Mycophenolate Mofetil-induced Oral Ulcerations in a Kidney Transplant Recipient

Abstract

Introduction: Mycophenolate Mofetil (MMF) is an immunosuppressive drug usually used in kidney transplants to prevent rejection. It has various adverse effects such as leucopenia, anemia, diarrhea but Mouth ulcers are rarely reported. Methods: We present a case report of MMF-induced mouth ulcers in an African patient. Case Report: A 41-year-old African-male patient has painful oral ulcers which developed 5 months after kidney transplantation. The immunosuppressive maintenance regimen comprised Steroids, Tacrolimus and MMF. Results: These ulcers were firstly related to a fungic or viral infection so the patient was prescribed Fluconazole and Aciclovir without any improvement. Then, Tacrolimus blood level was checked and it was in a therapeutic range. Finally, we decide to stop MMF and the ulcers healed quickly. Discussion: Oral ulcers are frequently seen complications in immunosuppressant patient but are rarely described with MMF. These ulcers can become large and very painful and degrade patient's life quality. So when infections causes are excluded, we have to keep in mind that these ulcers can be a drug adverse effect.

Diagnosis and management of oral ulcerations associated with mycophenolate mofetil in kidney transplantation

“…Overall, these lesions are clinically described as painful ulcers of varied sizes with irregular borders and erythematous halo covered with fibrin membrane. Currently, there is a consensus that the diagnosis of oral ulcers related to toxicity in transplant recipients is a challenge and that infection and malignancies should be excluded 9–17 …”

“…Although the therapeutic dose of MMF can be up to 3 g/day, the literature shows that renal transplant patients respond individually to this drug depending on the variability in the dose‐concentration relationship 9–17 . Exposure to MMF should be measured and its dosage adjusted according to the desired clinical outcomes 19 .…”

“…According to the literature, when a diagnosis of oral ulcers caused by MMF is diagnosed, two possible measures should be taken. The first one is to replace the drug by another one with less toxicity 9–17 . A substitute for MMF is the enteric‐coated mycophenolate sodium, which has been used for having pharmacokinetics different from that of MMF, thus resulting in better absorption at neutral pH in the small bowel 19 .…”

“…The second one is to reduce the dose or even discontinue the medication. The decision between reducing the dose and discontinuing the MMF is often made on an empirical basis and according to the nephrologists’ experience and patient's clinical condition 9–17 …”

“…Oral ulcerations in solid organ transplant recipients have been rarely described in the literature. The lesions can have different sizes, irregular borders or erythematous halo and as being single or multiple, painful or covered with fibrin membrane 9–17 . Although the pathogenesis of MMF‐induced oral ulcers is unknown, it is believed that MMF has a dose‐dependent toxicity that directly affects the epithelium of the lining mucosa 18 …”