SHM Converge Scientific Abstract ePoster Gallery-A Case of Refractory Mucositis

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A 61-year-old woman with no significant past medical history developed progressive oral mucositis and severe odynophagia beginning shortly after routine dental radiographs. Over three months, her mouth pain worsened to extensive oral ulcerations, inability to tolerate oral intake, and a 17-pound weight loss. She was initially treated for presumed infection after a positive outpatient HSV-1 PCR, receiving acyclovir, then amoxicillin, clindamycin, fluconazole, and a short course of high-dose prednisone, without improvement. An outpatient buccal biopsy performed before admission was initially concerning for squamous cell carcinoma.<br /><br />On admission, she had diffuse mucositis of the lips and buccal mucosa. During hospitalization, she developed dysuria, dry eyes, and genital erosions, though ophthalmologic exam showed no uveitis or episcleritis. Her course required symptomatic treatment with topical steroids, sucralfate, lidocaine, opioid analgesia, IV fluids, and nutritional support for severe dehydration and malnutrition. Infectious and autoimmune testing, including HSV, CMV, HIV, fungal studies, HLA-B51, ANA, SSA/SSB, and ANCA, were negative.<br /><br />Because of persistent concern for malignancy and inflammatory disease, multiple services were consulted, including Dermatology, Rheumatology, ENT, Ophthalmology, and Oncology. CT imaging showed prominent bilateral cervical lymphadenopathy without a discrete mass, and she later developed a new ulcerative lesion on the jaw. Ultimately, internal review of the biopsy demonstrated suprabasilar acantholytic changes consistent with pemphigus vulgaris, and anti-desmoglein 3 antibody was markedly elevated.<br /><br />This case highlights that mucosal-predominant pemphigus vulgaris can present without classic bullae and may mimic HSV infection, drug reactions, or squamous cell carcinoma. Anchoring bias around dental procedures, prior HSV results, and preliminary pathology delayed diagnosis. Early biopsy with immunofluorescence is essential, as routine histopathology may be misleading.

Asset Subtitle

Suzan Sargsyan

Meta Tag

Author List Jennifer Quartarolo, Suzan Sargsyan

Category Clinical Vignettes

Concept Pemphigus Vulgaris

Concept Mucosal Disease

Concept Anchoring Bias

Concept Biopsy

Concept Immunofluorescence

Distinguished Non-Finalist

Presenter Organization University of California San Diego

Presenting Author Suzan Sargsyan

Track Adult

Keywords

pemphigus vulgaris

oral mucositis

odynophagia

oral ulcerations

suprabasilar acantholysis

anti-desmoglein 3

mucosal-predominant disease

HSV-1 misdiagnosis

squamous cell carcinoma mimic

direct immunofluorescence

Pemphigus Vulgaris

Mucosal Disease

Anchoring Bias

Biopsy

Immunofluorescence