A nutrition-first, barrier-augmented, staged debridement management of grade IV oral mucositis in a leukemia patient with decompensated cirrhosis: A case report

RATIONALE: Oral mucositis (OM) is a common but serious complication of chemotherapy, particularly in patients with hematologic malignancies. Severe OM can significantly impair nutritional intake and quality of life, and may delay antileukemic therapy. This case report presents a multidisciplinary, integrative approach for managing grade IV OM in a patient with acute lymphoblastic leukemia and decompensated cirrhosis. PATIENT CONCERNS: A 63-year-old female with a 13-year history of liver cirrhosis was admitted because of abdominal pain. DIAGNOSES: Laboratory tests revealed B-cell acute lymphoblastic leukemia, pancytopenia, and hypoalbuminemia. On day 15 of chemotherapy, oral mucosal ulcerations emerged and progressed to grade IV OM by day 29, characterized by hemorrhagic eschar, intolerable pain (numeric rating scale score 6), and complete inability to eat. INTERVENTIONS: A multidisciplinary management strategy was implemented. Aggressive nutritional support was initiated, combining total parenteral nutrition with early enteral feeding via a nasogastric tube using a customized, blenderized formula enriched with branched-chain amino acids and whey protein. For wound care, hemorrhagic eschar was softened daily with saline, followed by cautious debridement to minimize pain and bleeding. Montmorillonite powder was applied to the wound to form a protective mucosal barrier and reduce infection risk. Pain management and psychological support were provided to enhance treatment adherence and maintain emotional stability. OUTCOMES: On day 63, oral mucositis had fully resolved, and antileukemic therapy proceeded without further interruption. LESSONS: An integrated "nutrition-first, barrier-augmented, staged-debridement" management strategy may significantly enhance the healing of oral mucositis.