Multiple oral ulcerations - An initial manifestation of COVID 19 infection: A personal experience!!

Sir,

Since the fag end of the year 2019, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused the COVID-19 infection, which has taken a gruesome face and transformed itself into a pandemic affecting the worldwide population.[1] The COVID-19 epidemic has resulted in serious threats to overall health and general well being, causing serious psychological tribulations such as stress, insomnia, anxiety and depressive psychosis.[2]

In terms of clinical symptoms, Coronavirus disease is associated with a variable inflammatory reaction that can induce vascular inflammation.[3] According to the CDC, people may start experiencing symptoms 2–14 days after exposure to the virus. Patients may report with various symptoms such as fever, cough, shortness of breath or difficulty in breathing, sore throat, congestion or a runny nose, fatigue, headache and muscle pain. Adding to this broad list of symptoms, loss of smell and taste in the early phases of the infection could also enable us to identify 87.5% of symptomatic COVID-19 cases.[4]

Anne-Gaëlle et al. have also reported a case of a 45-year-old female patient who presented with an irregular ulcer on the dorsal side of the tongue. The brief history of the lesion revealed painful inflammation of her tongue papilla followed by an erythematous macular discoloration, which eventually evolved into an irregular and asymptomatic ulcer.[5]

Here, I report a personal experience of two such small well-circumscribed ulcers in my oral cavity, which I perceive could be an initial manifestation of the coronavirus disease process.

My test results for COVID 19 swabs came positive on the “D” day. I started developing symptoms of mild fever (about 100° F) 2–3 days prior to my test day i.e., “D-2.” About 2 days before the onset of symptoms, I experienced severe burning and itching sensation on the left side of my oral cavity. Two small 0.5 mm × 0.5 mm ulcer had developed one at lower left labial mucosa and another at the left ventral surface of the tongue [Figures 1 and 2]. The ulcers were shallow, round to oval in shape, painful and surrounded by an inflammatory halo, similar to any known ulcer that develops as a consequence of viral infection. However, similar to a Herpes Zoster infection (HZI), my ulcers also showed unilateral distribution, sparing the right side of my oral cavity [Figure 3]. Oral lesions in HZI occur mostly in the movable mucosa extending up to the midline and are seen to occur along with skin lesions. Lesions in HZI manifest as 1–4 mm, white, opaque vesicles that rupture to form shallow ulcerations, a finding similar to my clinical picture.[6] It could have been quite interesting to conduct a swab culture from my surface oral ulcerations and check whether the lesions belonged to a SARS-COV-2 or VZV DNA source of HZI!! In contrast to the case reported by Anne-Gaëlle et al., my ulcers were extremely painful, which also disturbed my swallowing also.[5] However, as reported by Anne-Gaëlle et al., my intraoral ulcers started to heal after about 10 days from the time of onset of my initial symptoms [Figures 4 and 5].

Figure 1

Irregular ulcer with erythematous halo on the lower left labial mucosa

Figure 2

Well-circumscribed ulcer on the left antero-ventral surface of tongue

Figure 3

Right side of the tongue and oral cavity seemingly uninvolved

Figure 4

Healing ulcer from the labial mucosa after about 10 days its onset

Figure 5

Complete uneventful healing of the tongue ulcer after about a week of its onset

I have penned down this communication at a time when I am still hospitalized because of this COVID 19 infection. Fortunately, I have been asymptomatic since the time I have been admitted. As I have been relatively asymptomatic, the prescription of tablet hydroxychloroquine or tablet remdesivir was thankfully not rendered. The only thing I ensure is the daily practice of regular betadine gargling and frequent sips of warm water, apart from the doses of ascorbic acid and zinc supplements.

I hope this communication will be beneficial for all the readers, such as to briefly acquaint them with a few of the initial signs and symptoms that a suspected patient of COVID 19 infection can possibly experience and corrective remedial measures that can be undertaken during the period of hospitalization.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.