1.
Dear Editor,
Caused by SARS‐CoV‐2, the coronavirus disease 2019 (COVID‐19) is a potentially deadly coronavirus‐associated acute respiratory illness whose most common symptoms are cough, fever, fatigue, sputum production, and shortness of breath (Guan et al., 2020). Although only 0.2% of the 1,099 patients evaluated by Guan et al. (2020) developed cutaneous lesions, recent articles have reported relevant eruptive skin rash (i.e., exanthema) sometimes involving mucous membrane (i.e., enanthema) in COVID‐19 patients (Chaux‐Bodard, Deneuve, & Desoutter, 2020; Galván Casas et al., 2020; Martín Carreras‐Presas, Amaro Sánchez, López ‐Sánchez, Jané ‐Salas, & Somacarrera Pérez, 2020; Recalcati, 2020; Suchonwanit, Leerunyakul, & Kositkuljorn, 2020).
Recalcati (2020), for example, reported that 20.4% of 88 COVID‐19 patients presented cutaneous manifestations such as erythematous rash, generalized urticaria, and vesicles. They suggested that the skin lesions were similar to ones found in common viral diseases but emphasized that additional studies are necessary to confirm its association with COVID‐19. Other authors, after reviewing 18 articles reporting cutaneous lesions in COVID‐19 patients, suggested that the possible cutaneous manifestations of the virus may be classified into two groups—viral exanthema and vasculopathy‐related skin manifestation—but highlighted the possibility of secondary cutaneous reactions to treatment as well (Suchonwanit et al., 2020).
In a dermatological case collection survey of COVID‐19 patients, Galván Casas et al. (2020) classified the cutaneous manifestations in five clinical patterns: maculopapular eruptions, urticarial lesions, pseudo‐chilblains, other vesicular eruptions, and livedo or necrosis. The authors also reported that some patients presented other manifestations such as enanthema. In an atlas published as supplementary material, the authors presented the case of a patient with maculopapular eruption in the oral mucosa (i.e., enanthema) localized in the palate, palatal gingiva, lower buccal gingiva, and lower lip mucosa.
Oral manifestations of earlier coronavirus‐related diseases such as Middle East respiratory syndrome (MERS) are ill‐defined (Scully & Samaranayake, 2016). Concerning COVID‐19, to the best of our knowledge, only two reports specifically address oral enanthema. First, Martín Carreras‐Presas et al. (2020) described oral lesions in one confirmed and two suspected patients; the confirmed patient presented blisters in the internal lip mucosa, desquamative gingivitis, and widespread skin rash, while the other two cases presented painful palatal ulcers similar to herpetic lesions. Second, Chaux‐Bodard et al. (2020) reported an oral lesion as a possible inaugural symptom of COVID‐19 in a patient exhibiting painful inflammation of the tongue papillae on Day 1, which evolved into an erythematous macule and subsequently into an asymptomatic ulcer. An erythematous skin lesion developed on Day 3, and the positive diagnostic test was performed on Day 8.
In this context, when health professionals, especially dentists, are faced with enanthema in oral mucosa as a possible diagnostic challenge in the COVID‐19 pandemic, it is important to review some of the main viral diseases associated with oral enanthema, as illustrated in Table 1 (Castro & Ramos‐e‐Silva, 2020; Drago et al., 2017; Santosh & Muddana, 2020; Scully & Samaranayake, 2016). Such action is especially relevant in tropical countries such as Brazil, where other viral diseases are in endemic transmission.
Table 1.
Main viral diseases associated with oral enanthema
|
Viral disease |
Etiology | Oral enanthema | Additional signs and symptoms |
|---|---|---|---|
| Chikungunya a , b , d | Chikungunya virus | Aphthous‐like ulcers and oral lesions similar to Koplik's spots | Skin rash on face and arms and fever |
| Dengue fever a , b , d | Dengue virus (DENVs) | Gingival bleeding and gingival and lip swelling | Skin rash, fever, possible petechiae and purpura, myalgia, arthralgia, headache, nausea, and vomiting |
| Ebola virus disease b , d | Ebola virus | Gingival bleeding, white or red patches, aphthous‐like ulcers, and grayish exudative lesions | Skin rash, pain, epistaxis, bleeding, and conjunctivitis |
| Hand, foot, and mouth disease a | Echoviruses and coxsackievirus types A and B | Painful ulcers | Skin rash on hand and foot, fever, and malaise |
| Herpangina b | Coxsackievirus type A | Papulovesicular lesions in soft palate and tonsils | Fever, sore throat, vomiting, and backache |
| Herpes simplex infection b , c | HSV−1 and HSV−2 | Primary herpes simplex infection: vesicles, ulcers, and generalized gingivitis | Fever, malaise, nausea, headache, lymphadenopathy, and vomiting |
| Recurrent herpes simplex infections: vesicles or ulcers in lip vermilion and adjacent skin (i.e., recurrent herpes labialis) or in keratinized oral mucosa as palate or gingiva (i.e., recurrent intraoral herpes) | Local prodromal symptoms | ||
| Human immunodeficiency viruses b , d | HIV−1 and HIV−2 | Maculopapular lesions and painful oral ulcerations | Skin rash on the trunk, hand, and foot (associated with seroconversion) |
| Infectious mononucleosis b , c | Epstein–Barr virus (EBV) | Ulcers | Fever, lymphadenopathy, pharyngitis, cough, rhinitis, and hepatosplenomegaly |
| Measles a , b | Paramyxoviridae virus family | Koplik's spots (i.e., grayish‐white to erythematous papules typically seen on the buccal mucosa) | Fever, coryza, cough, conjunctivitis, and skin rash on the forehead, hairline, and postauricular area |
| Roseola infantum or exanthema subitum a , b | Human herpesvirus (HHV): HHV−6 or HHV−7 | Nagayama spots (i.e., erythematous papules involving the soft palate and uvula) | Skin rash starting on the trunk and spreading peripherally, periorbital edema, fever, cough, rhinorrhea, and diarrhea |
| Varicella‐zoster infection b , c | Varicella‐zoster virus (VZV) | Chickenpox infection: small, widespread blister‐like lesions | Skin rash starting on the trunk and spreading to the face and extremities, pruritus, fever, headache, pharyngitis, rhinitis, and anorexia |
|
Herpes zoster infection (i.e., shingles): Unilateral painful vesicular lesions in areas supplied by the trigeminal nerve |
Pruritus, paresthesia, postherpetic neuralgia, and the possibility of alveolar bone necrosis with tooth loss | ||
| Zika a , b | Zika virus | Ulcers | Skin rash, pruritus, prostration, headache, arthralgia, myalgia, non‐purulent conjunctivitis, and lumbar pain |
CONFLICT OF INTEREST
None to declare.
AUTHOR CONTRIBUTION
Breno Amaral Rocha: Conceptualization; Writing‐original draft. Giovanna Ribeiro Souto: Conceptualization; Writing‐original draft. SORAYA M C GROSSMANN: Conceptualization; Writing‐original draft. Maria Cássia Ferreira Aguiar: Conceptualization; Writing‐original draft. Bruno Augusto Benevenuto Benevenuto de Andrade: Conceptualization; Writing‐original draft. Mário Romañach: Conceptualization; Writing‐original draft. Martinho Campolina Rebello Horta: Conceptualization; Writing‐original draft.
ACKNOWLEDGEMENTS
This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior—Brazil (CAPES)—Finance Code 001. The authors are also grateful to the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) (437861/2018‐0) and the Fundação de Amparo à Pesquisa do Estado de Minas Gerais (FAPEMIG). BAR has a CAPES fellowship. MCRH is a research fellow of FAPEMIG (CDS‐PPM‐00653‐16).
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