Oral lesions in COVID‐19 infection: Is long‐term follow‐up important in the affected patients?

Abstract

It is still not well-established if SARS-CoV-2 infection is the direct cause or a predisposing factor for the onset of oral lesions (Rodríguez, Romera & Villarroel, 2020). Important aspects, such as systemic health deterioration, acute onset, and multidrug therapy may contribute in this process (Martín Carreras-Presas, Amaro Sánchez, López-Sánchez, Jané-Salas & Somacarrera Pérez, 2020) (Putra et al., 2020) (dos Santos et al., 2020). Therefore, it is plausible that the COVID-19 immunological scenario favors the occurrence of secondary oral ulcers (dos Santos et al., 2020) since SARS-CoV-2 could induce a similar immune response as observed in other viral infections (Russel et al., 2020). Besides, COVID-19 may cause an inflammatory immune response overactivation, leading to a cytokine storm and immune exhaustion (Putra et al., 2020) (Paces et al., 2020). Thus, most of the reported lesions were present during the COVID-19 infection period. We present a case of a patient with late oral ulcers after COVID-19 onset. A 33-year-old male patient sought medical assistance with headache, myalgia, fever, shortness of breath, anosmia, and ageusia. His wife presented the same symptoms. Under COVID-19 hypothesis, he was treated with ivermectin and azithromycin. PCR examination was not performed because it was restricted to severe cases. Seventy days after the initial symptoms, hyposmia and dysgeusia were still present, and painful mouth ulceration emerged in the floor of mouth. The lesion remitted in 10 days with topical application of corticosteroids. After twenty days, the patient still reported hyposmia and dysgeusia, and two other crateriform ulcers with a necrotic background emerged in the retromolar region and lip mucosa, both on the left side (Figure 1a,b). The patient did not report any similar oral lesions before, no episodes of recurrent aphthous ulceration (RAU) nor previous trauma at the site, and only secondary trauma due to feeding difficulties after the lesion's onset. Treatment included topical application of triamcinolone acetonide and the use of 0.12% chlorhexidine digluconate mouthwash for 7 days. Serologic assay detected IgG COVID-19 antibodies. Oral ulcerations remission occurred in 7 days. The patient reported persistent hyposmia and remains in clinical follow-up. Ulcerated oral lesions are usually caused by trauma, infection, immunological dysregulation, and neoplasia (Fitzpatrick et al., 2019). We considered traumatic ulcer, herpetic stomatitis, and RAU as the main differential diagnosis in this case. Interestingly, we did not observe the presence of an erythematous halo surrounding the ulcerated area, as expected for RAU. In addition, the patient reported no previous episodes and no associated trauma. It is possible that the COVID-19 systemic immune deregulation that leads to the deterioration of systemic health may bring a more prolonged immune imbalance, which could predispose these late secondary oral lesions. The persistent systemic immune imbalance in COVID-19 will require a close long-term follow-up of the infected patients. Routine intraoral examination should be performed in patients diagnosed with the new coronavirus in search of oral manifestations. This will also help to better understand the pathogenesis of the disease and its systemic and oral long-term manifestations. None. None to declare. Thâmara Manoela Marinho Bezerra and Sthefane Gomes Feitosa: Conceptualization; data curation; investigation; methodology; study design; clinical studies; literature research; supervision and writing—original draft. Diego Thiers Oliveira Carneiro: Conceptualization; investigation; clinical studies and literature research. Fábio Wildson Gurgel Costa, Fábio Ramoa Pires and Karuza Maria Alves Pereira: Conceptualization; data curation; investigation; methodology; study design; clinical studies; literature research; supervision; writing—review and editing. The peer review history for this article is available at https://publons.com/publon/10.1111/odi.13705.

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