Aloe vera induced oral mucositis: a case report

Aim: To report a probable case of Aloe vera induced oral mucositis in a two year old child. Case summary: A two years old female child brought to our emergency department with a severe form of oral mucositis. History from her mother revealed that the child had chewed the fleshy stalk of an Aloe vera plant leaf that grows in her garden. On the following day the child developed a severe form of oral mucositis and dermatitis of the peri-oral skin without much of constitutional symptoms. The child improved with symptomatic treatment. Discussion: The probability of etiological association is analyzed with the help of Naranjo Probability Scale which showed Aloe vera to be the “Probable” cause of mucositis in this child. Conclusion: Aloe vera, although has many healing properties, serious adverse reactions are also possible and has to borne in mind. A two years old previously normal female child was brought to our pediatric department with severe stomatitis (figure 1). She developed the lesion overnight without much systemic manifestations. Fig. 2 & 3 shows the course of recovery of the child in one week. Figure 1 Figure 1: Presentation on day 1: Shows severe mucositis of oral mucosa and dermatitis of the peri-oral skin. Figure 2 Figure 2: Presentation on day 3: Shows improvement with conservative management. Aloe vera induced oral mucositis: a case report 2 of 5 Figure 3 Figure 3: Presentation on day 5: The lesion healed with a post inflammatory hypopigmented area. Figure 4 Figure 4: Aloe Leaf brought by the mother. DISCUSSION ALOE VERA INDUCED IRRITANT CONTACT MUCOSITIS History from the mother revealed that on the previous evening she found her child chewing the fleshy leaf of an Aloe vera plant growing in her garden. She immediately removed it from her mouth and made a thorough rinsing with water. The child did not have any immediate local manifestations. On the following morning the child developed a severe form of oral mucositis and dermatitis of the peri-oral skin. The child had no systemic manifestations. History were negative for any infection in the recent past or any drug in-take prior to onset of the event. The child was on her regular food habits. CLINICAL EXAMINATION On general examination, she was moderately built, afebrile and conjunctival mucosa appeared slightly pale. No evidence of jaundice or generalized lymphadenopathy. Vital parameters were within normal limits. Systemic examination was normal. LOCAL EXAMINATION OF THE ORAL CAVITY Oral cavity showed severe mucositis involving the lips and buccal mucosa. The lesion appeared boggy and erythematous with few areas of pin point hemorrhages. The skin of the peri-oral area which came in contact with the aloe vera juice also showed dermatitis. No significant regional lymphadenitis noted. INVESTIGATIONS Complete Blood count and peripheral blood smear showed microcytic, hypochromic anemia and a normal leukocyte count. Renal, Liver function test and serum proteins estimations were within normal limits. A cytological smear from the mucosal lesion showed normal squamous epithelial cells and a few leucocytes in a dirty background. Swab taken from the lesion on culture showed Streptococcus viridians and negative in fungal studies. OUTCOME The child was managed symptomatically with proper oral hygiene, topical emollients and analgesics. The lesions healed in one week leaving a post inflammatory hypopigmented area. The etiological association of aloe vera with the clinical presentation is analyzed with Naranjo's probability scale(1) in table 1. Aloe vera induced oral mucositis: a case report 3 of 5 Figure 5 Table 1: Naranjo's Algorithm Legends: AR = Adverse Reaction; ADR = Adverse Drug Reaction Score of Naranjo's Algorithm: > 9 =Definite ADR 5-8 = Probable ADR 1-4 = Possible ADR < 1 = Doubtful ADR According to the results from Naranjo's probability scale, a conclusion of “Probably” Aloe vera induced irritant contact mucositis was made. IRRITANT CONTACT MUCOSITIS: It is the result of inflammation arising from the release of pro-inflammatory cytokines from epithelial cells, usually in response to noxious stimuli. The three main pathophysiological changes are Skin barrier disruption, Epithelial cellular changes, and Cytokine release. Irritant contact mucositis falls into three categoriesSimple Acute irritant mucositis which occurs within minutes after exposure or Acute delayed, occurring 8-12 hours and Cumulative irritant mucositis which may be delayed by weeks after exposure. Irritant contact mucositis is a clinical diagnosis. History of contact with an offending agent and subsequent development of lesions in the exposed areas suggests the diagnosis. Treatment is symptomatic and preventing further exposures. Aloe vera: A perennial plant, belonging to the family Liliaceae . The aloe leaf is the source of two herbal preparations: Aloe gel and latex. Aloe gel is the clear mucilaginous substance produced by parenchymal cells, composed mainly of water (99%) and monosaccharides (mainly mannose-6-phosphate) and polysaccharides (glucomannans). Recently a glycoprotein with antiallergic properties, called Alprogen and a novel anti-inflammatory compound, C-glucosyl chromone, has been isolated. Pericyclic tubular cells produce a bitter yellow irritant substance, the Aloe latex. It is used as laxative(2). The role of Aloe vera in medicine is well appreciated since the days of ancient civilizations. In modern days the extracts of the plant is used in skin care, cosmetics and as nutraceuticals. Table 2 shows a few medicinal uses of Aloe vera based on scientific evidences(3) .