VESICULAR STOMATITIS AND COVID-19. A CASE REPORT
..................
Ana
María Pérez Murcia ¹, Oscar
Eduardo Mora Hernández ²
, Elvis F. Gómez Osorio ³
, Laura VanessaVargas
Gualdrón ³
Abstract
Introduction. The SARS-CoV-2
(severe acute respiratory syndrome coronavirus 2) pandemic has
shown a wide variability of multisystemic clinical presentations, with
the skin and its annexes being
one of the most affected organs.
Presentation
of the case.
A 32-year-old male with no known medical
history presents with fever, conjunctivitis, nasopharyngotonsillitis,
and extensive blistering oral lesions, that requires hospitalization
exclusively for management of oral lesions. During hospitalization
a positive result for SARS-CoV-2 was identified, without lung
involvement.
Discussion. Although
skin manifestations are described and classified in COVID-19
(Coronavirus disease 2019), the involvement of the mucous membranes,
especially the oral cavity, are rare and have not yet been elucidated.
However, when they occur, they generate significant morbidity in the
patient, therefore it is necessary
to perform a complete physical examination to avoid omitting them and
treat them promptly.
Keywords: Vesicular Stomatitis; Aphthous Stomatitis;
Vesiculobullous Dermatoses; COVID-19;
SARS-CoV-2.
..............
¹ Servicio de Medicina Interna, Hospital de San José.
Especialista Docencia Universitaria, Fundación Universitaria de
Ciencias de
la Salud.
² Servicio de Dermatología, Hospital de San José. Decano y
Especialista Dcocencia Universitaria, Fundación Universitaria de
Ciencias de la Salud.
³ Servicio de Dermatología, Hospital de San José. Residente,
Fundación Universitaria de Ciencias de la Salud.
ESTOMATITIS VESICULOAMPOLLOSA
Y COVID-19. REPORTE DE CASO
Resumen
Introducción: La pandemia por
SARS-CoV-2 (del inglés severe acute respiratory syndrome
coronavirus 2) ha demostrado amplia variabilidad de presentaciones
clínicas multisistémicas,
siendo la piel y sus anexos uno de los órganos más afectados.
Presentación del caso:Varón
de 32 años sin antecedentes conocidos, que presenta fiebre,
conjuntivitis, rinofaringoamigdalitis y lesiones orales ampollosas
extensas, que requiere hospitalización exclusiva
para manejo de las lesiones orales. Durante la hospitalización se
identifica resultado positivo
para SARS-CoV-2, sin compromiso pulmonar.
Discusión: Si bien las
manifestaciones en
piel están descritas y clasificadas en la COVID-19 (del inglés
Coronavirus disease 2019), la
afectación de las mucosas, en especial en la cavidad oral son poco
frecuentes y aún no están
dilucidadas. Sin embargo, cuando ocurren generan una importante
morbilidad en el paciente,
por lo que es necesario realizar un examen físico completo para no
omitirlas y tratarlas oportunamente.
Palabras clave: Estomatitis Vesicular; Estomatitis Aftosa;
Dermatopatías Vesiculoampollosas; COVID-19; SARS-CoV-2.
..................
Introduction
Since the start of the SARS-CoV-2 (severe acute respiratory
syndrome coronavirus 2) pandemic, the disease
has shown wide variability of multisystemic clinical
presentations, with the skin and its annexes being one
of the most affected organs. However, there are few reports on the
involvement of the oral mucosa, a circumstance that is likely due to
lack of inspection of this
area related to the infection risk to the examiner (1).
Numerous case reports suggest that oral mucosal changes may precede or
accompany the disease without focusing on the direct impact of
SARS-CoV-2 infection
(2). Coinfection with other microorganisms, immunological alterations
and overlapping with secondary reactions to medications have been found
(3).
This article seeks to delve into the existing literature
on COVID-19 (Coronavirus disease 2019) on oral mucosal lesions, in
order to better understand an unusual
case that required exclusive in-hospital management
of oral lesions.
Clinical case
A 32-year-old male from Bogotá, Colombia with no
relevant medical history and fully vaccinated against
SARS-CoV-2 two months prior with Astrazeneca, presented to an
outpatient clinic with an eight day history
of fever, sore throat, and dry cough. The fever resolved
on day 5, but was followed by erythema and ocular
itching along with painful bullous lesions throughout
the oral mucosa prompting him to seek medical attention. The clinic
diagnosed the patient with bacterial tonsillitis and prescribed
benzathine penicillin. After
symptoms persisted for 1 more day, he sought medical
attention at the hospital.
Upon physical examination, he was afebrile, with normal respiratory
rate and adequate oxygen saturation,
but presented with dehydration, mild tachycardia,
edema of the cheeks and inside the oral cavity (lips,
cheeks, soft palate, and Stenon’s duct) exhibited tense blisters,
vesicles, aphthous ulcers and unremovable
yellowish-white plaques, without lingual involvement
or enlarged lymph nodes (Figure 1). Signs progressed
less than 24 hours following admission (Figure 2).
COVID-19 and herpetic stomatitis in probable immunosuppression were
suspected, and hospitalization
recommended by the Dermatology, Otorhinolaryngology and Internal
Medicine services, who together initiated empirical management with
analgesia, thromboprophylaxis, gastroprotection, corticosteroids,
magistral formula and oral acyclovir.
Chest radiograph, Tzanck test, Human immunodeficiency virus,
hepatotrophs, syphilis, viral panel, IgG
and IgM (Immunoglobulin G and M) for Herpes
simplex type I and II, electrolytes, liver and kidney
function tests were normal.
IgG for Cytomegalovirus was positive and IgM negative. He had elevated
C-reactive protein, leukocytosis
(attributed to dehydration), slightly elevated glycated
hemoglobin, and a positive reverse transcription-polymerase chain
reaction for SARS-CoV-2.
Biopsy confirmed subepithelial bullous stomatitis with
associated severe inflammatory changes, suggestive of
mucosal pemphigoid, but with negative immunofluorescence. He finished
management with 10 days of antiviral therapy and 15 days of
corticosteroid treatment,
the latter with gradual outpatient weaning, and due to
improvement of lesions, he was discharged.
Discussion
Within the spectrum of manifestations in the oral
mucosa after COVID-19, the formation of blisters,
aphthous ulcers, scaling gingivitis, whitish plaques,
cheilitis, erythematous macules (mainly on the tongue) and enanthema
have been reported in association with
Kawasaki disease. These may be the only clinical manifestations of the
infection or may be accompanied
by other associated skin manifestations in up to 60%
of the affected population (4). The most frequent locations within the
oral cavity are the palate and tongue,
followed by the gums and lips, with a resolution time
of 3 to 21 days spontaneously or with pharmacological treatment (5).
Oral manifestations are described in
Table 1 (6-10).
Figure 1. Upon hospital admission (Fourth day of oral lesions).
Tense blisters with serous content are evident on the
upper lips, and well-defined whitish plaques with irregular edges on
the soft palate (A). Presence of tense blisters with
serous content on the upper lips, and scarce on bilateral cheeks, well
defined but unremovable whitish plaques (B).
Vesicles, tense blisters with serous content, and large well-defined
whitish plaques with irregular edges are evident on
the mucosa (C)
Figure 2. Twelve hours of hospital admission (Fifth day of oral
lesions). Increased edema in the lower two thirds of
the face (A). In the upper lips, abundant yellow and whitish membranes
are evident, associated with multiple erosions
also present in the lower lips (B). In bilateral cheeks and on Stenon’s
duct, abundant whitish plaques with irregular
and well-defined borders (C, D).
Although the pathophysiology of blister formation in
the oral cavity after COVID-19 infection has not been
fully elucidated, it can be explained by the angiotensin
converting enzyme II and the serine transmembrane
protease 2, required for the cellular entry of SARSCoV-2, which are
found diffusely in the oral mucosa
and are related to a hyperinflammatory state that ends
in the deregulation of oral keratinocytes (11). Coagulation disorders
associated with COVID-19 can also
trigger the development of necrotic ulcers in the oral
mucosa, due to the reactivation of infectious entities
such as herpes, and mycosis, after immunological deterioration and
dysbiosis secondary to the management
of COVID-19 (6).
Bullous pemphigoid is a rare autoimmune disorder
directed against hemidesmosomes of the skin with
the appearance of tense blisters, that in up to 15% of
cases, may present oral manifestations. This disorder can be triggered
by COVID-19 (3) in relation to a
cross-reactivity of antibodies or activated lymphocytes
with antigens containing similar epitopes (12), giving
a higher mortality rate (8). It is more common to observe reports of
its development after the application
of the SARS-CoV-2 vaccine (13), although it has been
reported mainly in patients with previous subclinical
or eczematous manifestations (14).
There is no treatment for the patient with oral manifestations due to
COVID-19, and insufficient studies
in relation to therapeutic management. Resolution of the triggering
and/or underlying factors are key to the
reduction of these lesions, among them: optimization
of the oral hygiene, identification and treatment of
opportunistic infections, stress reduction, stabilization
of underlying diseases, avoid trauma, and reduce vascular compromise as
well as the hyperinflammatory
response (systemic corticosteroids) (15).
Table 1. Oral mucosal and skin changes in COVID-19.
In the case of the patient in question, he presented
conjunctivitis, fever, oral lesions and upper respiratory
tract symptoms associated with COVID-19, but there
was no involvement of the lung parenchyma. It was
also not possible to identify a viral or autoimmune
etiology that would explain the result of the pathology
suggestive of mucosal pemphigoid, which cannot rule
out these entities or confirm that it is caused by SARSCoV-2. What is
evident is the relationship between the
appearance of oral lesions and COVID-19 due to the
timing of their appearance generated either by secondary
immunosuppression that promotes co-infection,
by triggering autoimmunity and/or by intrinsic damage of the virus.
In conclusion, there are many systemic manifestations
currently related to SARS-CoV-2 infection. Although
the manifestations on the skin have been described
and classified, the involvement of the mucous membranes, especially the
oral cavity, are rare and have not
yet been elucidated. However, when they occur, they
generate significant morbidity in the patient, preventing oral feeding
and administration of oral treatment,
therefore necessary to perform a complete physical
examination to avoid omitting them and thus be able
to give adequate and timely management.
Patient Consent
Written informed consent was obtained from the patient for publication
of this case report and accompanying images. A copy of the written
consent is available
for review by the editor-in-chief of this journal upon
request
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Recibido: 28 de
febrero de 2022
Aceptado: 15 de
marzo de 2022
Correspondencia:
Ana María Pérez Murcia
amperez1@fucsalud.edu.co