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Stomatitis

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Shared care information

This can be extremely painful and usually requires pain team involvement and IV opiates. If it is severe, or there is associated fever, it may be secondarily infected with viral or fungal infection and swabs should be taken. Patients requiring admission should be discussed with the paediatric oncologist on call during working hours.

Causes

The commonest cause is chemotherapy. Other causes include infection (often in patients with mucositis already) with candida CMV or HSV.

Clinical features

  • Difficulty managing secretions (drooling)
  • Airway compromise in small children
  • Pain on swallowing.

Investigations

  • Endoscopy and tissue is required for a diagnosis of oesophagitis. Swabs for bacterial, fungal culture and viral PCR and culture should be sent but detection of CMV/HSV/Candida does not confirm diagnosis in oesophagus or exclude a different infection of oesophageal mucosa.

Management

  • Continue mouth care and prescribe fluconazole PO or IV. If the patient was already on fluconazole prophylaxis, use Liposomal amphotericin 3 mg/kg/day OD due to risk of resistance. Fluconazole can be effective if given intravenously if there are problems with oral intake, as the drug is secreted in the saliva.
  • Small children need careful monitoring of their airway status and may require one on one nursing or occasionally intensive care for airway maintenance.
  • Analgesia - this condition is very painful and most children will require opiate analgesia.
  • Metronidazole should not be used empirically.
  • Acyclovir should be given when the oral ulceration is focal/discrete and the patient is known to be HSV IgG +ve (do not recheck HSV status as it will be +ve from prior blood transfusions) or the viral PCR or culture is positive for HSV. However, a positive culture for HSV does not necessarily mean that the virus is the cause (may be asymptomatic shedding) so do not stop the other antimicrobials. Discuss with Infectious Diseases.

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Document Control

  • Date last published: 01 March 2014
  • Document type: Clinical Guideline
  • Services responsible: National Child Cancer Network