A rare cause of mucositis

A 39-year-old man presented with a 15-year history of recurrent painful oral ulceration of his lips and buccal mucosa. He also reported dysphagia and gave a history of 15 kg weight loss over a number of years. The patient was a heavy smoker and had chewed khat (Catha edulis) as a stimulant for many years. Physical examination revealed inflammation, erosion and ulceration of the lips, buccal mucosa and gingiva (Fig. 1a). The patient also had poor dental hygiene (Fig. 1b). A gastroscopy revealed severe inflammation and ulceration throughout the oesophagus. Blood tests revealed iron-deficiency anaemia and raised antinuclear antibody (ANA) titre (1 : 160; normal <1 : 80). Results of the following investigations were negative or normal: urea and electrolytes, liver function tests, human immunodeficiency virus and hepatitis virus screen, protein electrophoresis, tuberculosis screen, syphilis IgG, and levels of glucose, B12, folate, immunoglobulin, serum angiotensin-converting enzyme and antineutrophil cytoplasmic antibodies. Furthermore, human leucocyte antigen typing was not indicative of Bechet disease, and a stool sample and colonoscopy were also unremarkable.