Background. Chronic graft versus host disease (cGVHD) is a complication following bone marrow transplantation. The oral lesions are difficult to control with a systemic pharmacological therapy. Case Description. A 63-year-old female patient, who underwent an allogeniec transplantation for acute myeloid leukemia, developed a chronic oral and cutaneous GVHD. The patient was treated with topical tacrolimus 0.1%, twice daily for two months, and underwent a protocol of oral hygiene characterized by 3 appointments of scaling, root planning, and daily oral hygiene instructions. The patient showed marked resolution of gingival lesions and a significant improvement of related pain and gingival inflammatory indexes. Clinical Implications. This case report suggests that treatment with topical tacrolimus and professional oral hygiene may be helpful in the management of chronic oral GVHD with severe gingival involvement. 1. Introduction Chronic graft versus host disease (cGVHD) is a complication following bone marrow transplantation, which frequently involves the oral mucosa [1]. When affected, oral tissues present with lichenoid-like lesions, erythema, and ulcerations; lesions on gingiva can induce a “desquamative gingivitis,” similar to that of oral lichen planus and mucous membrane pemphigoid, presenting with epithelial desquamation, erythematous zones, and erosive lesions on the gingival tissue. Patients usually complain of pain and difficulty in eating, speaking in and swallowing, with a significant decrease in the quality of life. Oral hygiene is particularly difficult and the periodontal status often worsens [2]. Tacrolimus is a macrolide immunosuppressant derived from Streptomyces tsukubaensis. It is a relatively selective inhibitor of calcineurin and it was initially developed as a systemic agent to lessen allograft rejection [3, 4]. Previous reports suggest that topical therapy with tacrolimus can be helpful in the management of oral lesions caused by GVHD [5–7]. In some of those patients, however, the response on gingival lesions is often partial. We report a case in which the combined treatment of topical tacrolimus and periodontal therapy allowed satisfactory control of the severe gingival profile due to oral cGVHD. 2. Case Presentation A 63-year-old female patient, who underwent an allogeneic transplantation for acute myeloid leukemia about 5 years ago, with a complete clinical remission, presented with chronic, biopsy proven, oral, and cutaneous GVDH of moderate degree. The patient was referred to the Unit of Oral Medicine Section of the University of
References
[1]
M. M. Imanguli, I. Alevizos, R. Brown, S. Z. Pavletic, and J. C. Atkinson, “Oral graft-versus-host disease,” Oral Diseases, vol. 14, no. 5, pp. 396–412, 2008.
[2]
P. G. Arduino, V. Farci, F. D'Aiuto et al., “Periodontal status in oral mucous membrane pemphigoid: initial results of a case-control study,” Oral Diseases, vol. 17, no. 1, pp. 90–94, 2011.
[3]
A. H. Filipovich, “Diagnosis and manifestations of chronic graft-versus-host disease,” Best Practice and Research, vol. 21, no. 2, pp. 251–257, 2008.
[4]
K. A. Al Johani, A. M. Hegarty, S. R. Porter, and S. Fedele, “Calcineurin inhibitors in oral medicine,” Journal of the American Academy of Dermatology, vol. 61, no. 5, pp. 829–840, 2009.
[5]
A. R. Sánchez, P. J. Sheridan, and R. S. Rogers, “Successful treatment of oral lichen planus-like chronic graft-versus-host disease with topical tacrolimus: a case report,” Journal of Periodontology, vol. 75, no. 4, pp. 613–619, 2004.
[6]
A. Eckardt, O. Starke, M. Stadler, C. Reuter, and B. Hertenstein, “Severe oral chronic graft-versus-host disease following allogeneic bone marrow transplantation: highly effective treatment with topical tacrolimus,” Oral Oncology, vol. 40, no. 8, pp. 811–814, 2004.
[7]
H. Mawardi, K. Stevenson, B. Gokani, R. Soiffer, and N. Treister, “Combined topical dexamethasone/tacrolimus therapy for management of oral chronic GVHD,” Bone Marrow Transplantation, vol. 45, no. 6, pp. 1062–1067, 2010.
[8]
P. G. Arduino, E. Lopetuso, P. Carcieri, et al., “Professional oral hygiene treatment and detailed oral hygiene instructions in patients affected by mucous membrane pemphigoid with specific gingival localization: a pilot study in 12 patients,” International Journal of Dental Hygiene, vol. 10, no. 2, pp. 138–141, 2012.
[9]
K. S. Kornman, “Mapping the pathogenesis of periodontitis: a new look,” Journal of Periodontology, vol. 79, no. 8, pp. 1560–1568, 2008.
[10]
D. Conrotto, M. Carrozzo, A. V. Ubertalli et al., “Dramatic increase of tacrolimus plasma concentration during topical treatment for oral graft-versus host disease,” Transplantation, vol. 82, p. 1113, 2006.
[11]
J. C. Fricain, V. Sibaud, N. Swetyenga, R. Tabrizi, F. Campana, and A. Ta？eb, “Long-term efficacy of topical tacrolimus on oral lesions of chronic graft-versus-host disease,” British Journal of Dermatology, vol. 156, no. 3, pp. 588–590, 2007.
[12]
M. H. Albert, B. Becker, F. R. Schuster et al., “Oral graft vs. host disease in children—treatment with topical tacrolimus ointment,” Pediatric Transplantation, vol. 11, no. 3, pp. 306–311, 2007.
[13]
M. Schlaak, R. Treudler, A. Colsman, H. Al-Ali, and J. C. Simon, “Oral graft-versus-host disease: successful therapy with extracorporeal photopheresis and topical tacrolimus,” Journal of the European Academy of Dermatology and Venereology, vol. 22, no. 1, pp. 112–113, 2008.
