Oral ulcer in SARS-CoV-2 infection: a case report

Introduction

The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) at the end of 2019 marked the onset of the global pandemic declared by the World Health Organization in March 2020 (1). The most common clinical symptoms include fever, tiredness, headache, sore throat, dyspnea, myalgia, dry cough, abdominal pain, vomiting, and diarrhea. In addition to these primary manifestations, some oral symptoms have also been reported, such as xerostomia, aphthous-like lesions, ulcers, tongue depapillation, necrotizing gingivitis, and taste disorders, including the loss of taste and salivary gland infections (2-4).

Understanding the mechanisms of virus dissemination has contributed to improvements in diagnostic and screening techniques (5). However, given its significant mutability, the widespread adoption of mass vaccination remains the most effective option for controlling contagion (6). We present this article in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-23-158/rc).

Case presentation

A 95-year-old male patient was hospitalized in follow-up care and rehabilitation unit, of Minimes Geriatric Clinic, Toulouse, France. He had an alteration in his general health in the context of coronavirus disease 2019 (COVID-19) infection detected by reverse transcription polymerase chain reaction (RT-PCR). The medical history revealed chronic renal and cardiac insufficiencies. The patient had been vaccinated against COVID-19 six months prior.

Upon arrival in the department, after 7 days from the onset of infection, the patient presented an altered general condition with fever, superinfected pneumonia with severe cough, temporal disorientation and memory disorders. Blood analysis showed hemoglobin 9.7 g/dL, leukocytes 7.7 g/L, lymphocytes 75 g/L, platelets 170 g/L, natraemia 134 mmol/L, kalemia 4.1 mmol/L, total protein 53 g/L, C-reactive protein (CRP) 83 mg/L. The treatment administered upon arrival was: antibiotics (clavulanic acid and amoxicillin 3 g/day), corticosteroids (dexamethasone 6 mg/day), and nasal oxygen therapy.

Six days after the admission, the patient complained of a strong burning sensation of the mouth, especially on the tongue and the lips’ mucosa.

Intraoral examination revealed painful erosive areas on the lateral edges of the tongue and the mucous side of the lower lip (refer to Figures 1,2). The lesions had a whitish appearance with a pseudomembrane and an irregular red inflammatory periphery. The lesions were extremely painful and sensitive to touch, leading to difficulties in speaking, eating, and drinking, which affected the patient’s quality of life. Apart from these lesions, the patient had no other oral or dental pathologies, wore no dentures, and maintained good oral hygiene.

Figure 1 Clinical picture showing the oral lesion on the lateral edges of the tongue 6 days after admission.

Figure 2 Clinical picture showing the oral lesion on the mucous side of the lower lip 6 days after admission.

The proposed treatment to reduce the burning sensation was based on general analgesics (morphine sulfate), mouthwash with sodium bicarbonate, and the application of a lidocaine-based oral anesthetic and healing gel.

In collaboration with the dietitian, a comfort-oriented diet was proposed to the patient: a mixed oral diet and avoidance of acidic foods.

Thirteen days later, the patient reported a gradual improvement (Figure 3,4).

Figure 3 Clinical picture showing the oral lesion on the lateral edges of the tongue after 13 days of treatment.

Figure 4 Clinical picture showing the oral lesion on the mucous side of the lower lip after 13 days of treatment.

Twenty-two days later, the patient noted a significant improvement, and the intraoral examination revealed a clear improvement of the lesions.

Twenty-five days later, given the absence of local and general symptoms, it was considered for the patient to return home with follow-up appointments scheduled at the day hospital.

Ethical statement

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). 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 editorial office of this journal.

Discussion

A wide array of oral manifestations has been identified in patients with a history of COVID-19 infection. Among them, oral ulcers significantly impact the subject’s quality of life, causing intense pain, stress, difficulties in eating, and having repercussions on nutritional status.

According to Amorim Dos Santos et al. (7), erosive oral lesions typically develop 7 to 24 days after the onset of symptoms (lesion, pain, burning or tingling sensation) and are reported to disappear (within 6 days to 2 weeks) or regress in size with time. Iranmanesh et al. (2) reported that the most common sites of involvement, in descending order, are the tongue (38%), labial mucosa (26%), palate (22%), gingiva (8%), buccal mucosa (5%), oropharynx (4%), and tonsil (1%). Oral lesions are symptomatic (painful, burning sensation, or pruritus) in 68% of cases. Both women and men are affected, with severity increasing with age and the severity of the disease. The main known predisposing factors are a lack of oral hygiene, opportunistic infections, trauma, immunosuppression, vascular issues, and hyperinflammatory reactions secondary to COVID-19 (2,7,8). The new coronavirus uses the salivary glands as a reservoir and saliva plays a part in spreading the disease (9). The formation of lingual ulcers can be attributed to the dimensional changes occurring in tongue epithelial cells as a consequence of COVID-19. This virus can bind to receptors on the epithelial cells located at the posterior region of the tongue (10).

Recent studies on oral mucosa lesions associated with COVID-19 indicate a correlation with organic damage and potential complications such as thrombocytopenia, anticoagulant therapy, disseminated intravascular coagulation, and systemic inflammation. This suggests that in the context of COVID-19, the oral cavity may exhibit primary or secondary alterations linked to vascular-hematologic damage (11).

In a recent study, Colizza et al. (12) reported on the association between the COVID-19 vaccine and oral manifestations. Particularly, oral ulcers may appear 1 to 3 days after its administration. Our differential diagnosis considered ulceration concomitant with COVID-19 infection and other infectious ulcerations (13): bacterial (syphilis, tuberculosis), viral [cytomegalovirus, human immunodeficiency virus (HIV)], mycotic, parasitic, autoimmune bullous diseases triggered by COVID-19, traumatic and malignant ulcerations. But also, ulcers provoked by drugs. For the latter, the introduction of the drugs 6 days before the onset of symptoms cannot explain these ulcerations.

The treatment we provided was effective in alleviating pain and facilitating the healing of the lesions. Depending on the severity and extent of the lesions, it may be advisable to consider alternative treatments, including antibiotics, antiseptic rinses (such as chlorhexidine 0.12%, alcohol-free mouth rinses, and H₂O₂ 1%), and antifungal agents (fluconazole 200 mg tablets for one week) to prevent secondary infections (14,15).

Conclusions

This case report illustrates the possible link between COVID-19 and mouth ulcers.

However, caution must be exercised, and further studies are needed to confirm this hypothesis. This underscores the impact of the COVID-19 virus on the activity of dental surgeons. Firstly, there is a need to establish safe care conditions for both the patient and the practitioner (16). Additionally, it emphasizes the significance of oral examinations and the role of dentists in the management of patients with SARS-CoV-2.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-23-158/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-23-158/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-23-158/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). 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 editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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