Gingival Ulcerations in a Patient with Acute Myeloid Leukemia: A Case Report and Literature Review

Abstract

A 40-year-old female patient was admitted to the Department of Oral Medicine due to oral ulcerations. Oral ulcerations were present on vestibular mucosa above teeth 21, 22, 25 and 26 and were 1 cm in diameter, and also around teeth 45 and 46. The patient had prolonged neutropenia due to therapy-related myelodysplastic syndrome that progressed to therapy-related acute myeloid leukemia. Initially, the patient was successfully treated with polychemotherapy for non-Hodgkin lymphoma. Unfortunately, many toxic complications ensued, such as peripheral neuropathy, dilated cardiomyopathy and therapy-related myelodysplastic syndrome/therapy-related acute myeloid leukemia. The onset of therapy-related myelodysplastic syndrome was less than six months after initiation of chemotherapy treatment, which was rather early, but cytogenetic changes (monosomy 5 and 7) were consistent with the diagnosis. Upon admission to our Department, microbiological swabs were obtained and were all negative, while x-ray finding showed that ulcerations did not have dental cause. Biopsy was not obtained as the patient had severe neutropenia and thrombocytopenia. While viral and fungal swabs were negative, Stenotrophomonas maltophilia was cultured from the oral cavity. Thus, differential diagnoses are listed in this report. Neutropenic ulcerations did not heal albeit extensive medicamentous oral and systemic treatments were applied and the patient died.

Gingival Necrosis Related to Sepsis-Induced Agranulocytosis Due to Pseudomonas aeruginosa Bacteraemia: A Case Report

“…Further characteristics of agranulocytosis-related gingival necrosis are described in Table 2 and Table 3 . Agranulocytosis may be triggered by drugs [ 6 , 36 , 37 , 38 , 39 , 40 , 41 , 42 ], and it commonly occurs in immunocompromised patients [ 13 , 14 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 ]. Common systemic signs include fever, malaise, nausea, vomiting, lymphadenopathy, pharyngitis, dysphagia, sepsis [ 37 , 48 ], and septic shock [ 13 , 36 , 43 ], and it may result in death [ 14 , 44 , 45 , 48 ].…”

“…Patients with agranulocytosis may present with pale white necrotic lesions, as a late-stage presentation where the gingiva has already exfoliated [ 41 ], or where the necrotic lesions are black or violaceous in colour [ 43 , 45 ]. Oral lesions may also include ulcers or extension of necrosis to the tongue [ 6 , 41 , 48 ], retromolar pad [ 48 ], palate [ 36 , 39 , 40 , 43 , 44 ], floor of the mouth [ 47 , 49 ], lip [ 39 , 44 ], or vestibule [ 49 ].…”

“…Other studies report the use of empirical broad-spectrum antibiotics and/or antifungals [ 6 , 36 , 37 , 38 , 39 , 41 , 42 , 44 , 45 , 49 , 50 ] and substituted them later if cultures were performed [ 13 , 14 , 43 , 47 , 51 ]. Topical treatments include antiseptics [ 6 , 13 , 36 , 37 , 38 , 39 , 40 , 46 , 48 , 49 , 50 , 51 ], antibiotics [ 46 ], or antifungals [ 39 , 42 , 44 , 46 , 51 ] and analgesics [ 6 , 42 , 48 ] for pain management. Periodontal instrumentation and removal of necrotic tissues, sequestra, and excessively mobile teeth is usually performed when blood counts are deemed safe, and if the zone of necrosis is not too extensive [ 13 , 36 , 37 , 38 , 39 , 40 , 42 , 46 , 49 , 50 ].…”

“…When possible, drugs that are the suspected cause of decreased blood counts are discontinued or substituted [ 6 , 36 , 37 , 38 , 39 , 40 , 42 , 49 ]. Other treatment modalities include the use of recombinant granulocyte colony-stimulating factor [ 6 , 37 , 43 , 45 , 47 , 49 ], blood transfusions [ 40 , 48 , 50 ], policresulen [ 37 ], and low-level laser therapy [ 50 ]. Complete resolution of gingival healing varies from two days [ 14 ] to a year ( Table 3 ).…”

Oral manifestations associated with neutropenia in Syrian patients diagnosed with hematological malignancies and undergoing chemotherapy: A cross-sectional study

“…The necrotic tissue of these ulcers may emit an unpleasant odor, but they typically exhibit significant improvement with an increase in the ANC. [ 13 , 20 , 21 ] Therefore, when evaluating the occurrence of oral ulcers in patients with malignancies, it is essential to consider multiple factors including neutropenia, direct drug toxicity, and infection. [ 21 ] To our knowledge, no direct comparisons have been made between CIN and chemotherapy alone in the development of oral ulcers.…”