Chronic graft-versus-host disease - Oral Mucosal Lesion
The incidence of chronic GVHD is estimated to be 60%-70% in recipients of allogeneic stem cell transplants with mismatched and unrelated donors, and about 30% in recipients of fully histocompatible sibling donor transplants. Almost all chronic GVHD patients will have skin involvement, and the oral mucosa is involved in 90% of patients with chronic GVHD.
Acute oral GVHD usually manifests 15-20 days after transplantation when engraftment occurs. Patients generally complain of pain, sensitivity, soreness, dryness in the mouth, and sometimes tightness of the oral musculature. The lips, tongue, gums, and buccal mucosae can all be involved. There are often accompanying dental caries and gingivitis / periodontitis, skin rash, irritated eyes, diarrhea, and elevated liver function tests.
More chronically, changes that resemble oral lichen planus may occur. If sclerotic GVHD is present, perioral sclerosis results in reduction of motion of lips and loss of the mandibular and maxillary vestibules.
D89.811 – Chronic graft-versus-host disease
402356004 – Chronic graft-versus-host disease
Differential Diagnosis & Pitfalls
- Oral lichen planus is clinically indistinguishable from chronic GVHD except for the history of hematopoietic cell transplantation. Many oncologists refer to oral chronic GVHD as oral lichen planus developing after transplantation.
- Recrudescent herpes simplex virus (HSV) may appear as ulcers but generally is not associated with lichenoid striations. A culture will identify the virus. However, infection may reactivate within lesions of oral chronic GVHD, exacerbating symptoms.
- Similarly, cytomegalovirus (CMV) infection in the mouth presents as ulcers that may be solitary or multifocal. Simple viral cultures are not as effective as a biopsy in identifying CMV infection, which tends to infect deep tissues.
- Neutropenic ulcers occur in the same population, but this is usually within 5-15 days after conditioning regimens and transplantation, when the patient is profoundly neutropenic.
- Acute oral GVHD usually manifests 15-20 days after transplantation when engraftment occurs and is primarily erythematous and ulcerative without evidence of striations.
- Leukoplakia may be misdiagnosed as chronic GVHD and must be biopsied, since these patients are at high risk for oral cancer because of immunosuppression.