A strange “butterly-like” ulcer of the palate. May be it the results of an underlying trombotic event in a predisposed patient?

A 48-year-old female was referred to us from the emergency ward for a 2 weeks history of erosive/ulcerative lesion of the palate associated with pain, dysphagia, fever and weight loss. Her recent medical history revealed a previous surgical treatment for a breast cancer treated. Although the tumour did not showed positivity to the estrogen receptors, the patient’s oncologist recommended to start a pharmacological treatment with Tamoxifen that she keeps on for about 2 months. The oral examination showed a “butterfly-like” lesion symmetric with respect to the midline of the hard palate characterized by two areas of ulceration with a fibrinous yellowish floor and by erosive areas extending anteriorly. The patient underwent oral swabs to research mycotic and/or bacterial infections and was invited to use a chlorhexidine 0.12% without alcohol-base mouthwash and to stop smoking. After 1 week the lesion appeared as a single “butterfly-like” ulcer with central necrosis. Due to the rapid progression and the destroying aspect an incisional biopsy was performed revealing an unspecific chronic inflammatory infiltrate. No microorganisms and lymphomatous infiltrate were seen. All routine hematological, biochemical and microbiological investigations were normal. After another week the lesion worsened appearing deeper. The patient underwent a contrast enhanced CT of the maxilla-facial region that excluded bone perforation. Since the treatment with tamoxifen is associated with an increased risk of tromboembolic event, we hypothesize that the oral lesion may be the result of a ischemic necrosis. A coagulation screening was performed revealing positivity for the lupus anticoagulants antibodies (LAC). The serological tests for autoimmunity (ANA-ENA) were negative. According with the oncologist the patient suspended the treatment with tamoxifen, and the lesions was treated with gentle debridement and topical anti-septic, the wound healed by secondary intention in 4 months.