Lip Ulceration Associated with Intravenous Administration of Zoledronic Acid: Report of a Case

Abstract

Although osteonecrosis of the jaw is a wellknown adverse reaction of bisphosphonates (BPs), random cases of oral mucosal ulceration after per os administration of BP-aledronate have been attributed to prolonged mucosal irritation. This report, for the first time, describes the mucosal ulceration related to intravenous use of zoledronic acid (ZA). A 52-year-old female patient presented with painful ulcers on both cutaneous/mucosal surfaces of the lower lip and a 2-month history of osteonecrosis of the mandible beside the right lower canine. Her medical record included intravenous administration of ZA for 10 months for primary breast cancer metastatic to bone. Examination of the peripheral blood showed severe anemia and a slightly increased white blood cell count, due to urinary tract infection by E. coli, but no evidence of a viral infection. The treatment of anemia and E. coli infection did not improve the labial ulcers. Biopsy from the mucosal lesion revealed a nonspecific ulceration with moderate inflammatory infiltration. There was no evidence of infection or malignancy. ZA administration was discontinued and within 3 months the lesions were resolved after treatment with systemic antibiotics (amoxicillin), vitamins A and E, chlorexidine and H 2 O 2 (hydrogen peroxide) solutions and local pantothenic acid/ vitamin A creams. Recurrence was detected a month after ZA re-administration. Nevertheless, after new treatment, the patient was free of oral/skin lesions 18 months later. This case, which is the first report of ulceration associated with intravenous administration of bisphosphonates, suggests that systemic mechanisms may be implicated in BP-induced oral mucosal ulceration. Furthermore, ZA appears to cause the same oral mucosal manifestations as alendronate. This emphasizes the need for oral examination in all cases of BP therapy, whether per os or intravenously administrated.

Delayed Inflammatory Reaction to Hyaluronic Acid Dermal Filler Following Zoledronic Acid Administration: A Case Report

“… 3 Other rare side effects are dermatitis, figurate erythema, erythema multiforme, vasculitis, and lip ulceration. 4 Cases of Stevens-Johnson syndrome and toxic epidermal necrolysis are very rare (1/10,000) and have been reported for all of the bisphosphonates. 6 Zoledronic acid-induced dermatomyositis has been reported in a small number of patients who have been treated with zoledronic acid for osteoporosis.…”

“…Nonetheless, severe cutaneous adverse events such as toxic epidermal necrolysis may occur. 3 , 4 Hyaluronic acid soft tissue fillers are non-permanent and non-invasive aesthetic procedure. They have become one of the most prevalent non-surgical treatments due to their excellent safety profile and delivering significant results in facial rejuvenation and high patient satisfaction.…”

Zoledronic Acid–Induced Interface Dermatitis

“… 7 The second patient was a 52-year-old woman who was on ZA for metastatic breast cancer as well, but her clinical presentation was that of painful erosions on the lip. Her symptoms started after 8 months of initiation of ZA 8 (Table 1 ). In the other two, histopathologic findings were those of an interface dermatitis with concomitant clinical manifestations of dermatomyositis.…”

“Medication Related Osteonecrosis of the Jaw (MRONJ): Dental Atraumatic Treatment: Antiseptic Mouthwashes”.

“…[13] MRONJ produce in some cases oral mucosal ulceration after administration of Antiresorptives drugs and it has been attributed to prolonged mucosal irritation lesions which be solved after treatment with H2O2 (Hydrogen Peroxide) between others mouthwashes. [14] It is essential patients with MRONJ be treated in an Additionally, patients should be informed of the precautions to be taken, including regular dental appointments for oral health assessment. The risk of developing MRONJ should be evaluated according to the type of AR or antiangiogenic drugs administered and treatment duration.…”