A 31-year-old man comes to the office due to oral lesions that cause occasional discomfort during eating. He also reports fatigue and unintentional weight loss. The patient has no prior medical problems and takes no medications. Oral examination findings are shown below.
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The lesions can be easily scraped off, revealing erythematous mucosa underneath. There are several enlarged cervical and axillary lymph nodes. Which of the following diagnostic tests is most appropriate during further workup of this patient?
Thrush is an oropharyngeal Candida albicans infection that usually presents with creamy white, plaque-like lesions on the buccal mucosa, palate, tongue, or pharynx. The lesions can be easily scraped off with a tongue depressor, revealing underlying erythematous mucosa. The diagnosis is often made clinically, but microscopic examination will reveal budding yeasts with or without pseudohyphae.
Candida albicans is a normal commensal of the human digestive tract that can cause mucocutaneous infections when local microbial flora is disrupted (eg, antibiotic use) or the cell-mediated immune response is impaired. Although Candida infections of the skin (eg, diaper rash) and vulvovaginal region often occur in otherwise healthy individuals, oropharyngeal infection is rare in the absence of antibiotics, chemotherapy, or inhaled corticosteroids. Young, healthy individuals who develop thrush and have no clear inciting cause should be tested for HIV, particularly when HIV risk factors (eg, multiple sexual partners) or symptoms of the virus (eg, lymphadenopathy, weight loss) are present. A fourth-generation HIV antigen/antibody test is typically used for screening.
(Choice B) Leukoplakia is a benign lesion of the tongue caused by hyperplasia of the squamous mucosa that can evolve into dysplasia → carcinoma in situ → invasive carcinoma. Leukoplakia appears as white patches or plaques on the oral mucosa. However, these lesions cannot be easily removed with scraping (unlike thrush).
(Choice C) Coxsackievirus causes herpangina, which is usually seen in infants and children. It is characterized by high fever, sore throat, and yellowish or grey-white papulovesicular lesions on the throat (tongue lesions are rare). Coxsackievirus also causes hand, foot, and mouth disease, which is characterized by tongue macules, vesicles, and ulcers. However, it is also usually associated with a vesicular or macular skin rash.
(Choice D) Microscopy of herpes simplex virus (HSV) lesions will reveal multinucleated giant cells. HSV usually causes multiple vesicular lesions on an erythematous base, not white mucosal plaques.
(Choice E) Atrophic glossitis can be caused by vitamin B12 or folate deficiency. It is characterized by atrophy of the filiform papillae leading to a smooth, glossy, erythematous tongue.
Educational objective:
Oral thrush is caused by Candida albicans infection and usually presents as white, plaque-like oropharyngeal lesions that are easily scraped off with a tongue depressor. Affected patients typically have disruption to local microbial flora (eg, antibiotic use) or impairment in cell-mediated immunity (eg, corticosteroids, HIV). Young, otherwise healthy patients with thrush should be tested for HIV.