Differentials
Oral candidiasis
SIGNS / SYMPTOMS
Pseudomembranous oral candidiasis appears as white, curd-like plaques on the oral mucosa that can be removed with pressure, revealing an inflamed mucosa.
Erythematous oral candidiasis appears as red, inflamed areas on the oral mucosa that may cause low-grade pain and burning, and mimic mild (non-ulcerated) mucositis.
INVESTIGATIONS
Superficial smear of lesions for microscopy and/or fungal culture is positive.
Secondary fungal infection, usually caused by C albicans, but also by other species (C glabrata and C tropicalis) is common in patients receiving head and neck irradiation, especially those with significant salivary compromise.[40] However, it should be noted that a positive smear or fungal culture does not exclude oral mucositis (OM), because Candida infection can coexist with OM.
Herpes simplex virus infection
SIGNS / SYMPTOMS
Recurrent herpes simplex virus (HSV) lesions typically present on the outer lip as 'cold sores', but may present intra-orally, especially in patients undergoing myeloablative therapies (e.g., haematopoietic stem cell transplantation).
Intra-oral HSV begins as multiple 1- to 3-mm vesicles that lead to macular ulcers, most typically seen on keratinised mucosa such as the hard palate, dorsal tongue, and gingiva.
INVESTIGATIONS
Viral culture or polymerase chain reaction of vesicular lesions will be positive for HSV infection.
However, it should be noted that a positive viral culture does not exclude oral mucositis (OM) because reactivation of HSV infection can coexist with OM.
Graft-versus-host disease
SIGNS / SYMPTOMS
Acute graft-versus-host disease (GVHD) classically targets the skin, liver, and gastrointestinal tract; chronic GVHD can involve almost any organ.
Typically presents with an erythematous maculopapular rash, with intense pruritus; isolated oral GVHD is uncommon.
INVESTIGATIONS
Liver function tests may show elevated transaminases, alkaline phosphatase, and/or bilirubin.
In isolated oral GVHD, a mucosal biopsy reveals pathognomonic features (apoptosis at the base of epidermal rete pegs; perivascular lymphocytic infiltration in the dermis).
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