Simple cases
Case 51
60-year-old man complains of difficulty swallowing because of sore in his mouth.
History
How long have you had these lesions? Have some of them resolved?
They started about 3 months ago, and I don't think they have ever gone away completely. As soon as one heals, a new one comes.
This question makes it clear that the patient does not have a long history of oral lesions (such as aphthae). On the other hand, his present illness is chronic and unlikely to be post-traumatic.
Did it start after eating any special food?
No, I don't think so, and I don't what I eat makes much difference.
Some foods are implicated in aphthae, but this question doesn't bring us much further, as the patient has already made it clear he doesn't have aphthae.
Have you had similar lesions on the eyes, penis or anus?
No, I have never had pain at any of those places and never noticed anything else.
Whenever dealing with oral mucosal diseases, ask about involvement elsewhere. Both Behçet disease and Crohn disease can present with oral lesions.
Have you noticed lesions anywhere else on your body?
Yes; I have sores and crusts on my scalp. Once in a while, I get a water-filled blister elsewhere.
It may last months before the disease spreads from the mouth to show more widespread disease.
Does it itch?
No.
Some patients have itching before any cutaneous lesions are visible. Thus pruritus is sometimes a clue to combined skin and mucosal disease, as opposed to isolated mucosal disease.
Do you take any medications? If so, what and when?
No, I don't take anything, except once in a while something for headache.
Good question, because some blistering diseases can be triggered by medications. Then the only thing that helps is to find and stop the medication.
Have you lost weight? Do you have night sweats?
I think I lost a bit of weight. Eating is such a problem. I haven't had night sweats.
This question is important to get a feel for the possible presence of a paraneoplastic disorder.
Lesion
Choose the right efflorescences:
Erosions are superficial defects. The patient has widespread mucosal erosions on the buccal mucosa, palate and gingiva - not to be confused with the small ulcers of aphthae.
Bulla are fluid-filled lesions. This patient has fragile lesions because his disease involves intraepidermal blistering.
Erosions frequently become crusted. Crusts are mixtures of scales with serum, blood or pus.
Diagnosis
Choose the right diagnosis:
Severe herpetic gingivostomatitis (the primary infection with HSV) could be so severe, but never so chronic.
Lichen planus may have painful oral erosions with a lacy white network. If associated skin lesions are not present, a biopsy may be needed to confirm diagnosis.
Bullous pemphigoid rarely has such severe oral disease, usually involves even older patients, and has more stable blisters.
Oral candidiasis features easily removed white plaques (thrush). KOH examination and culture are also helpful.
This is a classic case with oral and scalp involvement.
Therapy
Choose the right therapy(ies):
False. This is an autoimmune disease, not a fungal infection.
These agents are the mainstays of therapy, especially at the start in order to rapidly bring the disease under control. Because of their many side effects, extreme care is needed when they are used for long periods.
A wide variety of alternatives are employed in order to reduce the dosage and side effects of corticosteroids.
Topical disinfectant measures are helpful in reducing the risk of a secondary infection.
Test
The following questions are related to the current case. Try to solve them.
