key: cord-0934695-fskc6ter authors: Martín Carreras‐Presas, Carmen; Amaro Sánchez, Juan; López‐Sánchez, Antonio Francisco; Jané‐Salas, Enric; Somacarrera Pérez, Maria Luisa title: Oral vesiculobullous lesions associated with SARS‐CoV‐2 infection date: 2020-05-29 journal: Oral Dis DOI: 10.1111/odi.13382 sha: da38c99c5e5f25bd92aca5b322bcd85eaa6df790 doc_id: 934695 cord_uid: fskc6ter The coronavirus pandemic that began in China at the end of last year, claimed its first confirmed death in Spain at the end of January 2020, where to date, 200,000 infections and 20,852 deaths have been recorded. In addition to the manifestations of SARS-CoV-2 infection described in the literature (fever, dry cough, diarrhea, and respiratory involvement) recently, skin exanthematic lesions have been described. We present three cases (two suspected and one confirmed) of patients presenting ulcers in the oral cavity. Oral manifestations developed during the lock-down period between the last week of March and the first week of April 2020, and consisted of pain, desquamative gingivitis, ulcers and blisters. To the best of our knowledge, this is the first case report describing of a COVID-19 patient with oral manifestations. Intraoral examinations should be carried out in patients affected by SARS-CoV-2, always when having the recommended protection measures available to a better understanding of the disease. Humans infected with SARS-CoV-2 are at risk of developing serious and life-threatening conditions, such as severe acute respiratory syndrome. Recent data suggest the more common signs and symptoms of SARS-CoV-2 infection to be headache, sore throat, hyposmia, hypogeusia, diarrhea, dyspnea, and in severe cases pneumonia. (Wang et al., 2020) . Some authors in Italy reported cases of dermatologic implication in patients affected by SARS-CoV-2 infection (Recalcati, 2020) . Since then, we have seen more reports describing dermatologic involvement, including lesions that range from affectation of hands and feet in teenagers to vasculitis, rash, urticaria, and varicella-like lesions. (Estebanez et al., 2020) . Spain has been severely affected by the COVID-19 outbreak (Bonanad et al., 2020) . The majority of dental clinics and university clinics are closed, only treating emergencies if the entity has the protective measures necessary. There is a nationwide lack of serological tests available, both for patients and for healthcare providers. We here present three cases associated with this virus: two where there is a suspicion of COVID-19 and one case of confirmed infection. All cases presented ulcers or blisters in the oral cavity, appearing and developing during the isolation period between the last week of March and the first week of April 2020. We were not able to examine them in our clinic due to the state of alarm declared from the 14th of March, but offered the possibility of video consultations. A 56-year-old healthy male patient without any relevant medical history was isolated with suspected infection of SARS-CoV-2. He presented asthenia and fever for 2 days, reporting hyposmia, dysgeusia, and enlargement of lymph nodes in the neck. Testing for COVID-19 was not performed in the hospital due to the non-severity of his case. He was sent home by his general practitioner. He complained of pain in his palate and sore throat. We asked him to send us a photograph ( Figure 1 ). The lesions resembled a herpetic recurrent © 2020 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd. All rights reserved F I G U R E 1 Multiple orange-colored ulcers with an erythematous halo and symmetric distribution on the right hard palate of the patient stomatitis; however, it was the first time the patient had them. We prescribed valaciclovir 500 mg every 8 hr for 10 days, and topical antiseptics with chlorhexidine and hyaluronic acid. After 10 days, there was a full recovery of the oral lesions. The patient is currently waiting for serological testing to confirm whether or not he had a non-severe COVID-19 disease. A 58-year-old male patient with diabetes and hypertension reported pain on his palate. He assumed it was a bacterial infection of a tooth and reached out to us for an appointment. His wife had been diagnosed with COVID-19, and they were both isolated in their home. We asked for a photograph, and we could see multiple small ulcers on his palate with unilateral affection (Figure 2 ). The patient did not have any previous history of herpetic infection. The lesions were painful and solved within 1 week using topical antiseptic mouthwash. A 65-year-old female patient developed high fever, diarrhea, and pain on her tongue, on the 12th of March 2020. She suffered from In our opinion, it makes good sense that this virus provokes exanthematic lesions that may resemble other viral processes we are used to diagnosing in the dental clinic. The patients presented ulcers or blisters, which are common elementary lesions observed in other viral processes, such as aphthous fever, hand, foot, and mouth disease and herpetic gingivostomatitis, as described by Scully and Samaranayake (2016) . The aspect of the back of the patient the day the biopsy was performed at the hospital. The patient reported that the lesions were more pruritic than painful. (b) The patient presented 3 blisters on the inner lip mucosa. The blister located closer to her right commissure was intact and tense. The bulla located on the left appeared to be broken. The lesions were affecting both intra-and extraoral mucosa, and the patient developed crusts on the external lip mucosa 3 days after this photograph was taken In the first 2 cases, lesions were affecting keratinized tissue, as seen in herpes simplex lesions (Scully & Samaranayake, 2016) . In the last case, oral lesions affected both keratinized and non-keratinized tissue and were more compatible with an erythema multiforme (Trayes, Love, & Studdiford, 2019; Schwartz & Janniger, 2020 ). As we were not able to perform biopsies, further studies need to be carried out in order to determine whether oral manifestations are common in patients affected by SARS-CoV-2 infection or if the emotional distress of the situation itself could trigger such lesions (Suzich & Cliffe, 2018; Chida & Mao, 2009) . It is important to mention that the 3 cases all reported having had pain, oral ulcers, or blisters before seeking medical advice. We suspect that intraoral lesions often are misdiagnosed due to the lack of intraoral examinations, considering the severity of other pathological processes that might concur with this viral infection. To the best of our knowledge, this is the first case report of a COVID-19 patient presenting intraoral manifestations. We encourage all medical doctors, dentists, and dermatologists to perform intraoral examinations in patients suspected or affected by SARS-CoV-2, always when having the recommended protection measures available. We would like to thank Dr. Diego Fernández-Nieto, dermatologist at Ramón y Cajal Hospital (Madrid), for sharing with us the anatomopathological result of the skin biopsy of patient number 3, and Fuensanta Martín and Dr. Helene Alseth-Alvarado for their reviews and comments. None to declare. Enric Jané-Salas https://orcid.org/0000-0002-3574-4603 Coronavirus: The geriatric emergency of 2020. 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