Diagnostic Considerations
Overall, candidiasis is the most frequent oral infection in patients who are myelosuppressed (see image below); recurrent herpes simplex virus (HSV)–1 infection is the most frequent oral viral infection in these patients (see images below).
Herpes simplex virus ulceration on the hard and soft palate. Note lesions on the right upper lip and the dorsum of the tongue.
HSV infection should be suspected when ulcers are noted extraorally on the lips and intraorally on keratinized sites (ie, tongue dorsum, gingiva, and hard palate); in immunocompromised patients, HSV may reactivate in nonkeratinized sites, and, in some cases, this can occur despite antiviral prophylaxis. Consider other viral infections, including human herpesvirus 6 (HHV-6), human herpesvirus 7 (HHV-7), and cytomegalovirus (CMV).
Acute graft versus host disease (GVHD) occurs typically within the first 100 days after allogeneic hematopoietic cell transplantation (HCT) and involves the skin; the liver; and the mucosae of the eye, mouth, and GI tract. Acute GVHD lesions in the oral cavity occur following engraftment and restoration of the WBC count and well after the resolution of oral mucositis lesions, although in some cases, they may manifest as a continuation or exacerbation of oral mucositis. An important difference is that lesions of acute GVHD may affect the keratinized mucosa, which is not a feature of oral mucositis (see image below).
Acute graft versus host disease involving the dorsal surface of the tongue. This is a keratinized site that is usually not involved by oral mucositis.
Risk factors include HLA disparity, sex mismatching, multiple donor pregnancies, and advanced age. Management includes controlling systemic acute GVHD with systemic immunosuppressive therapy, controlling pain, and providing local palliative measures. Chronic GVHD develops in most cases at least 3 months after HCT and should never be mistaken for mucositis.
A high index of suspicion of secondary or concomitant infection in lesions of oral mucositis is imperative. Cultures should be obtained to rule out such infections. Effective antimicrobial treatments are available for herpetic, fungal, and secondary bacterial infections. The failure to make the diagnosis and, therefore, to treat such conditions may lead to dissemination of infection or unnecessary and prolonged pain and suffering.
Differential Diagnoses
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Hairy tongue.
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Multiple mucoceles on the hard palate.
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Erythematous oral mucositis lesion on the buccal mucosa.
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Ulcerative oral mucositis lesion on the buccal mucosa.
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Ulcerative oral mucositis lesion on the lateral and ventral surfaces of the tongue.
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Ulcerative oral mucositis lesions on the labial mucosa and the floor of the mouth.
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Oral pseudomembranous candidiasis on the hard palate.
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Herpes simplex virus ulceration on the dorsal surface of the tongue.
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Herpes simplex virus ulceration on the hard and soft palate. Note lesions on the right upper lip and the dorsum of the tongue.
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Acute graft versus host disease involving the dorsal surface of the tongue. This is a keratinized site that is usually not involved by oral mucositis.
