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Chemotherapy-induced mucositis - Oral Mucosal Lesion
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Chemotherapy-induced mucositis - Oral Mucosal Lesion

See also in: Overview
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Contributors: Melissa Danesh MD, Susan Burgin MD, Carl Allen DDS, MSD, Sook-Bin Woo MS, DMD, MMSc
Other Resources UpToDate PubMed

Synopsis

Chemotherapy-induced mucositis develops 5-10 days after the initiation of treatment and resolves slowly 2-3 weeks after cessation of treatment, usually when the absolute neutrophil count rises above 500/ml. It occurs in approximately 20%-40% of patients receiving conventional chemotherapy and 80% of patients receiving high-dose chemotherapy. It starts with erythema of the mucosa, which usually breaks down to form ulcers. Ulcers may be single or multiple, round or irregularly shaped, and are usually on sites that are frequently traumatized (eg, buccal mucosa).

While not all chemotherapeutic agents will cause mucositis, many have this capability. Some agents (eg, methotrexate and etoposide) are excreted in saliva, which increases their toxicity. The degree to which mucositis is induced is also dependent on the drug and the age of the patient, with younger patients often experiencing more severe signs and symptoms. Chemotherapy-induced mucositis tends to be less severe in patients who have received recombinant human granulocyte colony-stimulating factor (G-CSF). Patients complain of pain and burning that is exacerbated by eating and by oral hygiene procedures.

Oral mucositis combined with gastrointestinal mucositis may occur in about 8% of patients who receive standard-dose chemotherapy with subsequent development of myelosuppression. Suggestive symptoms include pain, nausea / vomiting, and diarrhea.

Codes

ICD10CM:
K12.31 – Oral mucositis (ulcerative) due to antineoplastic therapy

SNOMEDCT:
403666006 – Drug-induced mucositis

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Diagnostic Pearls

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Differential Diagnosis & Pitfalls

  • Herpes simplex virus (HSV) infection – An immunosuppressed state can result in reactivation of herpes virus, and lesions often appear atypical in such patients. Clustered, coalescent ulcers on either the keratinized or nonkeratinized mucosa are suggestive, and cultures should be performed.
  • Acute graft-versus-host disease – This would develop only in patients who have received an allogeneic hematopoietic cell transplant. Involvement of the tongue dorsum and hard palate mucosa, or sudden exacerbation of oral ulcers after engraftment, should raise suspicions for this condition.
  • mTOR-inhibitor-associated oral ulcers (see drug-induced oral ulcer) – These are aphthous-like ulcers that occur 1-2 weeks after the start of mTOR inhibitors.
  • Pemphigus vulgaris – This condition is usually chronic and often affects the oral mucosa initially. Lesions are not associated with chemotherapy.
  • Paraneoplastic pemphigus – This uncommon condition develops in patients who have a history of hematologic malignancy, and oral ulcers are present in all cases. Often the polymorphous nature of the lesions, which can resemble lichen planus, pemphigoid, erythema multiforme, and/or pemphigus vulgaris, will suggest this diagnosis.
  • Erythema multiforme – This condition represents a hypersensitivity reaction, usually to reactivated or recrudescent HSV. Some patients may have only oral involvement, but a significant percentage will develop skin lesions also. The diagnosis can be made on the basis of characteristic "target" or "iris" lesions on the skin.
  • Mycoplasma-induced rash and mucositis (MIRM) – A relatively uncommon mucocutaneous condition resulting from Mycoplasma pneumoniae infection, characterized by prominent mucositis.
  • Ulcerative lichen planus – This condition is usually chronic and is characterized by symmetrical involvement of the oral mucosa. The ulcerations are surrounded by radiating white striae.
  • Mucous membrane pemphigoid – This condition is typically chronic and primarily involves the attached gingivae, unlike chemotherapy-induced mucositis. A biopsy with direct immunofluorescence studies confirms the diagnosis.
  • Oral squamous cell carcinoma (SCC) – This may present as an ulcer; however, the surface is typically irregular, rough, or granular. Oral SCC is often painless and will typically have been present for longer than mucositis.

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Management Pearls

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Therapy

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Drug Reaction Data

Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.

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References

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Last Reviewed: 06/05/2018
Last Updated: 07/16/2018
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Chemotherapy-induced mucositis - Oral Mucosal Lesion
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Chemotherapy-induced mucositis : Oral ulcers, Buccal mucosa, Mucosal lip, Oral erosions, Ventral tongue
Clinical image of Chemotherapy-induced mucositis
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