Moffitt AM Report 1/18/17: ORAL LESIONS

We discussed the case of a middle aged man with a history of positive PPD & ankylosing spondylitis who presented with odynophagia/dysphagia, and was found to have oropharyngeal ulcerations, centrilobular pulmonary nodules, sacroiliitis, and ileitis. See below for pearls on “oral lesions.”

  • Think of oral lesions in the following big-bucket categories: cancer, infectious, aphthous, autoimmune, hypersensitivity. This is not an exhaustive list, but some of the most common diagnoses we should consider!

NEOPLASTIC

  • SCC: consider in patients with history of tobacco and alcohol use. HPV 16 oral infection confers a 50 fold increased risk!
  • Leukoplakia: precancerous lesions that can progress to dysplasia –> carcinoma in situ –> invasive malignancy
  • Melanoma: pigmented lesions with ABCD characteristics (asymmetry, irregular borders, variable color, increasing diameter)


INFECTIONS

  • Candidiasis: think in denture use, diabetic patients, immunocompromised patients (steroids, AIDS, chemo)
  • HSV: painful lesions often at lip borders; diagnosis is confirmed by Tzanck smear & identifying multinucleated giant cells
  • VZV: grouped vesicles or erosions seen unilaterally on hard palate
  • Coxsackie virus
  • HIV-related: Oral cryptococcosis, Mucormycosis, Kaposi’s sarcoma, drug-related reactions
  • Syphilis: Split, fissured papules or oral commissures or oral erosions


APHTHOUS ULCERATIONS

  • Recurrent stomatitis: round, small, painful ulcers that heal within 1-2 weeks
  • Behcet’s syndrome: Neutrophilic infiltration. Look for genital lesions (occurs in 75% of patients with Behcet’s)
  • Complex aphthosis: recurrent large oral & genital lesions in the absence of other criteria for Behcet’s Syndrome

AUTOIMMUNE

  • SLE: MM involvement occurs in 50%. Can range from discoid (painful) lesions to punched out erosions or ulcers
  • Bullous pemphigoid: lesions affect flexural areas, groin, axillae. Oral lesions happen in 1/3 of cases
  • Pemphigus Vulgaris

HYPERSENSITIVITY REACTIONS

  • Think, Erythema multiforme and Stevens-Johnson Syndrome

 

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