key: cord-0824279-306h46ap authors: Riad, Abanoub; Kassem, Islam; Badrah, Mai; Klugar, And Miloslav title: The Manifestation of Oral Mucositis in COVID‐19 Patients: A case‐series date: 2020-10-30 journal: Dermatol Ther DOI: 10.1111/dth.14479 sha: 0b3873ee9724909b3c72990951877d0891199f4a doc_id: 824279 cord_uid: 306h46ap nan We have read with great interest the correspondence of Kahraman et al. (2020) on the emergence of oral mucosal changes adjacent to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection; hereby we demonstrate the characteristics of thirteen laboratory-confirmed coronavirus disease (COVID-19) patients with oral mucositis according to the CARE guidelines. 1, 2 The referenced patients sought care at our department from April to August 2020 due to generalized pain and soreness within the oral cavity related mainly to non-keratinized mucosa without a specific cause ( Table 1 ). All included patients had previously undergone polymerase chain reaction (PCR) testing for SARS-CoV-2, which confirmed their infection with a mean cycle threshold (Ct) value of 18.46 ± 3.8 (12-26). Their mean age was 51.08 ± 8.79 (34-62) years old, and eight of them (62.5%) were females. Regarding their COVID-19 symptoms, two patients (15.4%) had persistent fever, four (30.8%) had ageusia, and two (15.4%) had anosmia. The majority of them (69.2%) had a mild course of SARS-CoV-2 infection and were prescribed paracetamol (PCM); contrarily, four patients experienced a moderate course of infection -two patients (15.4%) were prescribed chloroquine and other two (15.4%) were prescribed dexamethasone. 3 The mean onset of mucositis emergence was 0.85 ± 0.8 (0-2) days calculated since the day of PCR testing, while its mean duration was 8.62 ± 3.07 (7) (8) (9) (10) (11) (12) (13) (14) days. An 11-item numerical rating scale (NRS) was used to evaluate the manifested intraoral pain where "0" denotes "no pain" and "10" denotes "pain as bad as you can imagine". 4 The mean score of pain intensity was 5.08 ± 2.36 (3-9). On intraoral examination, sporadic erythema with minor irritations was found all over the mouth (53.8%), on the buccal mucosa (30.8%), palate (15.4%), and gingiva (7.7%). Depapillation of the tongue was observed in all cases with a tendency to be more localized at the borders (Figure 1 ). This article is protected by copyright. All rights reserved. While nine patients (69.2%) were prescribed 'Magic mouthwash' containing lidocaine 1%, chlorhexidine 2%, and prednisolone 20 mg in 100 ml, four patients (30.8%) were prescribed PCM to relieve their symptoms of mucositis. Mann-Whitney test yielded a statistically significant difference favouring 'Magic mouthwash' in reducing the duration of mucositis, U (N Magic = 9, N PCM = 4) = 4.5, z = -2.85, p = 0.034. Inferential statistics revealed that COVID-19 severity was significantly associated with duration of mucositis and its pain (H = 5.76 and 9.29; P = 0.016 and 0.002 respectively). Ageusia was also significantly associated with Ct value, mucositis duration, and onset (U = 2, 4.5, and 1.5; P = 0.013, 0.034, and 0.018 respectively). Our findings support the suggested role of oral mucosa in providing an entry for SARS-CoV-2 due to the high expression of angiotensin-converting enzyme II (ACE2) receptors. 5 According to Sonis theory, oral mucositis is primarily initiated by oxidative stress and the formation of reactive oxygen species (ROS) in response to somatotoxic doses of non-surgical oncologic treatment. 6 The excessive production of ROS in the mucosal tissues of severely ill COVID-19 patients may explain the significant direct association observed in our cases between severity of COVID-19 and mucositis duration and pain intensity. 7 Secondary infections and drug reactions cannot be ruled out entirely, especially with severely ill patients due to immune dysregulation. 8 In addition, oral mucosal changes were consistently observed in children with paediatric multisystem inflammatory syndrome temporally associated with SARS-COV-2 (PIM S -TS), which is suggested to be linked to IgG antibody-mediated enhancement. 9 In conclusion, oral mucositis may occur in COVID-19 patients either as a direct manifestation of cellular damage triggered by SARS-CoV-2 or as an opportunistic infection due to immune dysregulation. This case-This article is protected by copyright. All rights reserved. Mucosal involvement in a COVID-19-positive patient: A case report The CARE guidelines: Consensus-based clinical case reporting guideline development Australian Guidelines for the clinical care of people with COVID-19 Oral Mucositis of COVID-19 Patients Australian Clinical Practice Guidelines Pain: A review of three commonly used pain rating scales High expression of ACE2 receptor of 2019-nCoV on the epithelial cells of oral mucosa Tissue damage from neutrophil-induced oxidative stress in COVID-19 COVID-19 Related Oral M anifestations, Early Disease Features? Oral Dis Pediatric multisystem inflammatory syndrome temporally associated with SARS-COV-2: Oral manifestations and implications The authors declare that there is no conflict of interest. The data that support the findings of this study are available from the corresponding author upon reasonable request.