Acessibilidade / Reportar erro

Uremic stomatitis Study conducted at the Irmandade Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil.

Dear Editor,

A 42-year-old male patient was seen at the Dermatology Service due to the presence of whitish lesions on the oral mucosa, affecting mainly the tongue. Moreover, he reported significant dysgeusia and a lack of appetite. He had chronic kidney disease and had been undergoing conservative treatment so far. The examination of the oral cavity showed whitish plaques with threadlike projections adhered to the lateral borders of the tongue (Figs. 1 and 2) and a white plaque on the left cheek mucosa (Fig. 3). He had ketone breath on examination. The patient was awaiting dialysis and had a serum creatinine level of 17 mg/dL, with uremia of 200 mg/dL. After a few hemodialysis sessions, the lesions regressed significantly.

Figure 1
Whitish plaque with threadlike projections adhered to the left lateral border of the tongue.

Figure 2
Whitish plaque with threadlike projections adhered to the right lateral border of the tongue.

Figure 3
Whitish plaque on the left cheek mucosa.

Uremic stomatitis is an underreported disease of the oral mucosa, possibly associated with long-term uremia in patients with chronic kidney disease.11 Leão JC, Gueiros LAM, Segundo AVL, Carvalho AAT, Barrett W, Porter SR. Uremic stomatitis in chronic renal failure. Clinics (São Paulo). 2005;60:259-62. It was first mentioned by Lancereaux in 1887 and described by Barie in 1889 as an uncommon but characteristic complication of advanced kidney disease.22 Antoniades DZ, Markopoulos AK, Andreadis D, Balaskas I, Patrikalou E, Grekas D. Ulcerative uremic stomatitis associated with untreated chronic renal failure: report of a case and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;101:608-13. It has a low incidence22 Antoniades DZ, Markopoulos AK, Andreadis D, Balaskas I, Patrikalou E, Grekas D. Ulcerative uremic stomatitis associated with untreated chronic renal failure: report of a case and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;101:608-13. which notably decreased with the advent of dialysis, and is rarely seen nowadays.33 McCreary CE, Flint SR, McCartan BE, Shields JA, Mabruk M, Toner ME. Uremic stomatitis mimicking oral hairy leukoplakia: report of a case. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1997;83:350-3. The etiology remains unknown, and it has been suggested that it may be due to high levels of ammonia compounds.11 Leão JC, Gueiros LAM, Segundo AVL, Carvalho AAT, Barrett W, Porter SR. Uremic stomatitis in chronic renal failure. Clinics (São Paulo). 2005;60:259-62. Ammonia is formed through the action of bacterial ureases that modify salivary urea, which is elevated in renal patients. The clinical characteristics are poorly defined and are rarely detailed in publications.11 Leão JC, Gueiros LAM, Segundo AVL, Carvalho AAT, Barrett W, Porter SR. Uremic stomatitis in chronic renal failure. Clinics (São Paulo). 2005;60:259-62. The affected patients may complain of pain, dysgeusia, and a burning sensation.11 Leão JC, Gueiros LAM, Segundo AVL, Carvalho AAT, Barrett W, Porter SR. Uremic stomatitis in chronic renal failure. Clinics (São Paulo). 2005;60:259-62.,44 Liao CY, Wu CC, Chu PL. Uremic stomatitis. QJM. 2017;110:247-48. Four clinical types of uremic stomatitis have been described: pseudomembranous, ulcerative, hemorrhagic, and hyperkeratotic.22 Antoniades DZ, Markopoulos AK, Andreadis D, Balaskas I, Patrikalou E, Grekas D. Ulcerative uremic stomatitis associated with untreated chronic renal failure: report of a case and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;101:608-13. The ulcerative type is the most common,22 Antoniades DZ, Markopoulos AK, Andreadis D, Balaskas I, Patrikalou E, Grekas D. Ulcerative uremic stomatitis associated with untreated chronic renal failure: report of a case and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;101:608-13. with an erythematous appearance, and the hyperkeratotic type is a rare alteration that can occur in long-term renal failure. Diagnosis is based on clinical signs and symptoms, and histopathology is characterized by epithelial hyperplasia and unusual hyperparakeratinization.11 Leão JC, Gueiros LAM, Segundo AVL, Carvalho AAT, Barrett W, Porter SR. Uremic stomatitis in chronic renal failure. Clinics (São Paulo). 2005;60:259-62.,55 Yano H, Kinjo M. Uraemic stomatitis. BMJ Case Rep. 2019;12:e231948. Lichen planus, hypertrophic candidiasis, oral hairy leukoplakia, and vitamin deficiencies are important differential diagnoses.44 Liao CY, Wu CC, Chu PL. Uremic stomatitis. QJM. 2017;110:247-48. The treatment consists in improving blood urea levels.22 Antoniades DZ, Markopoulos AK, Andreadis D, Balaskas I, Patrikalou E, Grekas D. Ulcerative uremic stomatitis associated with untreated chronic renal failure: report of a case and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;101:608-13. The manifestations usually persist for two to three weeks. Hydrogen peroxide washes can contribute to the elimination of anaerobic bacteria that produce ammonia.11 Leão JC, Gueiros LAM, Segundo AVL, Carvalho AAT, Barrett W, Porter SR. Uremic stomatitis in chronic renal failure. Clinics (São Paulo). 2005;60:259-62. Despite the high frequency of patients with kidney disease, only a few cases of uremic stomatitis have been published. Investigations are required for a better understanding of the pathogenic mechanism of this disorder.

  • Financial support
    None declared.
  • Study conducted at the Irmandade Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil.

References

  • 1
    Leão JC, Gueiros LAM, Segundo AVL, Carvalho AAT, Barrett W, Porter SR. Uremic stomatitis in chronic renal failure. Clinics (São Paulo). 2005;60:259-62.
  • 2
    Antoniades DZ, Markopoulos AK, Andreadis D, Balaskas I, Patrikalou E, Grekas D. Ulcerative uremic stomatitis associated with untreated chronic renal failure: report of a case and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;101:608-13.
  • 3
    McCreary CE, Flint SR, McCartan BE, Shields JA, Mabruk M, Toner ME. Uremic stomatitis mimicking oral hairy leukoplakia: report of a case. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1997;83:350-3.
  • 4
    Liao CY, Wu CC, Chu PL. Uremic stomatitis. QJM. 2017;110:247-48.
  • 5
    Yano H, Kinjo M. Uraemic stomatitis. BMJ Case Rep. 2019;12:e231948.

Publication Dates

  • Publication in this collection
    13 June 2022
  • Date of issue
    May-Jun 2022

History

  • Received
    25 Aug 2020
  • Accepted
    12 Sept 2020
  • Published
    17 Mar 2022
Sociedade Brasileira de Dermatologia Av. Rio Branco, 39 18. and., 20090-003 Rio de Janeiro RJ, Tel./Fax: +55 21 2253-6747 - Rio de Janeiro - RJ - Brazil
E-mail: revista@sbd.org.br