of greatest importance because of profound impact it has on many organ system

    LUPUS ERYTHEMATOSUSDiscoid lupus erythematosus (DLE) is the least aggressive form, affectingpredominantly the skin and rarely progressing to a more severe form

    It may be of great cosmetic significance because of its predilection for theface

    LUPUS ERYTHEMATOSUS

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    Subacute cutaneous lupus erythematosus (SCLE) lies intermediate betweenSLE and DLE

    Skin lesions of mild to moderate severity

    Mild systemic involvement

    Appearance of some abnormal autoantibodies

    LUPUS ERYTHEMATOSUSetiology & pathogenesis

    Result from an autoimmune process that may be influenced by genetic orviral factors

    Both humoral & cell-mediated arms of the immune system are involved

    LUPUS ERYTHEMATOSUSclinical features- DLE

    Characteristically seen in middle age, especially women

    Lesions frequently appear solely on the skin, most commonly on the face &scalp

    Oral & vermillion lesions are also frequently seen but usually accompanycutaneous lesions

    LUPUS ERYTHEMATOSUSclinical features- DLE

    On the skin, lesions appear as disk-shaped erythematous plaques withhyperpigmented margins

    As the lesions expand peripherally, the center heals, with the formation of scar & formation of pigment

    Involvement of hair follicles results in permanent hair loss (alopecia)

    LUPUS ERYTHEMATOSUSclinical features- DLE

    Mucous membrane lesions appear in 25% of the patients with cutaneous DLE

    Most frequently affected are: buccal mucosa, gingiva, & vermilion

    Lesions appear as erythematous plaques or erosions

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    Usually present are delicate, white, keratotic striae radiating from theperiphery of the lesions

    LUPUS ERYTHEMATOSUSchronic DLE

    LUPUS ERYTHEMATOSUSLE on the mucosa of hard palate

    LUPUS ERYTHEMATOSUSLE on the buccal mucosa

    LUPUS ERYTHEMATOSUSclinical features- DLE

    Diagnosis of oral lesions may not be evident on the basis on clinicalappearance, but it is often suspected in the presence of skin lesions

    Progression to SLE is very unlikely although the potential does exist

    LUPUS ERYTHEMATOSUSclinical features- SCLE

    Skin lesions are annular or papulosquamous in nature

    Lesion persist for weeks to months and heal without a scar

    Oral lesions are those similar to DLE

    Mild systemic symptoms in the form of musculoskeletal complains as well asserologic abnormalities are frequently seen

    LUPUS ERYTHEMATOSUSclinical features- SCLE

    Circulating antibodies to cytoplasmic components may be found in affectedpatients

    One is known as anti-Ro or Sjogrens syndrome A antibody (SS-A) sinceit may also be found in the serum of patients with Sjogrens syndrome

    anti-La (SS-B)- an auto-antibody

    LUPUS ERYTHEMATOSUSclinical features-SCLE

    Long term prognosis is believed to be good, with progressive to SLE anunlikely event

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    LUPUS ERYTHEMATOSUSclinical features- SLE

    Skin and mucosal lesion are relatively mild

    Patient complaints are dominated by multiple system involvement

    Numerous auto-antibodies directed against nuclear & cytoplasmic antigensare found in patients with SLE

    These antibodies when complexed to their corresponding antigens either inserum or in the target organ resulting in a wide variety of clinical signs &symptoms

    LUPUS ERYTHEMATOSUSclinical features- SLE

    Skin involvement results in an erythematous rash, seen over the malarprocesses and bridge of the nose resulting to butterfly appearance

    Other affected areas are: face, trunk and hands

    Disk-shaped lesions are non-scarring may flare as systemic involvementprogresses

    LUPUS ERYTHEMATOSUSclinical features-SLE

    Oral lesions are similar to that of DLE

    Ulceration

    Erythema

    Keratosis

    Areas frequently involved are:

    Vermilion

    Buccal mucosa

    Gingiva

    palate

    LUPUS ERYTHEMATOSUSclinical features-SLE

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    Systemic symptoms:

    initial

    Fever

    Weight loss

    Malaise

    Will progress into involving many organs:

    Joints

    Kidneys

    Heart

    lungs

    LUPUS ERYTHEMATOSUSclinical features- SLE

    The inflammatory of the various involved tissues result in a wide array of signs & symptoms

    Kidney- glomerulopathy- most important & the most common cause of deathfor patient with SLE

    LUPUS ERYTHEMATOSUSdiagnosis

    Serologic tests for autoantibodies are positive in patients with SLE

    The ANA test is the most reliable & relatively specific for SLE

    Another serologic test for SLE is the LE test , but less sensitive & less specific

    LUPUS ERYTHEMATOSUShistopathology

    The most important microscopic feature diagnostically is the interfacechange, since it appears that the basal layer is the primary target in the skin& mucous membrane

    LUPUS ERYTHEMATOSUSdifferential diagnosis

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    Lesions similar with erosive lichen planus, but lupus lesions are lesssymmetrical in distribution

    Keratotic striae in LE are more delicate & subtle than that of lichen planus

    LUPUS ERYTHEMATOSUSdifferential diagnosis

    The presence of characteristic skin lesions or systemic signs & symptomsmay help diagnose LE

    Biopsy & direct immunofluorescent testing should help confirm the clinicalimpression

    Negative serologic tests for autoantibodies would rule out systemicinvolvement

    LUPUS ERYTHEMATOSUStreatment

    DLE is usually treated with topical steroids

    High-potency creams can be used intra-orally but should be used withcaution on the facial skin because of secondary cutaneous changes

    LUPUS ERYTHEMATOSUStreatment

    Systemic steroids may be utilized in the treatment of SLE and SCLE

    Prednisone combined with immunosuppressive agends

    Anti-malarials, non-steroidal anti-inflammatories, dapsone, & retinoids

    DRUG REACTIONSetiology & pathogenesis

    Although the skin is more commonly involved in adverse reactions to drugs

    Oral mucosa ay occasionally be the target organ or maybe the sole site of involvement (or part of a skin reaction)

    Drugs Known to Cause Adverse Reactions

    Anti-malarials

    Aspirins

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    Barbiturates

    Chlorpromazine

    Cimetidine

    Codeine

    Erythromycin

    Gold compounds

    Indomethacin

    Ketoconazole

    Local anesthetics

    Meprobamate

    Methlydopa

    Oxyprenolol hydrochloride

    Penicillin

    Phenytoin

    Retinoids

    Streptomycin

    Sulfonamides

    Tetracycline

    Drug Reactionspathogenesis

    Immunologic mechanism

    Non-immunologic mechanism

    Drug Reactionpathogenesis

    Immunologic Mechanism

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    Triggered an antigenic component on drug molecule ( allergicreaction)

    Depend on the following factors:

    immunogenecity of the drug

    frequency of exposure

    the route of administration

    innate reactivity of the patients immune system

    Drug Reactionpathogenesis

    Non-immunologic Mechanism

    Do not stimulate an immune response in the patient

    Are not antibody-dependent

    Drugs directly affecting the mast cells, causing the release of chemicalmediators

    Reactions may be overdoe, toxicity or side effects

    Drug Reactionclinical features

    Cutaneous manifestations

    Oral manifestations

    Drug Reactionclinical features

    Cutaneous manifestations

    Varied depending upon many factors:

    Type of drug

    Drug dosage

    Individual patient differences

    Changes: (appear rapidly)

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    Anaphylaxis

    Angioedema

    Urticaria

    Drug Reactionclinical features

    Acquired Angioedema

    IgE-mediated allergic reactions

    Precipitated by drug or foods (nuts or shellfish)

    Substances act as sensitizing agent that elicit IgE production

    Drug Reactionclinical features

    Hereditary Angioedema

    Produces the similar clinical changes as that of acquired type

    Inherited through autosomal dominant trait having deficiency of the inhibitorof the first component of compemen, C1 esterase

    Drug Reactionclinical features

    Angioedema

    Either acquired or hereditary

    Appear soft, diffuse, painless swelling

    Usually affecting the lips, neck or face

    No color change

    Condition subsides after 1-2 days which may recur at a later date

    Emergency treatment may be required to prevent respiratory distress orglottic or laryngeal involvement

    Drug Reactionclinical features

    Other cutaneous manifestations

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    Urticaria

    Maculopapular rash

    Erythema

    Vesicles

    Ulcers

    Target lesions (EM)

    Drug Reactionclinical features

    Oral manifestations

    Erythematous, vesicular or ulcerative

    May mimic lichen planus ( lichenoid drug reations)

    Widespread of ulcers typical or EM are often representative of a drug reaction

    Drug Reactionshistopathology

    Non-specific: spongiosis, necrotic keratinocytes, lymphoid infiltrates,eosinophils

    Biopsy may be helpful but not diagnostic

    Drug Reactiondiagnosis

    Diagnosis requires a high index of suspicion and careful history taking

    Recent use of drug

    Withdrawal of suspected drug should result in improvement

    Drug Reactiontreatment

    Important measure in management is identification & withdrawal of thecausative agents

    Antihistamines

    Corticosteroids (occasionally)

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    Contact Allergyetiology & pathogenesis

    Antigenic stimulation of vast array of foreign substances

    Immune response is cell-mediated

    Sensitization phase:

    Langerhans cell recognize the foreign antigen & present them it the T-lymphocytes

    Local lymphocytes secrete chemical mediators producing allergicreactions

    Contact Allergyclinical features

    Lesions directly adjacent to the causativ agent

    Presenting lesions ranges from erythematous to ulcerative

    Frequently seen in skin, uncommon intraorally

    Contact Allergyclinical features

    Materials containing agents known to cause oral contact allergic reactions:

    Toothpaste

    Mouthwash, mouthrinse

    Candy

    Chewing gum

    Topical antimicrobials

    Topical steroids

    Iodine

    Essential oils

    Denture base materials

    Cinnamon white , lichenoid, red or ulcerative lesions

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    Contact Allergyhistopathology

    Epithelium & connective tissue sho inflammatory changes

    Spongiosis & vesiculation is also seen

    Dilated blood vessels

    Eosinophils may be seen

    Contact Allergydiagnosis

    Careful history taking is essential

    Establish a cause & effect relationship may not be possible

    Biopsy may be helpful but non-conclusive

    Patch testing may be helpful but may give a false-positive or false-negativeresult

    Contact Allergytreatment

    Elimination of the offending agent or material

    Healing should take place in 1- 2 weeks

    Topical steroids may hasten the healing process

    Wegeners Granulomatosis

    Inflammatory condition of unknown origin

    Wegeners Granulomatosisclinical features

    Triad of upper respiratory tract, lung and kidney involvement

    Occasionally, only 2 of 3 sites are affected

    Lesions may present in the oral cavity & skin & other organ system

    Basic process common to all foci is necrotizing vasculitis with granulomaformation

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    Wegeners Granulomatosisclinical features

    Rare disease of middle age

    Initial presentation often occur with head & neck

    Sinusitis, rhinorrhea, nasal stuffiness & epistaxis seen w/ or w/o feverarthralgia & weight loss

    In majority of the cases, nasal or sinus ( maxillary) involvement is seen & isoften seen in the course of the disease

    Wegeners Granulomatosisclinical features

    Destructive lesions are typically ulcerated

    Necrosis & perforation of nasal septum

    Perforation of hard palate is uncommon

    Intraorally, red granular gingival lesions

    Generalized & results in relatively uniform enlargement

    Wegeners Granulomatosisclinical features

    Most patients have kidney involvement

    Focal necrotizing glomerulitis

    Renal failure is the final outcome

    Inflammatory lung lesions

    Intensify from slight to severe

    May lead to respiratory failure

    Wegeners Granulomatosishistopathology

    Basic pathologic process is granuloatous with necrotizing vasculitis

    Presence of acute & chronic inflammatory cells

    Affected small vessels show a mononuclear infiltrate within their walls

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    Wegeners Granulomatosisdiagnosis

    Depend upon the finding of granulomatous vasculitis in biopsy tissue of URT,evidence of lung involvemen or kidney lesions

    Anti-neutrophil cytoplasmic antibodies (ANCA)

    Negative culture & tissue identification of microorganisms would help rule outinfectious processes

    Immunohistochemical staining could be used to rule out neoplasm

    Wegeners Granulomatosistreatment

    Cytotoxic agent

    Cyclophosphamide

    Corticosteroids

    Remissions seen 75% of cases

    Midline Granuloma

    Diagnosis made exclusion of other granulomatous & necrotizing midfaciallesions

    Represents an atypical or unrecognized lymphoma

    Midline Granulomaetiology

    Unknown etiology

    Hyper-immune response to an unidentified antigen

    Lymphoid neoplasia from chronic immune stimulation has been suggested

    Midline Granulomaclinical features

    Unifocal destructive process in the midline of the oronasal region

    Lesions appear as aggressive necrotic ulcers that are progressive & non-healing

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    Extension through soft tissue, cartilage & bone is typical

    Perforation of the nasal septum & hard palate is characteristic

    Midline Granulomaclinical features

    Without treatment, the inflammatory process eventually consumes thepatient

    Because of continuous erosion into vital structures especially blood vessels:death has been a typical outcome

    Midline Granulomahistopathology

    Appear like acute & chronic inflammation in partially necrotic tissue

    Several biopsies are required to confirm the diagnosis

    Midline Granulomadifferential diagnosis

    Wegeners granulomatosis

    Infectious disease

    Bacterial infection ( TB)

    Deep fungal diseases

    Neoplasm

    Poorly differentiated squamous cell carcinoma, sarcomas &lymphomas

    Midline Granulomattreatment

    Treatment of choice

    High dose of local radiation

    Optimistic prognosis

    Corticosteroids

    Chronic Granulomatous Disease

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    Inherited condition

    Resulting clinical defect: altered neutrophil macrophage function

    Cells have the capacity to phagocyte microorganism but lack the ability to killcertain bacteria & fungi

    Chronic Granulomatous Disease- clinical features

    Manifestations appear during childhood

    Predominantly occur in males

    Affect different organs: lymph nodes, lung, liver, spleen, bone & skin

    Recurrent & persistent

    Oral lesions: multiple ulcers

    Recurrent & persistent

    Chronic Granulomatous Disease- histopathology

    Granular nodular

    Granulomas may exhibit central lesions

    Chronic Granulomatous Disease- diagnosis

    Clinical features & tissue samples

    Neutrophil function tests confirm the diagnosis

    Differential diagnosis: Crohns disease, TB, histoplasmosis, blastomycosis,tularemia

    Chronic Granulomatous Disease - treatment

    Use of specific antimicrobial agents

    Neutropenia

    Rare blood dyscrasia of unknown cause

    Manifests as severe cyclic depletions of neutrophils from blood and marrow,with mean cycle of periodicity of about 21 days

    Signs & symptoms: fever, malaise, oral ulcers, cervical lymphadenopathy &infections may appear neutropenic episodes

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    Patients are prone to exaggeration of periodontal disease

    No definitive treatment