Some  COVID-19 Patients Might Present with Infection-Related Mouth Lesions

Mouth lesions might be a clue that patients have COVID-19, a new study suggests. Those symptoms might be missed, however, because safety concerns often keep clinicians from examining the inside of the mouth, according to the authors of a research letter. Here are more details of what the study team found, as well as tips of differentiating skin manifestations from drug reactions vs. infectious agents.

MADRID, SPAIN – Oral cavity lesions might provide a clue to COVID-19 patients in some patients, but, because of safety concerns, clinicians often avoid examining the inside of the mouth, according to a new Spanish study.

The research letter in JAMA Dermatology notes that skin manifestations have been reported worldwide among novel coronavirus patients, with researchers using terms such as  “erythematous rash,” “widespread urticaria,” and “chickenpox-like vesicles.”

Hospital Universitario Ramon y Cajal-led researchers advise that other rashes have been described, , including petechial and purpuric changes,2 transient livedo reticularis and acro-ischemic lesions.

“Whether these manifestations are directly related to COVID-19 remains unclear, since both viral infections and adverse drug reactions are frequent causes of exanthems,” the authors write. “An important clue to distinguish between both entities is the presence of enanthem. However, owing to safety concerns, many patients with suspected or confirmed COVID-19 do not have their oral cavity examined.”

In the letter, the authors describe variants of enanthem in a series of patients with COVID-19. Included were 21 consecutive patients from a tertiary care hospital who had skin rash and COVID-19, confirmed by real-time reverse transcriptase–polymerase chain reaction from a nasopharyngeal swab, and who required dermatology consultation from March 30 to April 8, 2020.

Researchers systematically examined the oral cavities of patients presenting with skin rash and classified enanthems into 4 categories: petechial, macular, macular with petechiae, or erythematovesicular.

Results indicate that six of the patients (29%) had enanthem. The age range was between 40 and 69 and 66% were women.

The authors point out that no enanthem was observed in patients with urticarial or typical maculopapular rashes. They note that enanthem was macular in 1 patient, petechial in 2 patients, and macular with petechiae in 3 patients, and was located in the palate in all patients, although no patient presented with an erythemato-vesicular enanthem.

The mean time between the onset of COVID-19 symptoms and the appearance of mucocutaneous lesions was 12.3 days, according to the authors, who add, “Interestingly, this latency was shorter in patients with petechial enanthem compared with those with a macular lesion with petechiae appearance. Drug intake and laboratory findings were not associated with any enanthem type.”

Background information in the article discusses how the etiological diagnosis of exanthems can be challenging for clinicians.

“Some useful clues are the rash morphology, the associated symptoms, and the presence of enanthem,” researchers explain. “Pustular morphology and dusky lesions are suggestive of drug etiology, while petechial or vesicular pattern, involvement of buttocks or acral sites, and enanthem suggest an infectious etiology, especially viral.”

The authors caution that their report describes preliminary observations and is limited by the small number of cases and the absence of a control group.

“Despite the increasing reports of skin rashes in patients with COVID-19, establishing an etiological diagnosis is challenging. However, the presence of enanthem is a strong clue that suggests a viral etiology rather than a drug reaction, especially when a petechial pattern is observed,” the study concludes.

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