History from the mother revealed that on the previous evening she found her child chewing the fleshy leaf of an Aloe vera plant growing in her garden. She immediately removed it from her mouth and made a thorough rinsing with water. The child did not have any immediate local manifestations. On the following morning the child developed a severe form of oral mucositis and dermatitis of the peri-oral skin. The child had no systemic manifestations.

History were negative for any infection in the recent past or any drug in-take prior to onset of the event. The child was on her regular food habits.

On general examination, she was moderately built, afebrile and conjunctival mucosa appeared slightly pale. No evidence of jaundice or generalized lymphadenopathy. Vital parameters were within normal limits. Systemic examination was normal.

Oral cavity showed severe mucositis involving the lips and buccal mucosa. The lesion appeared boggy and erythematous with few areas of pin point hemorrhages. The skin of the peri-oral area which came in contact with the aloe vera juice also showed dermatitis. No significant regional lymphadenitis noted.

Complete Blood count and peripheral blood smear showed microcytic, hypochromic anemia and a normal leukocyte count. Renal, Liver function test and serum proteins estimations were within normal limits. A cytological smear from the mucosal lesion showed normal squamous epithelial cells and a few leucocytes in a dirty background. Swab taken from the lesion on culture showed Streptococcus viridians and negative in fungal studies.

The child was managed symptomatically with proper oral hygiene, topical emollients and analgesics. The lesions healed in one week leaving a post inflammatory hypopigmented area. The etiological association of aloe vera with the clinical presentation is analyzed with Naranjo's probability scale(₁) in table 1.

Figure 5

Table 1: Naranjo's Algorithm Legends: AR = Adverse Reaction; ADR = Adverse Drug Reaction

Score of Naranjo's Algorithm:

> 9 =Definite ADR
5-8 = Probable ADR
1-4 = Possible ADR
< 1 = Doubtful ADR

According to the results from Naranjo's probability scale, a conclusion of “Probably” Aloe vera induced irritant contact mucositis was made.

It is the result of inflammation arising from the release of pro-inflammatory cytokines from epithelial cells, usually in response to noxious stimuli. The three main pathophysiological changes are Skin barrier disruption, Epithelial cellular changes, and Cytokine release.

Irritant contact mucositis falls into three categories- Simple Acute irritant mucositis which occurs within minutes after exposure or Acute delayed, occurring 8-12 hours and Cumulative irritant mucositis which may be delayed by weeks after exposure.

Irritant contact mucositis is a clinical diagnosis. History of contact with an offending agent and subsequent development of lesions in the exposed areas suggests the diagnosis. Treatment is symptomatic and preventing further exposures.

Aloe vera: A perennial plant, belonging to the family Liliaceae . The aloe leaf is the source of two herbal preparations: Aloe gel and latex. Aloe gel is the clear mucilaginous substance produced by parenchymal cells, composed mainly of water (99%) and monosaccharides (mainly mannose-6-phosphate) and polysaccharides (gluco-mannans). Recently a glycoprotein with antiallergic properties, called Alprogen and a novel anti-inflammatory compound, C-glucosyl chromone, has been isolated. Pericyclic tubular cells produce a bitter yellow irritant substance, the Aloe latex. It is used as laxative(₂).

The role of Aloe vera in medicine is well appreciated since the days of ancient civilizations. In modern days the extracts of the plant is used in skin care, cosmetics and as nutraceuticals. Table 2 shows a few medicinal uses of Aloe vera based on scientific evidences(₃) .

Figure 6

Table 2

Aloe vera is generally regarded as a safer herb. Few adverse effects occurs because the process of separation of gel from the sap is not always complete(₄). They includes irritations, hives, mild itching on topical application and cramping, diarrhea and electrolyte imbalance on internal use. Rare incidences of serious toxicities like severe hepatitis(₅), renal failure(₆), radiation-aloe vera induced dermatitis(₇) and even death on parenteral injections(₃) have been reported. Aloe vera shows significant drug interactions with digoxin (Lanoxin), diuretics, oral hypoglycemics, steroids and sevoflurane(₈). The internal use of Aloe vera is not recommended in pregnancy and in breast feeding mothers(₃).