Pathology · patient case with 2 questions
Oral ulceration after a stem cell transplant
Patient: Male, 73 years old
Chief complaint: “My mouth really hurts. I need something for the discomfort.”
History: Leukaemia; received an allogeneic stem cell transplant four weeks ago. Medications: acetaminophen, cyclophosphamide, rituximab.
Findings: Multiple scattered erythematous and leukoplakic ulcerations on the palate and buccal mucosa. Lesions are present in varying stages of healing. A lichenoid reticular pattern is visible in places.
Question 1
What is the most likely diagnosis?
Show answer and explanation
Correct answer: B. Graft-versus-host disease
- A. Medication allergy would give a more uniform, acute eruption temporally linked to a new drug, and would not follow a lichenoid pattern with mixed-stage lesions.
- B. CORRECT. Oral GRAFT-VERSUS-HOST DISEASE follows allogeneic transplantation when donor T lymphocytes recognise host tissue as foreign. The oral presentation is the one described: LICHENOID reticular white striae with erythema and ulceration, lesions at DIFFERENT STAGES simultaneously, xerostomia from salivary gland involvement, and often mucosal sensitivity to spice and acid. Timing fits — acute GVHD appears within the first 100 days, chronic GVHD after.
- C. Crohn disease causes linear ulcers in the buccal vestibule, cobblestone mucosa, and mucosal tags, usually with a history of gastrointestinal symptoms. It does not explain the post-transplant timing.
- D. Recurrent intra-oral herpes simplex produces crops of small vesicles that coalesce into ulcers on KERATINISED mucosa — hard palate and attached gingiva. It heals in 7 to 10 days as a single crop, not in mixed stages, and does not produce lichenoid striae.
Note: Oral GVHD matters beyond comfort: chronic oral GVHD carries an elevated long-term risk of oral squamous cell carcinoma, so these patients need lifelong surveillance. It is also often the FIRST site where chronic GVHD becomes apparent.
Question 2
What is the EARLIEST stage of wound healing in which both bacterial elimination and blood clot stabilisation have occurred?
Show answer and explanation
Correct answer: C. Inflammation
- A. Maturation and remodelling runs from about three weeks out to a year or more, as type III collagen is replaced by type I and tensile strength rises to roughly 80 percent of original. It is the LAST phase.
- B. Proliferation, around days 3 to 21, is when fibroblasts lay down collagen, angiogenesis restores perfusion and granulation tissue fills the defect. Bacterial clearance has already happened by then.
- C. CORRECT. The INFLAMMATORY phase, spanning roughly days 1 to 3, is where both events happen. NEUTROPHILS arrive first and phagocytose bacteria and debris, then MACROPHAGES take over from about 48 to 72 hours, continuing debridement and releasing the growth factors that drive the next phase. Meanwhile the fibrin clot formed during haemostasis is stabilised and becomes the provisional matrix that cells will migrate along.
- D. Migration of epithelial and mesenchymal cells across the provisional matrix begins as part of, and immediately following, inflammation — so it is not the EARLIEST phase in which both listed events are complete.
Note: The four-phase sequence: haemostasis, inflammation, proliferation, remodelling. Note the deliberate trap in this item — haemostasis forms the clot, but the question asks where the clot is STABILISED and bacteria eliminated, which is inflammation.