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Acute Necrotizing Ulcerative Gingivitis (ANUG) manifests as an aggressively degenerative gingival condition, in the context of an impaired host immune response. It is typified by the abrupt emergence of gingival inflammation, accompanied by discomfort and the distinctive appearance of excavated, crater-like lesions in the papillary gingival tissues. Represents a relatively uncommon oral infectious pathology, with documented incidence rates of approximately 1-2% globaly. Nevertheless, its prevalence significantly diminishes when specifically considering kidney transplant population.
We report a 59-year-old male presented with chronic kidney disease undergoing hemodialysis secondary to PLA2R-associated Membranous Nephropathy. The patient underwent a standard deceased donor renal transplant, with a calculated panel-reactive antibody level of 0%, three antigen mismatches (1 HLA-A, 1 HLA-B, 1 HLA-DR), a negative cross-match, and a Kidney Donor Profile Index of 13%. The patient received induction therapy with anti-thymocyte globulin (rabitt) (3 mg/kg) and methylprednisolone (1g/day) along with a maintenance immunosuppressive regimen: tacrolimus, prednisone, and mycophenolate mofetil. Prophylactic treatment with trimethoprim-sulfamethoxazole and ganciclovir was initiated. The patient experienced delayed graft function, requiring hemodialysis until the fourth postoperative day, and was discharged 15 days after the transplant. At three months post-transplant, he developed extensive gingival necrosis and pain, accompanied by severe leukopenia and neutropenia. Subsequently, the patient was admitted for clinical investigation and therapeutic management, ultimately receiving a diagnosis of ANUG. During the hospitalization, trimethoprim-sulfamethoxazole, ganciclovir, and mycophenolate were discontinued, and the patient received filgrastim, a course of antibiotic therapy with piperacillin-tazobactam, and topical treatment with chlorhexidine 2%. The patient demonstrated clinical and laboratory response, as shown in the table 1 and graph 1 below.
The presented case underscores the occurrence of Acute Necrotizing Ulcerative Gingivitis (ANUG) in a renal transplant recipient, with concomitant severe neutropenia. This report contributes to the scarce literature documenting cases of ANUG, a condition associated with a moderate risk of mortality.