ATYPICAL DISSEMINATED NECROTIZING AND EXTENSIVE ORAL ULCERATIVE LESIONS IN PATIENT WITH DERMATOMYOSITIS

Objectives Oral ulcerative stomatitis may be seen in patients with autoimmunity in treatment with methotrexate, demonstrating a wide clinical and histopathologic spectrum that ranges from non-specific ulceration to EBV (+/-) lymphoproliferative disorders, disseminated necrotizing and ulcerative lesions affecting the gingiva extensive to the tongue has not been previously reported, we present a rare oral manifestation of methotrexate and summarize the clinicopathologic features of previously published cases. Clinical presentation A 62-year-old female patient with a 5-year history of Hodgkin lymphoma in remission, and one year of dermatomyositis in treatment with prednisone, colchicine and methotrexate, presented with burning and pain in the gingiva, which lasted 10 days. Physical examination revealed that there was multiple necrotic ulcers located in the upper and lower marginal gingiva, including the interdental papillae that extend to the palate. The inserted gingiva shows edema and petechiae, there is radicular exposure without dental mobility or bone destruction. In the left lateral border of the tongue, a crater-like ulcer is detected, irregular and indurated edges. Intervention and outcome: It was decided to suspend methotrexate previous medical interconsultation and take a biopsy. The result of pathology reported B-cell diffuse lymphoma, the large-sizes lymphoid cells were positive for CD20, CD3, CD30, EBV, Ki67 and negative for CD2, CD56, Grandzima, CD15, CD1a, k and l. After 15 days of having stopped the methotrexate there is total remission of the lesions. Based on the clinical-histological correlation, lymphoproliferative lesion associated with methotrexate was established. Conclusion Oral necrotizing and disseminated ulcerative lesions are part of the wide clinical presentation of lymphoproliferative disorders associated to methotrexate. Clinical, histopathologic and immunohistochemical evaluation, may provide the correct diagnosis.