Red Ulcerated Lesions Flashcards
(48 cards)
1
Q
Epidermolysis Bullosa
A
- Family hx (sometimes)
- Childhood onset
- Defect in the attachment mechanisms of epithelial cells
- Skin lesions most prominent
- No cure
- Management: Supportive
- Vesicles & bullae due to minor trauma
- Hands, feet, ankles, knees, elbows, head, butt, oral cavity
- 4 broad categories
- Tx
- Avoid trauma
- Abx, corticosteroids, phenytoin
- Px
- Simplex: Good
- Recessive & junctional: Fatal
2
Q
Viral diseases
A
- Acute onset & duration (1-2wk)
- Malaise, fever, lymphadenopathy (lymphadenopathy not present w/ recurrent herpes & zoster)
- Multiple ulcers
- Vesicle stage, except mono
- No recurrence except recurrent herpes & zoster
3
Q
Different HHV strains (1-8)
A
4
Q
HSV1
A
- Spreads mainly through saliva or active perioral tissues
- Adapted best to oral or ocular areas
5
Q
HSV2
A
- Adapted best to genital zones
- Transmitted via sexual contact
6
Q
Course of herpes simplex
A
-
Primary infection
- Initial exposure w/o antibodies to virus
- Young age typically
- Often asymptomatic or subclinical
-
Latency
- Virus taken up by sensory nn ganglion
- Most common site for HSV1 is trigeminal ganglion
-
Recurrent
- Reactivation of virus
- Cause of reactivation is unknown, but associated with
- UV rad
- Trauma
- Immunosuppression
- Cause of reactivation is unknown, but associated with
- Reactivation of virus
-
Prodrome: Tingling, burning, paresthesia
- People will feel it traveling down the nerve
- Affect epithelium supplied by sensory ganglion
- Usually asymptomatic; asymptomatic viral shedding
7
Q
Primary herpes
A
- Usually in children, but can happen in adults
- 60-80% have subclinical symptoms
- When symptomatic
- Lymphadenopathy present
- Fever, malaise, diarrhea
- Gingival swelling and erythema
-
Multiple pinhead vesicles and ulcers
- Lesions enlarge slightly and develop central ulceration
- Sometimes yellow fibrin covers ulcers, which can coalesce
- Ulcerations on keratinized and non-keratinized tissue simultaneously
- May involve vermillion of lip
- Satellite vesicles on skin
- Self-inoculation can occur
- Resolves in 7-14 days
- Tx: Acyclovir (Zovirax) can help if started within 5 days after onset
- Rinse & swallow 5x/day. Adults 200mg
- Does not prevent, but reduces period of viral shedding
- Usually resolves 10-14 days in healthy patient
8
Q
Recurrent herpes
A
- AKA “cold sore” or “fever blister”
- Occurs @ terminal end of involved nerve supplied by ganglion
- Clinical manifestations
- Vesicles & ulcers
- Occur in small clusters
- On vermillion border, perioral skin, keratinized oral mucosal surfaces
-
Recur in same location
-
Most common site: vermillion border and adjacent skin of the lips
- Herpes labialis
-
Most common site: vermillion border and adjacent skin of the lips
- No lymphadenopathy
- Lesions may be generalized in immunocompromised
- Vesicles & ulcers
- Oral mucosa is also affected
- Limited to keratinized mucosa
- Symptoms are less intense
- Begin as 1-3mm vesicles
- Yellow ulceration develops
- Heal in 7-10 days
- Tzanck cell: Free floating epithelial cells
- Tx: Prevent onset or significantly shorten it
- Efficacy of topical tx has not been proven
- Medication is most effective is started at prodrome
- Rx: Valacyclovir (Valtrex)
- Acyclovir may be useful for prophylactic maintenance
- Sunscreen may prevent recurrence
9
Q
Herpes whitlow
A
- Fingers and thumbs
- Used to be common w/ dentists
10
Q
Herpes gladitorum or scrumpox
A
Herpetic infection found in wrestlers or rugby players w/ contaminated abrasions
11
Q
Herpes barbae
A
- Herpes over bearded region of face into minor injuries created by daily shaving
- Immunocompromised patients have extensive lesions (not limited to keratinized tissues)
12
Q
Varicella
A
- Primary infection with varicella-zoster virus (VZV, HHV-3)
- Prodrome: malaise, fever, lymphadenopathy
- Successive crops of pruritic papules, vesicles, ulcers on skin. Begin on trunk and spread to extremities and face
- Occasional oral vesicles and ulcers
- Microscopically identical to herpes simplex
- Tx:
- Symptomatic relief
- Antihistamines, topical lotions to relieve pruritus
- Px:
- Usually mild disease
- More serious
- Vaccine
13
Q
Herpes zoster (shingles)
A
- Varicella-zoster virus has latent state
- Zoster represents a recurrence
- Predisposing factors
- Immunosuppression
- Elderly
- Prodrome of pain, burning, paresthesia. Pain can mimic toothache
- Vesicles and ulcers
-
Unilateral, along the entire nerve path
- Follows peripheral nerve distribution
- Most common on trunk and trigeminal area
-
Unilateral, along the entire nerve path
- Tx: Acyclovir, if early in disease
- Px:
- Ulcers resolve in several wks
-
Post-herpetic neuralgia: chronic severe pain in nerve distribution after lesions
- Lowers pain threshold to where they’re very sensitive even though the vesicles are gone
- Facial nerve involvement can cause Bell’s palsy
14
Q
Herpangina
A
- Etiology: coxsackievirus, group A
- Fever, pharyngitis, N/V, diarrhea, lymphadenopathy
- Lesions
- Similar to HFM, but confined to posterior oral cavity
- Soft palate, uvula, tonsillar pillar
- Tx: Symptomatic
- Px: Mild disease, resolves in several days
15
Q
Hand, Food, Mouth Disease
A
- Not a human herpes virus
- Etiology: coxsackievirus, group A
- Flu like symptoms: mild fever, malaise, diarrhea
-
Lesions
- Vesicles and ulcers throughout oral cavity
- Oral lesions usually appear first
- Macules & vesicles on hands and feet
- Tx: Symptomatic
- Px: Good
16
Q
Infectious Mononucleosis
A
- Etiology: Epstein-Barr virus (EBV, HHV-4)
- EBV also associated w/
- Burkitt’s lymphoma
- Nasopharyngeal carcinoma
- Hairy leukoplakia
- Fever, malaise, pharyngitis, cervical lymphadenopathy
- Splenomegaly, hepatomegaly, hepatitis
-
Oral mucosa
- Erythematous
- Petechiae on palate
- Ulcers w/o vesicles, later in disease
- Skin rash, esp w/ ampicillin
- Tx: Supportive
- Px:
- Usually good, recovery can take wks though
- Most subclinical
- Chronic EBV syndrome: overwhelming fatigue, malaise, lymphadenopathy, depression
17
Q
Measles (Rubeola)
A
- Viral infection caused by a member of the paramyxovirus family
- RNA virus, known as “measles virus”
- Spread through respiratory droplets
- Peak incidence b/w March & April (late winter-spring)
- Measles is now an uncommon disease
- Koplik’s spots
- Mucosal erythema
- Buccal/labial mucosa, palate
- Small, blue/white macules
- “Grains of salt”
- Tx:
- Dx based on history & clinical features
- Complication rate is 21%
- Otitis, pneumonia, bronchitis, diarrhea, encephalitis
- Best tx is prevention (MMR vaccine)
- In otherwise health pts: fluids & non-aspirin antipyretics
18
Q
Autoimmune diseases
A
- Gradual onset: wks to mos
- Progressive
- Chronic, with exacerbations and remissions
- Lymphadenopathy not present
- These diseases cannot be cured but can be controlled w/ corticosteroids
- Tx of Non-Microbial Mucositis w/ Corticosteroids
- Topical steroid rinses & ointments, systemic steroids, intralesional steroids
19
Q
Erosive Lichen Planus
A
- Cause
- Immune abnormality involving T-lymphocytes
- Lichenoid drug rxn
- Graft vs. host rxn
- Skin lesions
- May occur independent of oral lesions
- Pruritic, violet-colored plaques with striations
- Oral lesions
- Erythema, painful erosions, ulcers; white striae along periphery
- Vesicles are rare
- Bilateral; focal or generalized
- Atrophy of filiform papillae
- Oral candidosis
20
Q
Pemphigus Vulgaris
A
- Desmosomes are attacked so skin will slough and erode and ulcer
- Etiology: autoantibodies to intercellular protein in desmosomes
- Fragile blisters rupture easily forming painful blisters
- Large areas of skin or mucosa involved; usually multifocal
- Oral lesions often present; may precede skin lesions
-
Nikolsky sign sometimes present, not specific for pemphigus
- Blowing air can cause bullae to form and ulcerate
- Microscopic
- Acantholysis, intraepithelial vesicle
- Tzanck cells
- Direct immunofluorescence on biopsy
- Indirect immunofluorescence on blood
- 2 Biopsies
- 1 submitted in formalin
- 1 submitted in Michels solution
- Both taken @ junction of normal and ulcerated area
- Tx: Corticosteroids rinse and systemic
- Px: Guarded; fatal w/o tx
21
Q
Mucous Membrane Pemphigoid
A
- Hemidesmosomes are attacked
- Etiology: Antibodies against basal lamina (hemidesmosomes)
- Vesicles and painful ulcers; may heal w/ scarring
- Nikolsky sign sometimes present
- EO lesions
-
Conjunctiva: May cause blindness
- Doesn’t always attack the eye but it can
- Nasal, pharyngeal, vaginal mucosa
- Skin
-
Conjunctiva: May cause blindness
- Oral Lesions
- Vesicles, painful ulcers
- Erythematous gingiva
- Tx: Corticosteroids, systemic and rinses
- Px: Good, monitor eye lesions. Goal is to control lesions, we cannot cure
22
Q
Bullous Pemphigoid
A
- Etiology: Antibodies against basal lamina
- Most common auto-immune blistering condition
- Skin lesions always present: thick-walled bullae and ulcers
- Oral lesions occasionally present
- Not common
- Oral bullae rupture sooner than skin bullae
- Large, shallow ulcerations
- Distinct margins
-
Compared w/ MMP
- BP more limited
- No scarring w/ BP
- Tx: Corticosteroids
- Px: Good
23
Q
Lupus Erythematosus
A
- Most common CT disease in US
- Oral lesions seen in 5-25% of pts
- Palate, buccal mucosa, gingiva
- Both keratinized & non-keratinized
- Generalized ulcerations in the mouth
- Lichenoid or non-specific
24
Q
Systemic Lupus Erythematosus (SLE)
A
- Serious multisystem disease
- Increased activity of B-lymphocytes and abnormal function T cells
- Precise cause is unknown (genetic factors may play a role)
- Women are 8-10x more affected
- Fever, weight loss, arthritis, fatigue, malaise
- Butterfly rash
- 40-50% pts
- Malar area and nose
- Worsens w/ sunlight
- Kidney affected in 40-50% of cases
- May lead to kidney failure
- Most significant aspect of disease
-
Cardiac involvement also common
- Pericarditis is most frequent complication
- Tx:
- Avoid excessive exposure to sunlight
- Mild disease: NSAID & malarial drugs
- Severe: Corticosteroids (oral lesions respond)
25
Chronic Cutaneous Lupus Erythematosus (CCLE)
* AKA **discoid lupus** erythematosus
* **Scaly, erythematous patches**
* Frequent in sun-exposed skin
* Common in head and neck
* **Scarring and pigmentation**
* Few or no systemic signs/symptoms
* Confined to **skin & oral cavity**
* Good Px
* Tx:
* Avoid excessive exposure to sunlight
* Topical corticoids (skin and oral lesions)
* Systemic antimalarial drugs in tx-resistant cases
* Prevent breakdown of collagen, keep cells together
26
Subacute Cutaneous Lupus Erythematosus (SCLE)
* Intermediate features b/w SLE & CCLE
* Cutaneous lesions are most prominent feature
* Frequent in sun-exposed areas
* **No scarring or pigmentation**
* **No renal changes**
* Arthritis and musculoskeletal
27
Possible differential dx's for chronic desquamative gingivitis: presents as sloughing of gingiva
* Erosive lichen planus
* Pemphigus
* Pemphigoid (MM or bullous)
* Lupus
28
Traumatic Ulcer
* Caused by simple mechanical trauma
* Lower lip, tongue, buccal mucosa
* Other causes: Factitious, iatrogenic
* Acute or chronic
* If you have an ulcer that lasts for 2wks or longer, you have to biopsy it
* **Riga-Fede Disease:** Seen in neonates due to neonatal teeth
* Tx: Remove source of irritation
* 15 days, reassess
* If no improvement, you biopsy
29
Candidosis
* Common opportunistic oral mycotic infection
* **Most common oral fungal infection in humans**
* **Agent: Candida albicans**
* **Fungal infection on the surface of the mucosa**
* "Classic" white patches
30
Acute Erythematous Candidosis
* **Most common form (more common than pseudomembranous)**
* Generalized **pain, burning, erythema**
* Typically follow **broad-spectrum abx**
* Diffuse loss of filiform papillae on the tongue
* Key: Diffuse redness of the tongue w/ pain
31
Chronic Erythematous Candidiasis
* Commonly seen in **denture wearers, AKA denture stomatitis**
* Denture stomatitis **may not be caused by candida**
* **Other factors: Poorly fitting dentures, prolonger wear, poor OH**
* Erythematous areas confined to denture-baring area
* May cause pain/burning or be asymptomatic
32
Angular Cheilitis
* Typically occurs w/ reduced vertical dimension of occlusion, **but does not have to be**
* Accentuated folds @ corners of mouth
* Saliva pools in areas and keeps it moist
* **20% C. albicans alone**
* **60% combined C. albicans and S. aureus**
* **20% S. aureus alone**
* Tx w/ antifungal & antibacterial
33
Median Rhomboid Glossitis
* Originally thought to be developmental problem, until it was found that C. albicans was the cause
* Anterior to circumvallate papilla
* "Kissing lesion" on palate may be present
* Tx:
* Mouth rinse
* Ointment
* Lozenges
* Systemic anti-mycotic
34
Deep Fungal Infections
* Characterized by primary involvement of lungs
* May disseminate into other organs, including oral cavity
* Implantation of infected sputum in oral mucosa
* Signs & symptoms of lung disease (cough, fever, chest pain)
* Oral: Non-healing, indurated, frequently painful ulcer(s)
* **Can look and sound like cancer**
* Dx: Histopathological exam or culture
* Tx: Varies depending on severity and host status
* Systemic **antifungals**
* **Clinically resembles squamous cell carcinoma**
* **Histoplasmosis**
* Most common systemic fungal infection in US
* **Blastomycosis**
* **Paracoccidioidomycosis** (SA blastomycosis)
* **Coccidioidomycosis**
* San Joaquin Valley Fever
* Flu-like illness
* **Cryptococcosis**
* Most dx'd pts are immunosuppressed
* **Zygomycosis**
* Found on decaying organic material
35
Syphilis
* Caused by Treponema pallidum
* Sexual contact, blood transfusion, vertical transmission
* 6x more in men
* **Primary**
* **Chancre** @ site of inoculation
* **Solitary lesion**, usually in genitalia
* Oral: Upper lip (male), lower lip (female); ulcer or PG-like
* **Secondary**
* Maculo-papuler **cutaneous rash**
* Mucous patches
* **Condyloma lata**
* **Tertiary**
* CNS (neurosyphyilis), CV problems
* **Congenital Syphilis**
* **Hutchinson's triad: Hutchinson's teeth, ocular interstitial keratitis, eight nerve deafness**
* Tx: PCN
* Dose, schedule vary according to pt and disease factors
* High rate of co-infection w/ HIV
36
Aphthous Ulcers
* Very common mucosal disease, AKA canker sores
* Affects ~20% population
* Caused by different things in different people
* **T-cell mediated immunologic rxn**
* Types: **Minor, Major, Herpetiform**
* Features
* Single or multiple painful ulcers; no vesicles
* Ulceration w/ a white pseudomembranous membrane surrounded by a red halo
* **Non-keratinized mucosa**
* Acute onset - heals in the same amount of time for a particular patient
* Recurrent
* **No systemic manifestation - usually no lymphadenopathy**
* Px: Can be controlled, but not cured
* Tx:
* Mild disease: Topical corticosteroids
* Major aphthae: More potent steroids
37
Minor Aphthous Ulceration
* 80% of cases
* 1-5 lesions
* Size between **3-10mm**
* Heals in **7-14 days**
* **No scarring**
38
Major Aphthous Ulceration
* 10% of cases
* 1-10 lesions
* Size between **1-3cm**
* Healing in up to **6wks**
* **More frequent recurrence**
* **May cause scarring**
39
Herpetiform Aphthous Ulcers
* 10% of cases
* 10-100 lesions
* Size b/w **1-3mm; may coalesce w/ one another**
* Heal in **7-10 days**
40
Bachet's Syndrome
* Serious, multisystem disease
* Aphthous-like oral ulcers, genital ulcers, ocular inflammation, skin pustules
41
Erythema Multiforme
* Blistering, ulcerative mucocutaneous condition of **unknown** cause
* Probably immunologically mediated
* Predisposing factors:
* 50% of cases, **preceded by herpes or pneumonia**
* Meds: abx, analgesics, sulfanomides
* Forms: **Minor, Major, Toxic Epidermal Necrolysis******
* Features
* **Acute onset**; time to heal varies
* Onset is what makes it different from pemphigus, pemphigoid, lichen planus, lupus
* **Key clinical feature: lesions appear suddenly**
* May have fever/malaise; rarely lymphadenopathy
* Skin lesions:
* Common, but not always present
* **"Iris" or "target" lesion:** erythematous macule w/ central vesicle
* Mainly on face and extremities
* Oral lesions:
* **Diffuse, painful ulcers**; may have vesicles
* Common: **lips**, buccal & labial mucosa
* Tx:
* Remove causative agents, if there are any
* Topical, systemic corticosteroids
* May be recurrent
42
Major Erythema Multiforme: Stevens-Johnson Syndrome
* More severe form
* Oral & skin lesions + ocular or genital
43
Toxic Epidermal Necrolysis: Lyell's Disease
Diffuse sloughing of skin
44
Drug Rxn
* Most common on the skin, but also seen in oral cavity
* Any drug has the potential to cause rxn
* 6% risk for 2 meds; 50% risk for 5 meds; 100% for 8 meds
* Different patterns
* Detailed hx needed for dx
* If potential drug is found, temporal relation must be established
* Often multiple culprits are suspected
* Rxns can be acute or chronic
45
Contact Stomatitis
* Most common on skin, but also seen in oral cavity
* Caused by a vast array of foreign substances
* Predominantly T-cell mediated
* Presentation varies from erythematous to vesicular to ulcerative
* Wide array of materials can cause oral contact allergies
* High index of suspicion needed for dx
* Removal of suspected agent helpful
* Signs and symptoms disappear w/in 1-2wks
* Biopsy may be req'd sometimes
46
Granulomatosis w/ Polyangitis
* Formerly Wegener's Granulomatosis
* **Granulomatous lesions** of the upper respiratory tract
* Necrotizing **glomerulonephritis**
* **Systemic vasculitis** of small aa & vv
* Dx made on clinical & microscopic features
* **c-ANCA test**
* Tx: Oral prednisone & cyclophosphamide
* Pts usually respond well
47
Crohn's Disease
* Inflammatory & immunologically mediated
* Primarily affects distal small bowel & primary colon
* Changes may be seen anywhere, from mouth to anus
* Oral lesions precede GI lesions in 30% of cases
* Prevalence appears to be increasing, but reason unknown
* Teenagers, w/ second peak \>60yr
* GI signs and symptoms (cramps, diarrhea, pain)
* Weight loss & malnutrition
* Wide range of oral lesions
* Swelling, "cobblestone" and ulcers
* Tx:
* Sulfa type of drug
* Metronidazole: second line
* Oral lesions tend to resolve w/ systemic tx
* If not, topical corticosteroids may be used
48
Erythroplakia
* **Asymptomatic, persistent, red or red/white lesion. Not ulcerated**
* Most common on floor of mouth, ventral/lateral tongue, retromolar trigone, soft palate, tonsillar pillar area
* Microscopically dx'd as **epithelial dysplasia, carcinoma-in-situ, superficial squamous cell carcinoma**
