A 17-year-old male patient was referred from the internal medicine department to the dental surgery unit of University Hospital Farhat Hached, Tunisia. The patient was complaining about recurrent intraoral ulcers, diagnosed with recurrent aphthous stomatitis. He was treated with colchicine for two months without any improvement.
Our patient was afebrile with all vital signs within normal limits, and his medical history was noncontributory.
Extraoral examination at this point revealed nonspecific 3 to 4 purplish red cutaneous lesions on the forearms. Only some itching was reported. However, intraoral examination revealed diffuse and painful irregular erythematous lesions and postbullous ulcerations on the palate (Figure 1) and all buccal mucosae. Moreover, poor oral hygiene was noticed as the patient was unable to brush his teeth regularly.
Based on the clinical examination, the diagnosis of recurrent aphthous stomatitis was excluded. Yet a bullous disease was suspected such as bullous pemphigoid, lichen planus, or even a drug reaction related to the use of colchicine. Aimed at confirming our diagnosis, a histological exam with a biopsy in the left buccal mucosa was performed.
The patient was told to stop all medications and start using corticosteroids: Solupred (20 mg) 1 tablet *3 per day for 20 days and a topical steroid for the cutaneous lesions in order to relieve him and enable him to eat and speak conveniently.
One week later, the patient showed a clear improvement of mucosal lesions as well as pain relief. The histopathological analysis showed a prominent dermal inflammatory reaction with vasodilation and oedema. A dermal inflammatory infiltrate consisting of lymphocytes and histiocytes was identified as well as some necrotic epidermal cells (Figure 2). Thus, the diagnosis of erythema multiforme was retained.
Unfortunately, one month later, the patient reported complaints about more severe postbullous lesions on buccal, gingival, and labial mucosae (Figure 3). The lesions were diffuse, multiple, irregularly mixed, red and white, surrounded by erythematous margins, and covered with white slough in addition to postvesicular heme-crusted polycyclic erosions of vermillion lips and philtrum.
Furthermore, numerous targetoid erythematous lesions over the back of hands, fingers, arms, and back were noticed (Figure 4).
Considering the presence of a herpes lesion and the recurrence in a short period of time, a correlation between herpes simplex infection and erythema multiforme was suspected. Therefore, serology tests were indicated. The patient was negative for human immunodeficiency virus (HIV) while positive for herpes simplex virus (HSV) pinpointing a chronic infection (IgM: negative; IgG: positive).
Clinical evidences, positive serology tests, and pathological findings were in accordance with diagnostic features of HAEM.
The patient was treated with prednisolone 60 mg a day for 10 days, antiseptic, analgesic, and anesthetic mouthwash, topical steroid ointment, and valaciclovir 500 mg a day for 6 months to prevent the recurrence.
The patient when recalled after 2 months showed marked improvement in his condition with no signs of recurrence.