key: cord-268883-nf4fm7r7
authors: Corchuelo, Jairo; Ulloa, Francisco Chavier
title: Oral manifestations in a patient with a history of asymptomatic COVID-19. Case Report
date: 2020-09-01
journal: Int J Infect Dis
DOI: 10.1016/j.ijid.2020.08.071
sha: 
doc_id: 268883
cord_uid: nf4fm7r7

The pandemic situation has led to public health measures that have forced patients with and without the SARS-CoV-2 virus to remain isolated and take steps to prevent the spread. Many of these patients have been unable to attend the control of medical-dental services, which in many cases complicates their situation. This study reports on the oral manifestations of an asymptomatic COVID-19 patient treated interdisciplinary by teleconsultation due to the sudden appearance of lesions in the oral mucosa. Lesions are diagnosed, therapeutic measures are taken, and improvement is shown. This case shows that the problems that arise in the oral mucosa in patients with suspected or confirmed SARS-CoV-2 infection can be monitored through interdisciplinary teleconsultation during the pandemic with the support of information technology currently available worldwide. It also decreases the risk of transmission of SARS-Cov-2 between patients and health professionals.

SARS-CoV-2 is a respiratory coronavirus, zoonotic disease having both bats and pangolins as the most probable origin and intermediate host (Association 2020; Chan et al. 2020) . is believed to be spread through close person-to-person contact (about 2 meters), a distance at which the respiratory droplets from an infected person either symptomatic or asymptomatic that coughs, sneezes, or speaks can spread to other people who do not have adequate barriers.

Another route of transmission occurs indirectly when saliva droplets fall on other surfaces, such as the ground and objects made of different materials, and people come into contact with them (Kwok et al. 2015) . Their mortality is independent of their immune status (Mehta et al. 2020) ; the virus is resistant to standard defenses that do not appear to respond efficiently to inflammatory invasion and cytokine storm (Guo et al. 2020 ). Lymphocytopenia and T-cell over-activation with reduction of an effective humoral / cellular immune response have been reported in COVID-19 patients(Dziedzic and Wojtyczka 2020; Xu et al. 2020 ). Dysfunctions such as anosmia and ageusia have been found as inflammation-induced symptoms of COVID-19 (Petrescu et al. 2020 ).

Due to the use of intensified therapeutic methods possibly aggravated by SARS-CoV-2, an increase in cases with oropharyngeal symptoms / conditions, dental-oral problems associated with soft tissues, saliva production (dry mouth) as side effects, could be predicted, even after recovering from COVID-19. The Candida albicans is a normal inhabitant in many mouths, diagnostic confirmation of infection is often based on a successful response (i.e., resolution of lesions) to antifungal medications. This form of diagnostic confirmation can be further enhanced by culturing the pathogen, preparing a fungal smear, or even an incisional biopsy (Zegarelli 1993 ).

Immunoinflammatory processes have been associated with hyperpigmentation of melanin from the oral mucosa (Chandran et al. 2016) . Different factors produced during inflammation, such as prostaglandins, leukotrienes, cytokines, and inflammatory mediators, may play a role in this response and increased melanogenesis (Taylor et al. 2009; Lambert et al. 2019) . Inflammation mediators, such as histamine and arachidonic acid metabolites, trigger melanogenesis (Mackintosh 2001 ) and inflammatory cytokines such as TNF-α and IL-1α induce J o u r n a l P r e -p r o o f the secretion of melanogenic agents (SCF, HGF, bFGF, endothelin) by keratinocytes (Feller et al. 2014 ). Together, these agents explain the melanin pigmentation that is sometimes seen in association with inflammatory conditions of the skin or oral mucosa (Satomura et al. 2007 ).

Physiological melanin pigmentation of the oral mucosa occurs most frequently in the gingiva and does not transgress the mucogingival junction (Meleti et al. 2008) . Pigmentation is more extensive in the anterior part of the mouth than in the posterior part and on the labial / labial surfaces (Feller et al. 2014 ). The objective of this brief article was to report a relevant case of oral manifestations in an asymptomatic patient with COVID-19.

40-year-old female patient who works as assistant manager in a bank in New York (USA) who attends the teleconsultation (Cali-Colombia) accompanied by her husband and manifests the presence of reddish plaques on the lower lip and the appearance of dark brown pigmentation in the gum of 8 days of evolution. In the teleconsultation, the patient presented a photo of the lower lip ( Fig.1A) . She is asked for authorization to observe the injury through the mobile phone and the husband is asked to operate the camera and take photographs of different points of the mouth. During the anamnesis the patient indicates that she have been taking the following medications:

ibuprofen which is taken occasionally for headache, vitamin D2 (1 pill every week), and J o u r n a l P r e -p r o o f azithromycin which she took in 2 instances for five days (3 weeks and 1 week prior to the dental teleconsultation) prescribed by his primary care doctor through telehealth, since he had lymphadenopathy at the neck level, in addition to having tested positive for the antibodies (SARS CoV 2 AB IGG Positive) three weeks before the dental teleconsultation and her husband was diagnosed with COVID-19 six weeks before.

The patient states that her husband, with whom she cohabits, is a health care worker that had acquired the infection in the hospital by working with patients with Covid-19 at the height of the pandemic in the first half of 2020 in New York. He was tested multiple times presenting a positive RT-PCR tests (Testing was performed using the Cobas 8800 SARS-CoV-2 test.) and positive antibodies for COVID-19 (Testing was performed using the Chemiluminescent Immunoassay). The patient reports that her husband was symptomatic with a fever greater than 38°C and he was in disability for 52 days. minutes, then rinse with water and let the brush dry. The patient is contacted again by dental teleconsultation after 20 days, the oral cavity is verified by telephone and a recovery of the lesions of the lips is observed (Fig. 1B) . She does not present aphthous ulcers and the whitish color of the tongue was significantly reduced (Fig. 1F) . The recent photo, showing the melanin pigmentation in the attached gingiva of the anterior teeth, is compared with a photo taken 6 months before (Figs.1 E, H) . This comparison shows that the patient did not have the pigmentations. It is explained to her that the pigmentation is related by her Afro-descendant origin where this pigmentation is frequent and that the inflammatory process lived in response SARS-CoV-2 could cause the proliferation of melanocytes in that part of his body. It is left under observation for the next control. Oral candida infection has been reported to almost always involve a locally or systemically compromised host (Zegarelli 1993) . Taking into account that Candida albicans is part of the oral microbiome and that there were favorable events for its pathological development, such as the decrease in salivation manifested in the patient by the sensation of dry mouth, in addition to the frequent use of antibiotics and a mild predisposing factor such as the female sex (Zegarelli 1993) and the successful response to nystatin treatment, we can clinically confirm candida infection The hyperpigmentation of the gums in the anterior teeth due to the aesthetic problem that it represents for the patient is the one that causes of most concern. The patient is fair-skinned and At the last follow-up appointment the patient stated: "I feel happy because the lesions on the lip and tongue disappeared with the treatment, and I will be reviewing the evolution of the gum pigmentation until the next control appointment."

In conclusion, we can affirm that the problems that arise in the oral mucosa in patients with suspected or confirmed SARS-CoV-2 infection can be monitored through interdisciplinary teleconsultation during the pandemic with the support of information technologies available to many people worldwide, as demonstrated in this case with an asymptomatic patient with J o u r n a l P r e -p r o o f 

A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster

An update on the epidemiological characteristics of novel coronavirus pneumonia (COVID-19)

COVID-19) -Transmission

Face touching: a frequent habit that has implications for hand hygiene

First case of 2019 novel coronavirus in the United States

COVID-19: consider cytokine storm syndromes and immunosuppression

The origin, transmission, and clinical therapies on coronavirus disease 2019 (COVID-19) outbreak-an update on the status

Pathological findings of COVID-19 associated with acute respiratory distress syndrome. The Lancet respiratory medicine

The impact of coronavirus infectious disease 19 (COVID-19) on oral health

Oral mucosa lesions in COVID-19. Oral Diseases [Internet

Fungal infections of the oral cavity

HIV-associated oral mucosal melanin hyperpigmentation: A Clinical Study in a South African Population Sample

Journal of cutaneous medicine and surgery

The physiology of melanin deposition in health and disease

The antimicrobial properties of melanocytes, melanosomes and melanin and the evolution of black skin

Melanin: the biophysiology of oral melanocytes and physiological oral pigmentation. Head & face medicine

Possible involvement of stem cell factor and endothelin-1 in the emergence of pigmented squamous cell carcinoma in oral mucosa

Pigmented lesions of the oral mucosa and perioral tissues: a flow-chart for the diagnosis and some recommendations for the management

Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology

Oral erosions and petechiae during SARS-CoV-2 infection

Oral mucosal lesions in a COVID-19 patient: new signs or secondary manifestations?

Oral vesiculobullous lesions associated with SARS-CoV-2 infection. Oral Diseases [Internet

Treatment of severe physiologic gingival pigmentation with free gingival autograft. Quintessence international

Black and Brown: Non-neoplastic Pigmentation of the Oral Mucosa. Head and neck pathology

Beneficial actions of melatonin in the management of viral infections: a new use for this "molecular handyman

Oral manifestations, counts of CD4+ T lymphocytes and viral load in Brazilian and American HIV-infected children

Authors' contributions: Corchuelo J: conceptualization, study design, clinical studies, literature