Pathology · patient case question
The medical history and oral findings together are most suggestive of which condition?
Patient case: White striations of the palate and buccal mucosa in a young woman
Patient: Female, 29 years old
Chief Complaint: “I have white patterns in my mouth and my mouth feels sore when I eat spicy food.”
Background: Two years of intermittent joint pain, marked fatigue, and a facial rash that flares in the sun across the cheeks and bridge of the nose. Recent episodes of hair thinning and mouth ulcers. No medications known to cause oral lichenoid reaction.
Vital Signs: BP 118/74 mmHg · HR 82 bpm · T 99.1°F
Findings: WHITE, NON-WIPEABLE striations with surrounding erythema on the HARD PALATE and on the buccal mucosa BILATERALLY, with irregular radiating peripheries. Scattered shallow ulcers. Malar erythema sparing the nasolabial folds.
Show answer and explanation
Correct answer: C. Systemic lupus erythematosus
- A. Reticular LICHEN PLANUS gives fine lacy white striae, characteristically BILATERAL on the BUCCAL MUCOSA, with the tongue and gingiva next in frequency and the hard palate distinctly uncommon. It carries no photosensitive rash, no arthralgia and no alopecia. Histologically it shows a band-like subepithelial lymphocytic infiltrate with basal cell degeneration and sawtooth rete ridges — features that overlap considerably with lupus, which is why the systemic history matters so much.
- B. Mucous membrane pemphigoid presents as desquamative gingivitis with subepithelial blistering and a positive Nikolsky sign, and direct immunofluorescence shows a linear band at the basement membrane. It does not produce white striations.
- C. CORRECT. The oral lesions alone could pass for lichen planus, but the SYSTEMIC picture decides it — photosensitive MALAR RASH sparing the nasolabial folds, arthralgia, fatigue, alopecia and recurrent oral ulceration is the classic SLE cluster. Two oral features point the same way: involvement of the HARD PALATE, which lichen planus rarely affects, and lesions with irregular RADIATING peripheries and surrounding erythema rather than the fine, lacy, symmetric Wickham striae of lichen planus. Confirmation is serological — ANA as the screen, then anti-dsDNA and anti-Sm, which are highly specific.
- D. Erythema multiforme is ACUTE and dramatic: haemorrhagic crusted lips, widespread mucosal ulceration and target lesions on the skin, developing over days and often triggered by herpes simplex or a drug. This presentation is chronic and striated.
Note: The dental implications of a lupus diagnosis are worth holding: long-term corticosteroid and immunosuppressant therapy with the adrenal-suppression and infection questions that follow; secondary SJÖGREN syndrome with xerostomia and rampant cervical caries; a raised risk of INFECTIVE ENDOCARDITIS from Libman-Sacks verrucous endocarditis; and antiphospholipid antibodies in a subset, which bring both thrombosis risk and, paradoxically, anticoagulation.