A Case Report On Pemphigus Vulgaris Presenting With Extensive Mucocutaneous Erosions, Oral Candidiasis, And Electrolyte Disturbance

Following confirmation of pemphigus vulgaris, systemic corticosteroid therapy was initiated with oral prednisolone (30 mg daily). Pantoprazole was prescribed for gastrointestinal protection, while desloratadine was added for symptomatic relief of cutaneous manifestations. Topical therapy included triamcinolone oral paste for active oral erosions and clotrimazole mouth paint to prevent steroid-induced fungal overgrowth. Mucaine gel was prescribed before meals to reduce odynophagia and improve oral intake. Mupirocin ointment was applied to cutaneous erosions over the neck and chest.

Considering the patient's advanced age and multiple metabolic comorbidities, Dermatology planned to introduce mycophenolate mofetil during follow-up as a steroid-sparing immunosuppressive agent to minimize long-term corticosteroid toxicity.

CLINICAL OUTCOME AND FOLLOW-UP

The patient experienced gradual symptomatic improvement following initiation of comprehensive medical management. Oral pain decreased considerably, allowing improvement in food intake and hydration. Oral candidiasis responded well to antifungal therapy, and correction of hyponatremia was successfully achieved prior to discharge.The patient was discharged in stable condition with instructions for close dermatological follow-up, blood glucose monitoring, blood pressure monitoring, electrolyte assessment, and gradual introduction of long-term immunosuppressive therapy. Continued surveillance was recommended for disease activity, corticosteroid-related adverse effects, electrolyte disturbances, and progression of mucocutaneous lesions.

DISCUSSION

Pemphigus vulgaris (PV) is a chronic autoimmune blistering disorder characterized by the production of pathogenic autoantibodies against desmosomal proteins, predominantly desmoglein-3 and, in patients with mucocutaneous disease, desmoglein-1. Disruption of desmosomal adhesion results in intraepidermal acantholysis and formation of fragile vesicles and bullae, which subsequently rupture and produce painful erosions. Oral involvement is particularly common in PV and may precede cutaneous manifestations. The present case demonstrated extensive mucocutaneous involvement associated with severe oral ulcerations, secondary oral candidiasis, poor oral intake, and electrolyte disturbance, highlighting the complexity of managing PV in a patient with multiple comorbidities.

The clinical presentation of the present patient was comparable to the case reported by Janumpally Varshitha Thanmai et al.,^[21] in which a 55-year-old female presented predominantly with painful oral ulcerations, dysphagia, and burning sensation. Histopathological evaluation supported the diagnosis of pemphigus vulgaris, and the patient was treated with systemic corticosteroid therapy along with topical triamcinolone. In the reported case, prednisolone was initiated at a relatively higher dose of 60 mg/day and was subsequently tapered over a period of approximately six months. In comparison, the present 64-year-old female presented with extensive and painful oral ulcerations involving the palatal, sublingual, and labial mucosa, accompanied by dysphagia, poor oral intake, epigastric discomfort, and subsequent progression to the neck, chest, genital region, and pharyngeal mucosa. Prednisolone was initiated at 30 mg/day in the present case, along with topical and supportive therapies. The differences in corticosteroid dose and clinical progression may reflect differences in disease extent, comorbidities, clinical assessment, and treatment strategy.

An important additional finding in the present case was the presence of secondary oral candidiasis. The development of candidiasis was considered multifactorial rather than attributable to a single factor. The patient had extensive oral mucosal erosions secondary to PV, which resulted in disruption of the normal mucosal barrier. Such mucosal damage can facilitate colonization and proliferation of opportunistic organisms, including Candida species. Furthermore, extensive oral lesions were associated with pain, dysphagia, and reduced oral intake, which may have further compromised the patient’s nutritional and general physiological status.

A particularly important contributing factor was the patient’s poorly controlled type 2 diabetes mellitus, as evidenced by an HbA1c level of 11%. Poor glycaemic control is associated with increased susceptibility to opportunistic infections, including candidal infections. Hyperglycaemia may promote fungal growth and can impair several components of host immune defence. Therefore, the markedly elevated HbA1c in the present patient represents an important predisposing factor for the development and persistence of oral candidiasis. In this context, the candidiasis should not be considered an isolated complication of PV but rather the result of the interaction between extensive mucosal injury, metabolic dysfunction, and medication-related factors.

Another relevant factor was the patient’s treatment with an inhaled corticosteroid-containing regimen, budesonide/formoterol, for bronchial asthma. Inhaled corticosteroids are well-recognized risk factors for oropharyngeal candidiasis because deposition of corticosteroid particles in the oral cavity can produce local immunosuppressive effects and alter the local oral environment. The risk may be increased when inhaler technique is inappropriate or when patients do not adequately rinse and gargle the mouth after administration. In the present case, the concurrent use of inhaled budesonide, extensive oral mucosal erosions, and poorly controlled diabetes could have acted synergistically to increase susceptibility to Candida overgrowth. Therefore, inhaled corticosteroid exposure represents an important medication-related consideration in interpreting the occurrence of oral candidiasis in this patient.

The relationship between corticosteroid therapy and candidiasis is also clinically important because the patient subsequently required systemic prednisolone for control of pemphigus vulgaris. Systemic corticosteroid therapy can suppress immune responses and potentially increase susceptibility to secondary infections. Thus, once candidiasis had developed, continued corticosteroid therapy required careful monitoring for persistence or worsening of fungal infection. In the present case, antifungal therapy with oral fluconazole and topical clotrimazole mouth paint was provided, and the oral candidiasis subsequently showed clinical improvement. The use of antifungal therapy alongside corticosteroid treatment illustrates the importance of balancing effective immunosuppression for autoimmune disease with prevention and management of opportunistic infections.

The subsequent initiation of dapagliflozin during hospitalization is also clinically relevant to the medication history. Dapagliflozin is an SGLT2 inhibitor and is associated particularly with an increased risk of genital mycotic infections because of increased urinary glucose excretion. However, its initiation occurred during the hospital course and should not be assumed to be responsible for the oral candidiasis that was already clinically evident. Therefore, temporal association should be considered when attributing adverse effects or infection risk to individual medications.

The presence of oral candidiasis in this patient is particularly important because oral pain and mucosal ulceration can substantially impair nutritional intake. The patient already experienced painful oral lesions and dysphagia, and superimposed candidiasis could further increase discomfort and interfere with eating and drinking. This may contribute to dehydration, nutritional compromise, and disturbances in electrolyte balance. In the present case, electrolyte abnormality, particularly hyponatremia, was observed and subsequently corrected during treatment. Although the electrolyte disturbance cannot be attributed solely to candidiasis, the combined effects of poor oral intake, systemic illness, comorbid conditions, and medication-related factors may have contributed to the patient’s metabolic imbalance.

The management of oral candidiasis with fluconazole 150 mg once daily for seven days together with clotrimazole mouth paint resulted in clinical improvement. This response supports the clinical assessment that the oral fungal infection was an important component of the patient’s oral symptoms. The addition of topical antifungal therapy was particularly relevant because the patient had extensive oral mucosal involvement. The case also emphasizes the importance of monitoring for fungal overgrowth when systemic or inhaled corticosteroids are used. Clotrimazole was incorporated during treatment to reduce the risk of persistent or recurrent fungal involvement while corticosteroid therapy was continued.The present case also demonstrates the importance of differentiating primary PV lesions from secondary infectious complications. The painful erosions were primarily related to the autoimmune mucocutaneous disease, whereas the yellowish pseudomembranous discoloration of the tongue and other clinical findings were consistent with superimposed oral candidiasis.

Failure to recognize secondary infection may lead to inappropriate escalation of immunosuppressive treatment, potentially worsening the infection. Therefore, careful oral examination and early recognition of superimposed fungal infection are essential components of comprehensive PV management.

The extensive mucocutaneous progression observed in the present patient further emphasizes the need for continuous clinical assessment. In addition to oral lesions, involvement of the neck, chest, genital region, and pharyngeal mucosa indicated progressive disease activity. Pharyngeal involvement is particularly significant because it may worsen dysphagia and compromise oral intake. The planned introduction of mycophenolate as an additional immunosuppressive strategy reflects the need for longer-term disease control while minimizing prolonged dependence on systemic corticosteroids where clinically appropriate.

Supportive treatment was another important component of management. Mucaine gel was used to provide symptomatic relief of gastrointestinal and mucosal discomfort, while Kenacort oral paste and topical triamcinolone-related therapy provided local management of oral lesions. Desloratadine was used for symptomatic relief, and mupirocin was included for local management of skin lesions where indicated. These interventions demonstrate that treatment of PV extends beyond immunosuppression and requires a multidisciplinary approach involving dermatology, dental/oral care, medicine, nursing, and clinical pharmacy.

From a clinical pharmacy perspective, the case highlights several opportunities for medication optimization and patient counselling. In patients receiving inhaled corticosteroids, correct inhaler administration should be reinforced to minimize unnecessary oropharyngeal drug deposition. Patients should be advised to rinse and gargle the mouth with water after inhaled corticosteroid administration and avoid swallowing the rinse. Proper inhaler technique should also be assessed regularly, particularly in older patients and those with multiple comorbidities. In the present patient, these measures are especially relevant because inhaled budesonide represented an additional risk factor for oropharyngeal candidiasis.The coexistence of poorly controlled diabetes and corticosteroid exposure also emphasizes the importance of glycaemic monitoring. An HbA1c of 11% indicates substantial chronic hyperglycaemia and may increase vulnerability to infections and adversely affect recovery.

Corticosteroid therapy can further increase blood glucose concentrations, making monitoring of capillary blood glucose and appropriate adjustment of antidiabetic therapy clinically important during hospitalization and subsequent follow-up.

Overall, this case differs from the previously reported case by Janumpally Varshitha Thanmai et al. not only in age and disease progression but also in the presence of significant comorbidities, poorly controlled diabetes mellitus, secondary oral candidiasis, electrolyte disturbance, and the need for management of concomitant respiratory therapy. While both cases demonstrate the importance of systemic corticosteroids and topical therapy in controlling PV, the present case illustrates the additional challenges created by secondary infection and metabolic abnormalities.

The occurrence of oral candidiasis in the present patient was therefore most appropriately interpreted as a multifactorial complication, with major clinically relevant contributors including extensive pemphigus-related mucosal disruption, poorly controlled diabetes mellitus with an HbA1c of 11%, inhaled corticosteroid exposure, and subsequent systemic corticosteroid therapy. Early recognition and treatment of candidiasis with antifungal therapy resulted in clinical improvement and allowed continued management of the underlying autoimmune disease. The case emphasizes the importance of comprehensive medication review, monitoring for treatment-related complications, optimization of inhaler technique, glycaemic control, oral hygiene counselling, and multidisciplinary follow-up in patients with pemphigus vulgaris and multiple comorbidities.

CONCLUSION

Pemphigus vulgaris should be considered in the differential diagnosis of persistent, painful oral ulcerations, particularly when lesions are extensive, recurrent, and associated with dysphagia or nutritional compromise. In the present case, comprehensive multidisciplinary evaluation followed by histopathological examination established the diagnosis after exclusion of other autoimmune and infectious disorders. The coexistence of oral candidiasis, progressive hyponatremia, and multiple chronic comorbidities increased the complexity of management and highlighted the importance of individualized treatment. Early initiation of systemic corticosteroid therapy, together with appropriate antifungal treatment, correction of electrolyte imbalance, topical corticosteroids, and supportive care, resulted in clinical stabilization.

Planned introduction of mycophenolate mofetil as a steroid-sparing immunosuppressive agent represents an evidence-based long-term strategy to maintain disease remission while minimizing corticosteroid-related adverse effects. This case highlights the importance of early biopsy in persistent oral lesions, multidisciplinary collaboration, continuous monitoring for treatment-related complications, and active involvement of clinical pharmacists in optimizing medication therapy and patient counseling. Early diagnosis and individualized immunosuppressive treatment remain fundamental to improving functional outcomes, preventing disease progression, and enhancing quality of life in patients with pemphigus vulgaris.

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