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Oral Path 1 > Red Ulcerated Lesions > Flashcards

Red Ulcerated Lesions Flashcards

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
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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
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3
Q

Different HHV strains (1-8)

A
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4
Q

HSV1

A
  • Spreads mainly through saliva or active perioral tissues
  • Adapted best to oral or ocular areas
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5
Q

HSV2

A
  • Adapted best to genital zones
  • Transmitted via sexual contact
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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
  • Prodrome: Tingling, burning, paresthesia
    • People will feel it traveling down the nerve
  • Affect epithelium supplied by sensory ganglion
  • Usually asymptomatic; asymptomatic viral shedding
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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
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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
    • No lymphadenopathy
    • Lesions may be generalized in immunocompromised
  • 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
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9
Q

Herpes whitlow

A
  • Fingers and thumbs
  • Used to be common w/ dentists
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10
Q

Herpes gladitorum or scrumpox

A

Herpetic infection found in wrestlers or rugby players w/ contaminated abrasions

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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)
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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
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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
  • 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
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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
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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
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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
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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
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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
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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
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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
  • 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
Q

Chronic Cutaneous Lupus Erythematosus (CCLE)

A
  • 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
Q

Subacute Cutaneous Lupus Erythematosus (SCLE)

A
  • 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
Q

Possible differential dx’s for chronic desquamative gingivitis: presents as sloughing of gingiva

A
  • Erosive lichen planus
  • Pemphigus
  • Pemphigoid (MM or bullous)
  • Lupus
28
Q

Traumatic Ulcer

A
  • 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
Q

Candidosis

A
  • 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
Q

Acute Erythematous Candidosis

A
  • 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
Q

Chronic Erythematous Candidiasis

A
  • 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
Q

Angular Cheilitis

A
  • 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
Q

Median Rhomboid Glossitis

A
  • 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
Q

Deep Fungal Infections

A
  • 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
Q

Syphilis

A
  • 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
Q

Aphthous Ulcers

A
  • 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
Q

Minor Aphthous Ulceration

A
  • 80% of cases
  • 1-5 lesions
  • Size between 3-10mm
  • Heals in 7-14 days
  • No scarring
38
Q

Major Aphthous Ulceration

A
  • 10% of cases
  • 1-10 lesions
  • Size between 1-3cm
  • Healing in up to 6wks
  • More frequent recurrence
  • May cause scarring
39
Q

Herpetiform Aphthous Ulcers

A
  • 10% of cases
  • 10-100 lesions
  • Size b/w 1-3mm; may coalesce w/ one another
  • Heal in 7-10 days
40
Q

Bachet’s Syndrome

A
  • Serious, multisystem disease
  • Aphthous-like oral ulcers, genital ulcers, ocular inflammation, skin pustules
41
Q

Erythema Multiforme

A
  • 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
Q

Major Erythema Multiforme: Stevens-Johnson Syndrome

A
  • More severe form
  • Oral & skin lesions + ocular or genital
43
Q

Toxic Epidermal Necrolysis: Lyell’s Disease

A

Diffuse sloughing of skin

44
Q

Drug Rxn

A
  • 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
Q

Contact Stomatitis

A
  • 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
Q

Granulomatosis w/ Polyangitis

A
  • 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
Q

Crohn’s Disease

A
  • 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
Q

Erythroplakia

A
  • 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

Oral Path 1 (10 decks)

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