Oral cavity lesions as a manifestation of the novel virus (COVID‐19)

Abstract

In early December 2019, the acute respiratory illness began in the Wuhan, China, which quickly spread around the world, that today known as COVID-19 (Sun, Qie, Liu, Ren, & Xi, 2020). Preliminary studies have shown that hospitalized patients have different symptoms, including myalgia, whooping cough, fatigue, and dyspnea and gastrointestinal complaints (Guo et al., 2020; Zhang et al., 2020). In more recent studies, skin manifestations have also been reported in COVID-19 patients (Estébanez et al., 2020; Recalcati, 2020). With our current knowledge, only one update of the English literature has reported oral manifestations of COVID-19 patients (Martín Carreras-Presas, Amaro Sánchez, López-Sánchez, Jané-Salas, & Somacarrera Pérez, 2020). In this report, we introduce two patients with COVID-19 who have oral cavity ulcer and describe the histopathology of their lesions, to help identify lesser-known manifestations of COVID-19. A 56-year-old woman with a history of diabetes mellitus was admitted to hospital with fever and shortness of breath. Her PCR test was positive for COVID-19 from nasopharyngeal swab. She was treated with remdesivir, azithromycin, and supportive treatment. On the fifth day after the onset of symptoms, the patient complained of sores in the mouth. Clinical examination of the oral cavity showed several painful ulcers with irregular margins and varying sizes in red and non-hemorrhagic background. The ulcers involved almost the entire hard palate (Figure 1). The incisional biopsy of the sores underwent H&E staining. The histopathology report was as follows: Tissue diffuses edema with mucosal desquamation, along with granulation and ulceration under the mucosa with invasion of mononuclear cells with large and glassy nuclei. Neutrophilic cell invasion was also seen following secondary bacterial infection. A 75-year-old man with a history of hypertension was admitted to the hospital with hypoxia due to COVID-19 (confirmed by PCR test from a nasopharyngeal sample). He was treated with azithromycin and supportive treatment. He complained of dysphasia one week after his hospitalization. On clinical examination, we observed several painful small ulcers, with irregular margins, in red, and non-hemorrhagic background on the anterior part of the tongue (Figure 1) His sores also underwent incisional biopsy, and the histopathology report was almost identical to the first patient. In both patients, the specimens were positive for COVID-19 PCR test and the serological tests were negative for herpes simplex virus type 1 and type 2 antibodies. Topical medications, such as a mixture of diphenhydramine, dexamethasone, tetracycline, and lidocaine, were used to wash-out the patient's oral symptoms. Their ulcers healed after about one week without scarring. We cannot definitively rule out the effects of stress as a trigger for these lesions in our patients (Gallo, Mimura, & Sugaya, 2009). Of course, the histopathology of the patients' ulcers and their clinical appearance was the detriment of oral stress and aphthous ulcer. The importance of our experience is that the lesions presented in our study were very similar in appearance to the lesions presented in the Martín Carreras-Presas et al.'s., (2020) study, which, in their opinion, are due to COVID-19. Therefore, it can be expected that COVID-19 cause mucosal lesions in addition to skin lesions. But further investigation of these clinical manifestations seems to help better understand the disease. We would like to thank Dr. Farzad Yazdani Bioki, a pathologist at Amiralam Hospital (Tehran), for histopathological examination of samples, and Dr. Ebrahim Karimi, an otolaryngologist at Amiralam Hospital (Tehran), for their reviews and comments. None to declare. Reza Ansari: Conceptualization; Investigation; Writing-original draft. Mina Gheitani: Conceptualization; Investigation; Writing-original draft. Farokh Heidari: Resources; Writing-review & editing. Firouzeh Heidari: Writing-review & editing. Financial resources are provided by the authors. All ethical standards are met in this study. This study has been approved by the ethics committee in the research of Tehran University of Medical Sciences.

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