oprm-web-case-op-st-8

Patient: Mentally retarded boy

Chief Complaint:
The patient has persistent oral discomfort of one month duration which involves the entire oral mucosa. Penicillin therapy increased the discomfort. The patient reports a thick, white toenail.

Medical History:
The patient has just completed a 14 day course of penicillin, 250 mg, four times a day, prescribed for the chief complaint. A heart murmur was identified at birth but was not present at age ten. The patient had pneumonia at age three. He has acne.

Dental History:
A maxillary central incisor was avulsed and a lip was lacerated at age eight. The oral hygiene is poor.

Clinical Findings:
The entire oral and pharyngeal mucosa is tender and erythematous, with white plaques which rub off. The gingiva is swollen, compressible and blanches. Compressible, nonfixed submandibular and anterior cervical lymph nodes are palpable. Submandibular lymph nodes are tender to palpation. Other clinical findings include bilateral angular cheilitis, erythema around the nose, and white plaques on the tympanic membrane.

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:
This is a vesicular-ulcerated-erythematous surface lesion of the oral mucosa
  ~White plaques that rub off
  ~Mucosa under the plaques is tender and erythematous

Lesions to Exclude in the Differential Diagnosis:
All Hereditary Lesions
  ~Ulcers, and often vesicles are present
  ~Skin lesions are present
  ~Lesions are present from birth or childhood
All Viral Lesions
  ~Viral lesions have an acute onset
  ~Vesicles may be present although they often rupture before they are noticed.
  ~Ulcers are present
  ~Systemic manifestations and lymphadenopathy, although these are not always present with viral infections.
All Autoimmune Lesions
  ~Blisters and painful ulcers of slow onset
  ~May get better and worse, but are persistent and progressive
All Idiopathic Lesions
  ~Aphthous Ulcers
       *Ulcers are present
       *Acute or abrupt onset
       *Usually resolves in 7-14 days, or the same amount of time for each patient
       *Location – on non-keratinized mucosal surfaces
  ~Erosive Lichen Planus
       *The white patches do not rub off
       *White patches often have a network pattern (Wickham’s striae)
  ~Erythema Multiforme
       *Acute onset of blisters and ulcers
       *May have systemic manifestations
       *Does not usually have white patches that rub off.
  ~Medication-Induced Stomatitis and Contact Stomatitis
       *Associated white lesions do not rub off
  ~Erythroplasia
       *These lesions are asymptomatic – patient is almost never aware of these
       *If white lesions are present they do not rub off

Lesions to Include in the Differential Diagonsis:
Mycotic Lesions – Candidosis
  ~Produces white plaques that appear as cottage cheese or curdled milk and rub off
  ~Leaves a tender, erythematous base
  ~Patient is taking antibiotics, which may be disrupting the normal oral bacterial flora

Management:
Educate the patient and/or parents about the cause and nature of candidosis (candidiasis), stressing that it is best understood as an overgrowth of fungal organisms that many people harbor in their mouths.
Provide treatment options, including topical antifungal medications, and stress the importance of compliance, that is, using the medications properly.
Discuss the prognosis: The lesions may recur whenever the patient takes antibiotics but candidosis can be managed with antifungal medication.

Final Diagnosis:
Candidosis