oprm-web-case-op-st-18

Patient: Young boy.

Chief Complaint:
The patient complains of multiple, painful sores which started as blisters, of three days duration. Two episodes of similar lesions occurred earlier this year. The previous lesions healed spontaneously in ten to fourteen days. The lesions have always been in the same location and have not occurred intraorally.

Medical History:
No abnormalities are identified.

Dental History:
No history of dental problems.

Clinical Findings:
Multiple, soft, fluid-filled, tender vesicles are present on the lips, paraoral skin and fingers. The skin and mucosa surrounding the vesicles are erythematous, slightly raised, compressible, and blanch upon pressure. The vesicles are covered by a hard, dry crust which feels rough to palpation and rubs off.

There are no radiographs available for this case.

There are no lab reports available for this case.

There are no charts available for this case.

Summary:
These lesions are vesicular-ulcerated-erythematous lesions.
Key Points
  ~Acute onset of vesicles
  ~History of previous lesions in same location involving keratinized mucosa
  ~Lesions resolve in same amount of time each episode
Based on the above key points, a diagnosis of recurrent herpes can be made.

More discussion is given below.

Lesions to Exclude from the Differential Diagnosis:
Hereditary
  ~Epidermolysis Bullosa
      *Ulcers of the skin would be present
      *Onset is typically at birth or in early childhood
      *Ulcers are continuously forming and do not recur with complete healing in a consistent amount of time
Mycotic and Bacterial Lesions
  ~Mycotic (candidosis)
      *Lesions are not primarily ulcers.
      *Lesions do not heal in a predictable amount of time
Autoimmune Disorders
  ~Onset of ulcers is slower and not as abrupt
  ~Ulcers are more persistent and progressive
  ~Do not recur in the same location with complete healing in a consistent amount of time.
  ~Usually occur bilaterally
Idiopathic Lesions
  ~Aphthous Ulcers
      *Occur on non-keratinized mucosa
  ~The remaining Idiopathic lesions can be excluded because they do not heal in a consistent period of time.  In addition:
      *Erythema multiforme
Ulcers are bilateral and generalized throughout oral cavity
      *Erosive lichen planus
            Ulcers have more gradual  onset
            Lesions are bilateral
      *Erythroplakia
            Lesions do not occur as discrete ulcers which heal and recur
Viral Lesions
  ~Primary herpetic gingivostomatitis
      *Ulcers bilateral and generalized throughout oral mucosa
      *Tender cervical lymphadenopathy and sometimes systemic manifestations
      *Does not recur as primary herpes
  ~Varicella
      *Skin papules, pustules, and itching rash are most prominent
      *If oral ulcers are present, they are more generalized
      *Varicella does not recur as varicella
  ~Herpes Zoster (shingles)
      *Lesions follow the distribution of a sensory nerve and extend to midline
      *Typically do not recur multiple times
  ~Herpangina
      *Vesicles and ulcers are confined to posterior oral cavity
Hand, foot, and mouth disease
      *Skin lesions present       

Lesions to Include in the Differential Diagnosis:
Recurrent Herpes
  ~Definitive diagnosis can be made on basis of history and clinical appearance. 
  ~This case illustrates that recurrent herpes labialis can involve the skin around the lips.
  ~The lesions on the fingers represent autoinoculation from the labial and paraoral lesions.

Management:
This is a severe case of recurrent herpes.  Treatment includes systemic acyclovir or similar medications and palliative care with an emphasis on maintaining hydration. Prophylactic acyclovir should be prescribed for use when the patient first experiences prodromal symptoms or events that usually lead to recurrences in the patient. Prophylactic acyclovir may also be prescribed for daily low-dosage intake if the patient continues to experience recurrences that are frequent and severe.

Final Diagnosis:
Recurrent herpes