Oral ulceration

A 60 year-old female treated for breast cancer develops leukopenia and severe stomatitis and oral ulcerations. Which of the following agents most likely caused these findings ... 

Orai uicerations Oral ulcerations may develop that may have the appearance of aphthous stomatitis. Although rare, cheilosis, glossitis, and gingivostomatitis have been reported. 

Combination therapy - For toxicities likely to be associated with zalcitabine (eg, peripheral neuropathy, severe oral ulcers, pancreatitis, elevated liver function tests, especially in patients with chronic hepatitis B see Warnings and Precautions), interrupt or reduce dose. For severe toxicities or those persisting after dose reduction, interrupt zalcitabine therapy. For recipients of combination therapy with zalcitabine and other antiretrovirals, base dose adjustments or interruption for either drug on the known toxicity profile of the individual drugs. 

Oral ulcers Severe oral ulcers occurred in approximately 3% of patients in 2 trials. Less severe oral ulcerations occurred at higher frequencies in other clinical trials. Esophageal ulcers Infrequent cases of esophageal ulcers have been attributed to zalcitabine therapy. Consider interruption of therapy in patients who develop esophageal ulcers that do not respond to specific treatment for opportunistic pathogens in order to assess a possible relationship to zalcitabine. Cardiomyopathy/CHF Cardiomyopathy and CHF have occurred with the use of nucleoside antiretroviral agents in AIDS patients infrequent cases have occurred in patients receiving zalcitabine. Approach treatment with caution in patients with baseline cardiomyopathy or history of CHF. 

Adverse reactions may also include tachycardia hypertension palpitations syncope cerebrovascular accident vasodilation vasculitis gingivitis dyspepsia oral ulcer/abscess gastritis gastric ulcer hypersalivation dry mouth splenomegaly melena hematochezia esophagitis colitis pancreatitis pancytopenia neutropenia eosinophilia thrombocytopenia hepatitis hepatomegaly hepatic dysfunction renal... 

Herpes zoster Angular cheihtis Recurrent oral ulcerations Papular pruritic eruptions Seborrhoeic dermatitis Fungal nail infections of fingers Clinical stage HI... 

Damage to the normally proliferating mucosa of the gastrointestinal tract may produce stomatitis, dysphagia, and diarrhea several days after treatment. Oral ulcerations, esophagitis, and proctitis may cause pain and bleeding. 

Assess the patient for signs and symptoms of superinfection, such as anal orgenital pruritus, black hairy tongue, oral ulceration orpain, diarrhea, increased fever, sore throat, and vomiting... 

Rash (pruritic, erythematous, maculopapular, morbilliform), reduced/altered sense of taste (hypogeusia), G1 disturbances (anorexia, epigastric pain, nausea, vomiting, diarrhea), oral ulcers, glossitis Occasional... 

Monitor for stomatitis (burning/erythema of oral mucosa at inner margin of lips, sore throat, difficulty swallowing, oral ulceration)... 

Pain, swelling, tenderness of skin, rash, hives, itching, oral ulcers Occasional... 

Diarrhea, abdominal pain, oral ulcers, cough, pruritus, myalgia, weight loss, nausea,... 

Zalcitabine NRTI1 0.75 mg tid3 Administer 1 h before or 2 h after an antacid Peripheral neuropathy oral ulcerations, pancreatitis, headache, nausea, rash, arthralgias Avoid concurrent cimetidine avoid concurrent neuropathic drugs (eg, ddl, zalcitabine, isoniazid). Do not administer with lamivudine... 

Sunirinib (Sutent) [Kinase Inhibitor] Uses Advanced GI stromal tumor refractory/intolerant of imatinib advanced RCC Action Kinase inhibitor Dose Adults. 50 mg PO daily x 4 wk, followed by 2 wk holiday = 1 cycle 4- to 37.5 mg w/ CYP3A4 inhibitors (Table VI-8), to T 87.5 mg w/ CYP3A4 inducers Contra w/ atazanavir Caution [D, -] Multiple interactions require dose modification (eg, St. John s wort) Disp Caps SE -l WBC pit, bleeding, T BP, -l ejection fraction, T QT interval, pancreatitis, DVT, Sz, adrenal insuff, N/V/D, skin discoloration, oral ulcers, taste perversion, hypothyroidism Interactions Multiple interactions require dose modification (eg, St. John s wort) EMS Monitor ECG for T QT interval grapefruit juice may T adverse effects may affect potassium level (hypo-/hyperkalemia) monitor for S/Sxs of heart failure drug can 4- ejection fraction OD May cause abd pain, muscle weakness, and chills symptomatic and supportive... 

The adverse effects of zalcitabine include peripheral neuropathy, oral ulceration and stomatitis. Additional side effects may include elevated hepatic transaminases, arthralgias, myalgias, fatigue, headache, fever and cardiomyopathy. 

A 47-year-old woman weighing 59 kg took acarbose 50 mg tds. Her blood glucose improved but she lost about 1 kg/month. She had a sore tongue without oral ulcers and no evidence of malabsorption. Later she developed general weakness and iron deficiency anemia but no other evidence of malabsorption. After she had lost 7 kg in 5 months, acarbose was withdrawn. Her complaints disappeared, her weight normalized, and she had no signs of iron deficiency anemia, even without iron therapy. 

Leukopenia with oral ulceration has been attributed to atorvastatin in a patient with insulin allergy who had received a pancreatic transplant the symptoms resolved on withdrawal (13). 

Farshi, F.S., et al. 1996. In-vivo studies in the treatment of oral ulcers with liposomal dexametha-sone sodium phosphate. J Microencapsul 13 537. 

Causes neurotoxicity, autonomic and central nervous system toxicity, alopecia, mild leukopenia, mild anemia, and mild thrombocytopenia, as well as nausea, vomiting, diarrhea, constipation, stomatitis, and oral ulceration.3... 

Lll. Levinsky, R. J., and Lehner, T., Circulating soluble immune complexes in recurrent oral ulceration and Bechet s syndrome. Clin. Exp. Immunol. 32, 193-198 (1978). 

Human NS Gastro 0.57 (oral ulcer, diarrhea, Zhang and Li... 

A review of drug-induced oral ulceration mentioned lithium as a possible cause, based on two older references (350,351). 

FLUOROURACIL ANTIBIOTICS -METRONIDAZOLE t risk of toxic effects of fluorouracil (>27%), e.g. bone marrow suppression, oral ulceration, nausea and vomiting due to T plasma concentrations of fluorouracil Metronidazole i clearance of fluorouracil Avoid co-administration... 

Thalidomide has anti-inflammatory and immimo-suppressant actions and retains a limited specialist use in, for example, lepromatous leprosy, and oral ulceration in AIDS (some cases). 

Zaldtabine (DDC) (tY 1 h) is similar. Adverse effects include peripheral neuropathy, hepatitis and pancreatitis which are reason to discontinue the drug. Oral ulceration, gastrointestinal symptoms and bone marrow suppression have also been reported. 

D- icjtiriorrij CJri Nausea and vomiting hepatic toxicity with ascites diarrhoea severe local tissue damage and necrosis on extravasation anaphylactic reaction Scomatitis oral ulceration bone marrow depression alopecia folliculitis dermatitis in previously irradiated areas... 

Mijsiine (chlormethinc) Nausea and vomiting local reaction and phlebitis Bone marrow depression alopecia diarrhoea oral ulcers leukaemia amcnorrhoea sterility hyperu ricacmia teratogenic... 

Simple rashes are not uncommon in patients taking sulfasalazine, including maculopapular rash, pruritus, urticaria, angioedema, eczematous dermatitis, photosensitivity, skin discoloration, and oral ulceration. Raynaud s phenomenon and toxic epidermal necrolysis associated with erythroid hypoplasia and agranulocytosis have occurred in one case of toxic epidermal necrolysis there was marked immunosuppression (SEDA-18, 375). 

Dinsdale RC, Walker AE. Amiphenazole sensitivity with oral ulceration. Br Dent J 1966 121(10) 460-2. 

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