INTRODUCTION

The coronavirus disease (COVID‐19), is an infectious disease caused by a newly discovered severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). Since the identification of this new airborne infectious microorganism (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]) in Wuhan, China, millions of cases have been diagnosed worldwide, with mortality rates ranging from 3% to 12%¹.

This disease has high virulence with human-to-human transmission, and an incubation period ranging from 2 to 14 days². The virus is resistant to standard defenses that do not appear to respond efficiently to inflammatory invasion and cytokine storm³. The clinical course of COVID-19 depends on the host immune response, and frequent symptoms include fever, headache, malaise, cough, dyspnea, loss of taste and smell; and other symptoms like diarrhea, abdominal pain, confusion, lymphopenia, and hemodynamic disorders have been described^{4, 5}. Lymphocytopenia and T-cell over-activation with reduction of an effective humoral/cellular immune response have been reported in COVID-19 patients⁶.

SARS-CoV-2 binds to the angiotensin-converting enzyme 2 (ACE2) receptor, which is detected in the cell membrane of numerous human organs and tissues, including the lungs, kidneys, liver, epithelial cells of the tongue and salivary glands, upper respiratory tract, nervous system, and skeletal muscle, among others^{7, 8}  

It has been reported that atypical manifestations could be in some cases the first and/or the only manifestations of this disease therefore, knowledge of early atypical symtoms can contribute to early diagnosis, then to control outbreaks, identifying early signs and symptoms of COVID-19 to speed-up self-isolation procedures⁹.

Since the oral health of COVID-19 patients can be affected by the infection, there is still doubt whether these manifestations could be a typical pattern resulting from the direct viral infection. Therefore, the range of COVID-19 manifestations in the oral cavity has broad and current interest. ⁹.  The aim  of this article it is to report a case of early oral manifestations in a COVID-19 patient and to highlight the importance of the early signs and symptoms of this disease.

CASE REPORT

A twenty-four-years-old male presented to the ED reporting the following symptoms: fever, chills, sore throat, muscle aches, pain with white and red patches and inflammation in his tongue  with 3 days of evolution. Patient reported living with his wife who was not having any symptom.  The patient was asked about symptoms of gustatory and olfactory disfunction, and he reported hypogeusia. In the medical history, the patient reported no significant medical history. The patient denied asthma, vomiting, just one episode of diahrrea, no history of herpes, or any other symptom. The clinical exam revealed,  tender cervical lymph nodes bilaterally.  Mild tachycardia with no murmurs, rubs or gallops. No evidence of respiratory distress was noted. The  patients lung exam was normal. Abdomen was not tender, no rebound, guarding, or rigidity. Oral examination revealed 1 cm shallow Aphthous-like ulcer well circumscribe circular with a whitish center and surrounded by an erythematous halo on lower lip just to right of midline (Figure 1), red and white patches located in the dorsum and medial of the tongue (Figure 2, 3, 4), tongue was diffusely erythematous and inflamed, midly tender to touch with a geographic pattern  (Figure 5, 6). Tonsils were 2 bilaterally erythematous with the presence of exudates. Inform consent to take intraoral photographs for further publication was signed by the patient. 

Figure 1

Aphthous-like ulcer well circumscribe circular with a whitish center and surrounded by an erythematous halo on lower lip just to right of midline

Figure 2

Red and white patches located in the dorsum and medial of the tongue.

Figure 3

Red and white patches located in the dorsum and medial of the tongue.

Figure 4

Red and white patches located in the dorsum and medial of the tongue.

Figure 5

Shows tongue diffusely erythematous and inflamed, with a geographic pattern.

Figure 6

Shows tongue diffusely erythematous and inflamed, with a geographic pattern.

 A nasopharyngeal swap  for rapid Strep A screen  was performed resulting Negative for Streptococcus A. Then the nasopharyngeal swab following reverse-transcription polymerase chain reaction (RT-PCR) for SARS-CoV-2 RNA amplification tested positive.

The systemic symptoms were treated with Acetaminophen 500 mg and Ibuprofen 600 mg and diphenhydramine HCI in suspension was established as an oral palliative intervention. The patient was discharged from the Emergency Department with instructions to follow the quarantine protocol at home.

DISCUSSION

Coronavirus disease (COVID-19) is an infectious disease capable of attacking various organs and presenting multiple manifestations. Just a few articles focused attention on oral clinical manifestations as one of the first signs and symptoms of the disease.

Recognition of disease signs and symptoms is critical for early detection, prompt treatment and hence better prognosis¹⁰.

This article decribed a case report of a patient with oral manifestations as the first sign of the disease. Thanks to the available literature of  reports of cases of patients with these manifestations, it was ordered a COVID-19 test with nasopharyngeal swab following reverse-transcription polymerase chain reaction (RT-PCR) for SARS-CoV-2 RNA amplification, which tested positive.

Cruz Tapia et al¹¹, reported four patients with angina bullosa hemorragica-like lesion, vascular disorder, and nonspecific stomatitis, one patient with histological analysis demonstrated perivascular reactive lymphocitic infliltrate, focal capillary thrombosis, and hemorrhage. All cases were dignosed with COVID-19 disease and confirmed by polymerase chain reaction (PCR). 

Martín Carreras-Presas et al¹²,  reported three cases associated with COVID-19: 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. It is important to mention that the 3 cases all reported having had pain, oral ulcers, or blisters before seeking medical advice. It was suspected 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.

Corchuelo J, et al¹³, reported a case of oral clinical manifestations of an asymptomatic patient with COVID-19 evaluated by teleconsultation between the cities of New York and Cali.

Amorism dos Santos J. et al⁹ reported a case of oral lesions in a patient diagnosed with COVID-19 who presented oral manifestations such as recurrent herpes simplex, candidiasis, and geographic tongue.  They also reported that the oral conditions presented by their patient supports the hypothesis that they are highly suggestive of secondary lesions resulting from the deterioration of systemic health or due to treatments for COVID-19.  Unlike our case,  where the patient reported pain and swelling of the tongue in the fisrt 24 hrs of the onset of symptoms.

Some of the oral manifestations reported in the literature including dysgeusia, petechiae, candidiasis, traumatic ulcers, HSV-1 infection, geographical tongue, thrush-like ulcers, among others. Moreover, further studies are highly recommended to evaluate the oral manifestations in patients with COVID-19. In conclusion, as  health care provider we should be alert of the oral clinical manifestation in our patients, to be able to identify early oral signs and symptoms of COVID-19, to control the spread of this deadly disease.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.