Pathology · patient case question
What is the most likely diagnosis?
Patient case: 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.
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.