Simple cases
Case 45
28-year-old HIV-positive patient is referred because of suspected candidal esophagitis
History
How long have you had these lesions?
I noticed them about 3-4 weeks ago.
The time course can offer clues for the differential diagnosis.
Do you have any other health problems?
I am HIV-positive.
Wouldn't it be unfortunate to overlook this point?
Can you remove the spots?
I have tried to brush them away with my toothbrush, but they are stubborn.
A critical question, as thrush (most common candidal infection of mouth) is easily removed.
Do they hurt?
No, not at all.
Oral pain always demands prompt treatment, as it interferes with eating and drinking.
Do you have any new lesions elsewhere on your body?
No.
A total body check is always wise, and especially in the case of HIV, which has so many possible cutaneous findings.
Do you smoke?
No.
Always a good question when confronted with oral mucosal lesions; here it plays no role.
Lesion
Choose the right efflorescences:
Vesicles are fluid-filled, and not seen here.
Here is a type of papulea white plaque which on the oral mucosa is usually described as leukoplakia.
Scales are never found in the mouth. The saliva and mechanical pressures do not let them form.
There is no epithelial defect here.
Diagnosis
Choose the right diagnosis:
The key question, but candidal plagues are easily removed. KOH examination and biopsy can decide the question. A positive candidal culture from the mouth is not helpful.
Lichen planus typically has patches with a white lacy network (Wickham striae) or erosions.
Very good. The clinical picture with location on the side of the tongue is perfect. The appearance of oral hairy leukoplakia suggests a progression of HIV.
Pemphigus vulgaris presents with oral bulla and erosions.
The tongue can be burned, but then it becomes erythematous, perhaps eroded, and heals quickly.
Therapy
Choose the right therapy(ies):
Worth a try.
In experienced hands, sometimes helpful, but officially podophyllin should not be used in the mouth.
The treatment of choice; as the HIV infection is controlled, the oral hairy leukoplakia will improve.
No reason to think this would help.
