Overlapping findings or oral manifestations in new SARS-CoV-2 infection.

Dear Editor,

We have read the short communication “Oral vesiculobullous lesions associated with SARS‐CoV‐2 infection” (Martin Carreras‐Presas, Amaro Sanchez, Lopez‐Sanchez, Jane‐Salas, & Somacarrera Perez, 2020) by Dr. Martín Carreras‐Presas et al. with great interest. We congratulate the team for contributing to the knowledge about this devastating infection in such challenging times. However, we raise some concerns that must be addressed.

First, the diagnosis of COVID‐19 is difficult in mild cases once its signals and symptoms may resemble other infections. The non‐confirmed status of SARS‐CoV‐2 infection in the two first cases is worrisome once the oral lesions the patients presented are compatible with other frequent diseases.

Second, we detected several weaknesses in the diagnostic process as follows. In the first case, the authors state the lesions “resemble recurrent herpetic stomatitis; however, it was the first time the patient had them.” The primary infection by herpes simplex virus (HSV) may be subclinical (Crimi et al., 2019); thus, this not a reason to rule out HSV infection. Moreover, the other signals and symptoms the patient presented—compatible with an infection—may have led to an immunosuppressed state and potentially contributed to the reactivation of HSV. In the second case, the patient presented the classical clinical appearance of varicella zoster virus recurrent infection: multiple vesicles unilaterally spread at the route of the maxillary branch of the trigeminal nerve. In this case, the authors stated that “the patient did not have any previous history of herpetic infection.” However, zoster is the secondary infection of the varicella zoster virus. And, again, these first two patients did not have the diagnosis of COVID‐19 confirmed. In the third case, the patient developed oral lesions several days after hospital discharge and multiple drug therapy. Since some of the drugs are associated with oral manifestations (Israr et al., 2011), we raised the possibility that these lesions are more related to the drugs or immunosuppression driven by the drugs rather than to COVID‐19. Even traumatic injuries should be considered in the differential diagnosis.

Third, the authors affirmed that “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.” We add that the so‐called “oral manifestations” might actually be other overlapping diseases. And we strongly agree that further studies—or more detailed examination of the patients?—should be performed. Finally, the lesions the patients presented might be closely associated with distress (Crimi et al., 2019). Considering the patients were into a myriad of unusual situations (possibility of having COVID‐19, social isolation, potential loss of family or friends, and detriment in economic conditions), their mental status must be considered.

We understand the eagerness to understand how COVID‐19 can impact the oral cavity balance but very preliminary cases should be carefully analyzed before its publication. In times when the information is rapidly spread and often misinterpreted, we must provide accurate and complete data about the cases and findings we are broadcasting.

AUTHOR CONTRIBUTION

Jose Burgos Ponce: Conceptualization; Formal analysis; Writing‐original draft; Writing‐review & editing. Kellen Cristine Tjioe: Conceptualization; Data curation; Formal analysis; Writing‐original draft; Writing‐review & editing.