Involvement Of Oral Cavity Research Articles

Geographic Stomatitis with Multiple Areas Involvement of Oral Cavity: A Case Report and Review of Literatures

Background: Geographic stomatitis is an uncommon migratory benign lesion of oral mucosa with unknown etiology. It can affect all the areas of the oral mucosa, but the dorsum and lateral borders of the tongue are the most commonly involved areas called geographic tongue. The clinical appearance of this condition is the oval or circular erythematous areas with irregular elevated keratotic borders. These characteristic features of geographic stomatitis are diagnostic for all clinicians when appearing on the dorsum of the tongue, despite other affected areas of oral mucosa that can confuse clinicians. This condition may be associated with some diseases such as psoriasis, Reiter’s syndrome, and atopic conditions, so the clinicians should rule out these diseases and diagnose the geographic stomatitis. Case Report: A 17-year-old male attended to our department for a routine dentistry checkup. During the intraoral examination, we found multiple erythematous areas surrounded by a thin white border on different surfaces of his oral cavity. His extraoral examinations were completely normal. Conclusion: Due to the rarity of this lesion on the other sites of oral mucosa rather than dorsum and lateral borders of the tongue such as labial mucosa, buccal mucosa, the floor of the mouth, ventral surface of the tongue, and palate, it is necessary to report, study and evaluate each case of this condition that clinicopathologic findings have confirmed this diagnosis, to treat and advice these patients on the best approach. [GMJ.2021;10:e2071]

1790. Characteristics of Patients with Mpox Treated with Tecovirimat during the 2022 Outbreak in Puerto Rico

Abstract Background In June 2022, the first case of Mpox, was diagnosed in Puerto Rico, followed by a sharp increase in cases that peaked in August 2022. In total, 108 cases were confirmed during this period. Throughout this time period, Tecovirimat (Tpoxx) was already available upon request to the Puerto Rico Department of Health (PRDoH). In this report we aim to describe the clinical characteristics and outcomes of all the patients in Puerto Rico who received Tecovirimat. Methods A cross sectional study was conducted to describe clinical and epidemiological profile of Mpox patients who received Tecovirimat. We use the data collected from our institution (PRDoH), who was responsible for the approval, delivery and monitoring of Tecovirimat prescription during the outbreak. The analysis period ranges from August 2022 to November 2022. Univariate analysis was conducted, including the median and percentage, to provide a summary of the distribution of the variables of interest. Results We present the clinical characteristics of 27 male patients who received Tecovirimat for a diagnosis of Mpox during the outbreak in Puerto Rico. Most patients were treated during August and September (85%), followed by October and November 2022 (15%). Most received treatment in outpatient settings at private clinics (63%) followed by government clinics (37%). Of the patients that required Tecovirimat, 67% had human immunodeficiency virus (HIV) and the median age was 32 years. Prior immunization with smallpox vaccine was reported by two patients, while 70% were not immunized and the immunization status of 22% was unknown. The most common indications for Tecovirimat prescription were genital structure involvement (67%), severe pain (37%), oral cavity involvement (22%), proctitis (19%), and immunosuppression (11%). Only two patients received Tecovirimat while admitted to an acute care setting. No severe adverse events or deaths were reported among these patients, and there were no suspected cases of Tecovirimat resistance. Conclusion This study provides relevant clinical information on the use of Tecovirimat in patients with Mpox during the outbreak in Puerto Rico. These findings may have important implications for the clinical management of future outbreaks of Mpox and other related infections. Disclosures Iris Cardona Gerena, MD, Valneva: Honoraria

Disseminated cysticercosis with tongue involvement: a rare case report from Nepal

Introduction and importance: Cysticercosis is a condition in which humans are infected by the larval form of the pork tapeworm Tenia solium. Cysticercosis in humans is common in the cerebral tissue but rare in the tongue. Case presentation: Here, the authors report a rare case of a 38-year-old male with neurocysticercosis and cysticercosis of the tongue. The patient presented with a complaint of loss of consciousness for 4–5 min. Local examination of his oral cavity revealed a swelling of ~2×2 cm on the tongue. An MRI of the brain showed various stages of neurocysticercosis involving the neuroparenchyma and tongue. For this, he was started on low-dose prednisolone of 50 mg tapered over 6 weeks and levetiracetam of 500 mg BD continued for his seizure episodes. He is responding well with the medications and is planned to start antiparasitic agent only after the perilesional edema decreases. Clinical discussion: Cysticercosis may involve the central nervous system, muscle, heart, lungs, peritoneum, eye, and subcutaneous tissue. Oral cavity and perioral involvement by cysticercous larva is rare in humans. Radiologic imaging, serology, and tissue biopsy can be used to confirm a diagnosis of cysticercosis. The most common locations for oral cysticercosis are the tongue, buccal mucosa, lower lip, and upper lip. Only 102 cases of oral cysticercosis have been reported based on a PubMed English-language literature search. Conclusion: Oral cysticercosis is a rare event, and it represents a difficulty in clinical diagnosis. But a patient with a mass in the tongue should be considered as a possible case of cysticercosis especially in endemic regions like Nepal.

Pesquisa documental dos aspectos clínicos e epidemiológicos do linfoma em cães atendidos na Universidade Federal Rural do Rio de Janeiro

Lymphomas, malignant neoplasms that originate in the lymphocytes, have a high incidence in domestic animals. This paper aimed to describe the clinical and epidemiological findings of 200 cases of canine lymphoma evaluated over nine years (2011–2019) at the Oncology Service of the Veterinary Hospital at The Federal Rural University of Rio de Janeiro. A majority of mixed-breed canines (84/200-42%) were observed, followed by the Labrador Retriever, Pitbull, and Rottweiler with similar incidence (15/200-7.5%). The average age was 7.7 years and the most affected canines were aged approximately 3 and 11 years old (146/200-73%). As for the anatomical classification, the cases classified as multicentric (131/200-65,5%) were the most common, followed by cases of the cutaneous form (44/200-22%), alimentary form (7/200 - 3.5%), mediastinal form (5/200-2.5%), and extranodal form (16/200-6,5%). Among extranodal cases were described cases of ocular involvement (5/200-2.5%), oral cavity involvement (4/200-2%), cardiac involvement (3/200-1.5%), and pulmonary involvement (1/200-0.5%). The clinical manifestation observed was related to the affected region in the different anatomical forms. More studies of this nature are needed to profile the disease presentation and contribute to clinical identification and diagnosis.

Primary Extranodal Non-Hodgkin Lymphoma of Cheek

Non-Hodgkin’s lymphomas (NHL) comprise a group of extremely diverse lymphoproliferative neoplamas that have a predisposition for extranodal sites. Amongst the extranodal locations rare involvement of oral cavity has been reported and occurrence of these neoplasms on the cheek are thin on the ground. The most commonly encountered is the Diffuse large B-cell lymphoma. The B-cell neoplasms are clonal tumors of mature and immature B cells and the relatedness of B-cell lymphomas to normal B-cell counterparts forms a key aspect in their nomenclature of classification. Diffuse large B-cell lymphoma, not otherwise specified (DLBCL, NOS), consists of medium-sized to large B cells with a diffuse growth pattern. This lesion is a morphologically and molecularly heterogeneous entity which does not meet the diagnostic criteria of any specific large B-cell lymphoma neoplasms. Amongst the cases of DLBCL in n the head and neck region involvement of cheek/ buccal mucosa is scarce.

Palatal manifestations of Langerhan cell histicytosis in pediatric age: a case report with review of literature

Langerhans cell histiocytosis (LCH) is characterised by multisystem disorder with various entities grouped together under same name. Oral cavity manifestations of this disease is yet to be explored. In oral cavity it can present with ulceration, swelling or osteolysis of underlying bone. Oral cavity involvement due to LCH might confuse the examining doctor resulting in misdiagnosis of such dreadful disease. So here we are reporting a case of LCH in a 4 years old female presented to us with ulceration over hard palate mucosa. Biopsy was taken from the ulcer site which was positive for LCH. On further examination and evaluation of the patient multisystem involvement was found with involvement of skull bone.

Erosive and ulcerative stomatitis in dogs and cats: which immune-mediated diseases to consider?

Immune-mediated and autoimmune diseases of the skin often present with oral cavity involvement. Autoimmune subepidermal blistering diseases and pemphigus vulgaris are classic examples. While the primary lesions (vesicles and bullae) are relatively specific, these fragile lesions evolve rapidly into erosions and ulcers, which are lesion types that overlap with many diseases. Furthermore, some immune-mediated diseases such as severe adverse drug reactions, lupus diseases, canine uveodermatological syndrome, and vasculitis, may or may not involve the oral cavity, and often nonoral clinical manifestations are more diagnostic. In these situations, disease knowledge combined with signalment, lesion distribution, and history help to narrow the differentials. Surgical biopsy is required for confirmation in most diseases, while immunosuppressive treatments most typically involve glucocorticoids with or without nonsteroidal immunosuppressants.

Tuberculous osteomyelitis in body of mandible: A case report

Tuberculosis is chronic infectious disease and major cause of morbidity and mortality worldwide. It can affect any part of body, including oral cavity. Oral lesions of tuberculosis, though uncommon, have been observed in both primary and secondary stages of disease. This article presents case of tuberculosis in oral mucosa and mandible in 45 years old female. Involvement of oral cavity in TB is quite rare. Oral lesions seem to occur as chronic ulcers, nodular or granular areas. Most extra-pulmonary lesions represent secondary infections of primary lung infectious focus; therefore, early and accurate diagnosis is required for planning of best treatment and strategies to control disease.

Photogallery of diseases of the oral mucosa. Part I

Nowadays, more than 300 diseases of the oral mucosa have been established in the scientific literature. Since pemphigus vulgaris and lichen planus can mimic many other skin conditions it could be difficult to make the diagnosis according only to clinical features. Moreover, pemphigus vulgaris is known to be an autoimmune life-threatening disorder which necessarily need to be treated with high doses of systemic glucocorticoids, whereas lichen planus in some cases can be transformed into squamous cell carcinoma.
 The drug associated erythema and the herpes associated erythema multiforme both affect not only the oral mucosa but also the skin, which makes differential diagnosis easier. Nevertheless, in our practice we can encounter only the oral cavity involvement. Previously, StevensJohnson syndrome was considered as severe form of erythema multiforme affecting both the skin and the oral mucosa.
 Additionally, cheilitis can be observed in patients with atopic dermatitis even in the remission stage.
 Furthermore, MelkerssonRosenthal syndrome is a rare neurological disorder characterized by recurring facial paralysis, swelling of the face and lips, and the development of folds and furrows in the tongue.

Capnocytophaga sputigena Bacteremia in an Immunocompromised Child, When to Suspect? A Case Report and Review of the Literature

Background Within febrile neutropenic episodes, bacteremia is the most frequent cause. Capnocytophaga species bacteremia represents less than 3% of all etiologies, being an uncommon agent. Only a few pediatric cases have been reported in the literature. Case Presentation A 6-year-old male patient was diagnosed with acute lymphoblastic leukemia and a bone marrow relapse. He was admitted to our institution with an episode of febrile neutropenia with grade II mucositis. A nonhemolytic gram-negative rod was isolated from a blood culture, with gray colonies in blood agar at 48 hours of incubation. Capnocytophaga sputigena was identified by matrix-assisted laser desorption/ionization and time of flight. The patient was successfully treated with imipenem-cilastatin for 10 days. Conclusions Although this pathogen is uncommon, Capnocytophaga species bacteremia should be suspected as a causal agent in immunocompromised patients, particularly in cases of febrile neutropenia with oral cavity involvement.

Rhino-orbital mucormycosis with palatal involvement: series of four cases

<p class="abstract"><span lang="EN-US">Mucormycosis (Zygomycosis) is a rare, opportunistic fungal infection caused by mucorales.­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­ The clinical hallmark of invasive mucormycosis is angioinvasion and subsequent thrombosis. Palate is the least common site and ulceration with palatal perforation is late occurrence. Involvement of oral cavity usually appears as palatal ulceration or necrosis with denudation of bone and later perforation of palate. In our cases, the patients had both debilitating conditions resulting from poorly controlled diabetes and acute inflammatory immune response due to COVID-19 infection. Radiographically opacification of sinuses may be observed in conjunction with patchy effacement of bony walls of sinuses. Potassium hydroxide smear of lesion can reveal non septate fungal hyphae. Culture on sabouraud’s dextrose agar is preferred but histopathological examination of biopsy specimen is conclusive. Successful treatment of mucormycosis consists of rapid diagnosis of the condition followed by radical surgical debridement of infected necrotic tissue with systemic administration of antifungal drugs. Mucormycosis, along with other deep fungal infections, should be considered as an important outcome of SARS-CoV-2 infection.</span></p>

Predictors of Infection and Benefit of Antibiotics in Gunshot Wounds to the Face.

Gunshot wounds (GSWs) to the face are at high risk for infection due the extent of tissue injury and often-observed violation of oral and sinus cavities. Given the ambiguous data on antibiotic benefit in GSW to the face, the purpose of this study is to characterize antibiotic usage, infection details, and risk factors associated with higher infection rates in GSW to face. We conducted a retrospective review of patients presenting with GSW to the face from 2009 to 2017. The primary outcome was to identify risk factors associated with infections in patients with facial GSWs. A stepwise multivariate linear regression analysis was performed to determine the impact of specific injury details. Two hundred sixty-nine patients qualified for the study. Demographic information and details of hospital stay are presented in tables. Most patients (88.8%) received admission antibiotics. Facial infections were observed in 36 patients (13.4%). The infected cohort required more antibiotic days (P < 0.001), higher percentage of invasive airway procedures (P = 0.01), longer length of stay (P < 0.001), greater number of surgeries (P < 0.022), and higher readmission rates (P < 0.001). Factors associated with head or neck infections included oral cavity (odds ratio, 1.23; P = 0.04) and sinus involvement (odds ratio, 1.10; P = 0.045). Bullet trajectories that violated the oral or maxillary sinus cavities were associated with higher head and neck infection rates. Patients without oral cavity or sinus involvement had a lower chance (4.1%) of developing an infection and therefore may have marginal benefit from antibiotics.

Clinicopathological Features and Mortality in Patients With Kaposi Sarcoma and HIV: A Retrospective Analysis of a Thirty-Year Study From a Peruvian Oncologic Center.

PURPOSEKaposi's sarcoma (KS) is a multifocal angioproliferative disease. In Peru, the implementation of the highly active antiretroviral treatment (HAART) program was in 2005, the model for treating patients with HIV-positive KS shifted to a potential cure. In this study, we aim to compare clinicopathological characteristics and prognostic factors associated with outcomes in patients with HIV-positive KS.METHODSWe developed a retrospective cohort study that includes patients with HIV/AIDS and KS seen in the Instituto Nacional de Enfermedades Neoplasicas between 1987 and 2017. Patients were divided into two groups according to the implementation of HAART in our country: the non-HAART group and those treated with HAART after 2005. Multivariate analysis for overall survival (OS) was performed with the Cox proportional hazard regression model.RESULTSThere was a greater visceral compromise and more extensive oral cavity involvement in the non-HAART group (60% 31.7%, P < .01). Regarding the immune status, there was a significant difference from the CD4 count at 1-year follow-up (73 v 335, P = .01). The CD4/CD8 rate were significant different before QT (0.23 v 0.13, P = .01) and at 1-year follow-up (0.12 v 0.32, P = .03.). The estimated 5-year OS rate was significantly lower (P = .0001) for the non-HAART group (41.7%; 95% CI, 25.9 to 56.9) compared with the HAART group (79.3%; 95% CI, 66.8 to 87.5). In the multivariate model for OS, full-HAART regimen and previous diagnosis of HIV/AIDS (P < .01) were significantly associated with longer survival.CONCLUSIONClinical and demographic characteristics of our patients are compatible with the literature, but we report a higher rate of gastrointestinal involvement. Furthermore, our findings provide evidence for the importance of HAART and its ability to reduce KS-related mortality.

A Malignant Lymphoma Presenting as a Non-healing Oral Ulcer

Lymphomas are the second most common non-epithelial malignant tumour in the oral and maxillofacial region. Non-Hodgkin lymphoma (NHL) is more frequently diagnosed eventhough oral cavity involvement is less than 4% of all NHLs. Usually, the oral manifestation of NHL is secondary to the widespread involvement. Primary oral NHL is relatively rare and difficult to diagnose in clinical setting as it presents as local swelling, pain, discomfort and mimics pyogenic granuloma, periodontal disease, osteomyelitis and other malignancies. A chronic, solitary non-healing ulcerative lesion of the oral mucosa is often misdiagnosed as non-neoplastic especially in a previously healthy young adult. Here, we share a case of extranodal diffuse large B-cell lymphoma of the soft palate, in a 22-year-old healthy gentleman with no other symptoms. Meticulous clinical evaluation and complete investigations are required for prompt diagnosis, timely treatment which carries betterprognosis.

Recurring oral erythema multiforme-like lesions elicited by COVID-19 infection: a case report

Oral mucosa could be the first site infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) –thecausative agent of coronavirus disease 2019 (COVID-19). Indeed, different oral and paraoral lesions, conditionsand symptoms have been reported in patients with COVID-19. Experts thought that such oral lesions could besecondary to the COVID-19-associated deterioration of systemic health or due to treatments of COVID-19. Wepresent here a case of a 24-year-old male presented with painful multiple ulcers involving the labial and buccalmucosae bilaterally after a while of feeling very mild symptoms that laboratory-confirmed by reverse-transcriptionpolymerase chain reaction to be COVID-19. Involvement of eyes was also reported. The above clinical presentationwas consistent with minor erythema multiform. Many topical preparations were prescribed but with limitedimprovement. Hence, oral prednisolone was prescribed with a 40-mg loading dose that was tapered by 10 mgevery 3 days. Complete healing of oral mucosa was observed on the 10 day. Strikingly, the patient got affectedwith the second episode of similar oral lesions 5 months later without any apparent triggering factors, suggestivea long term effects of COVID-19 in a subset of patients. The present case report provides dentists with usefulinformation and increases their awareness regarding possible involvement of oral cavity with multiple ulcerativelesions associated with COVID-19. KEYWORDSOral erythema multiforme; Oral manifestations; COVID-19; Case report.

Geographic Stomatitis with Multiple Areas Involvement of Oral Cavity: A Case Report and Review of Literatures.

Background:Geographic stomatitis is an uncommon migratory benign lesion of oral mucosa with unknown etiology. It can affect all the areas of the oral mucosa, but the dorsum and lateral borders of the tongue are the most commonly involved areas called geographic tongue. The clinical appearance of this condition is the oval or circular erythematous areas with irregular elevated keratotic borders. These characteristic features of geographic stomatitis are diagnostic for all clinicians when appearing on the dorsum of the tongue, despite other affected areas of oral mucosa that can confuse clinicians. This condition may be associated with some diseases such as psoriasis, Reiter’s syndrome, and atopic conditions, so the clinicians should rule out these diseases and diagnose the geographic stomatitis.Case Report:A 17-year-old male attended to our department for a routine dentistry checkup. During the intraoral examination, we found multiple erythematous areas surrounded by a thin white border on different surfaces of his oral cavity. His extraoral examinations were completely normal.Conclusion:Due to the rarity of this lesion on the other sites of oral mucosa rather than dorsum and lateral borders of the tongue such as labial mucosa, buccal mucosa, the floor of the mouth, ventral surface of the tongue, and palate, it is necessary to report, study and evaluate each case of this condition that clinicopathologic findings have confirmed this diagnosis, to treat and advice these patients on the best approach.

Evaluating the Rationality of the International Guideline's Recommendations Regarding Selective Coverage of Level Ib in Node Clinical Target Volume With Nasopharyngeal Carcinoma: Results From a Real-World Series

<h3>Purpose/Objective(s)</h3> Although the International Guideline for the delineation of clinical target volume (CTV) in nasopharyngeal carcinoma (NPC) patients has provided practical reference for the elective coverage of level 1b, there are marked variations in practice among different institutions, and the rationality of the recommendations remained proven. The purpose of this study was to evaluate its rationality in real-world data and provide clinical evidence for the refinement of nodal CTV delineation in nasopharyngeal carcinoma (NPC). <h3>Materials/Methods</h3> Patients with histologically-proven NPC who received definitive Intensity-modulated radiation therapy (IMRT) with or without chemotherapy at Dr. SJ Lin's attending group in our institution between June 2005 and December 2012 were candidates for this retrospectively study. Other main eligible criteria including the following five situations: 1) level Ib metastasis;2)involvement of the submandibular gland;3) involvement of structures that drain to level Ib as the first echelon site (the oral cavity, anterior half of nasal cavity involvement);4) involvement of level II LNs with extracapsular extension (ECE); 5) level II nodal involvement with maximum nodal axial diameter (MAD) greater than 2 cm. Survival outcomes focused on regional recurrence-free survival (RRFS) and incidence rate of Ib recurrence were analyzed. <h3>Results</h3> A total of 451 patients were finally included according to the above criteria. There were 27, 37, 6, 12, 285 and 414 cases be classified as level Ib metastasis, submandibular gland involvement, oral cavity involvement, anterior half of nasal cavity involvement, level II LNs involvement with ECE and level II nodal involvement with MAD greater than 2 cm, respectively. Among these 451 patients, 60 patients received level Ib-covering IMRT due to the first three principles of the International Guideline according to our attending group's protocol. Of note, patients who had Ib involvement would receive ultrasound guided puncture, only those who had positive pathological results would undergo Ib-covering IMRT in our attending group. For the remaining 391 patients who only fulfilled the last two criteria and/or Ib involvement with negative pathological results, they all received level Ib-sparing IMRT, reported 6-year RRFS was 94.3%. For the 22 patients who had regional recurrence at censorship, only 3 (3/391, 0.78%) were recorded as Ib recurrence. <h3>Conclusion</h3> Level Ib-sparing IMRT should be safe and feasible for patients who only had involvement of level II LNs with ECE, and/or had a MAD of greater than 2 cm in level II LNs, and/or Ib involvement with negative pathological results. Further well-designed multi-center prospective trials should be conducted to confirm our results.

Frequent and Persistent Salivary Gland Ectasia and Oral Disease After COVID-19

The clinical picture of coronavirus disease 2019 (COVID-19) in various target organs has been extensively studied and described. However, relatively little is known about the characteristics of oral cavity involvement. This is surprising, considering that oral mucosal and salivary gland cells are known targets for the direct replication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and that the presence of the virus in saliva is a source of transmission of the infection. The aim of our study was to investigate the presence and prevalence of oral manifestations in COVID-19 survivors. We profiled the oral involvement in 122 COVID-19 survivors that were hospitalized and followed up at a single-referral university hospital in Milan, Italy, between July 23, 2020 and September 7, 2020, after a median (interquartile range) time from hospital discharge of 104 (95 to 132) d. We found that oral manifestations, specifically salivary gland ectasia, were unexpectedly common, with oral manifestations being detected in 83.9% while salivary gland ectasia in 43% of COVID-19 survivors. Salivary gland ectasia reflected the hyperinflammatory response to SARS-CoV-2, as demonstrated by the significant relationship with C-reactive protein (CRP) and lactate dehydrogenase (LDH) levels at hospital admission, and with the use of antibiotics during acute disease. Both LDH levels and antibiotic administration survived as independent predictors of salivary gland ectasia at multivariable analysis. Temporomandibular joint abnormalities, facial pain, and masticatory muscle weakness were also common. Overall, this retrospective and prospective cohort study of COVID-19 survivors revealed that residual damage of the oral cavity persists in the vast majority of patients far beyond clinical recovery, and suggests that the oral cavity represents a preferential target for SARS-CoV-2 infection. Further studies are needed to clarify the connection between SARS-CoV-2 infection and oral disorders.

17033 Morphologically discordant Stevens-Johnson syndrome in a geriatric patient

A 90-year-old man was hospitalized for pubic symphysis osteomyelitis when he developed a tender, pruritic, erythematous eruption on the chest on hospital day 3. The eruption progressed to the back and extremities by day 4 when dermatology was consulted. Recent medications included cephalexin and piperacillin/tazobactam started 39 days and 3 days before onset, respectively. Notably, the patient had used each in the past uneventfully. Initial physical exam revealed coalescent erythematous macules on the neck, trunk, upper extremities, and proximal thighs with confluent erythema on the back. Nikolsky sign was positive. Desquamation of the lower lip was noted without oral cavity involvement. There were no bullae nor erosions. The patient was afebrile and had right axillary lymphadenopathy. Labs demonstrated transaminitis and eosinophilia. Shave biopsy of the right shoulder showed full thickness epidermal necrosis, consistent with Stevens-Johnson syndrome (SJS). Piperacillin/tazobactam was discontinued and the patient was treated with intravenous immunoglobulin with eventual full recovery from partial sloughing of skin on his back. Excluding mild denudation of the lip and a positive Nikolsky sign, initial presentation showed no classic features of SJS. Furthermore, the typical onset of SJS is 5-28 days after initiation of a new medication; our patient’s two antibiotics were started outside of this timeline. Our initial concern for SJS was further decreased by the uneventful past use of each antibiotic. While the incidence and mortality rates of SJS in elderly patients are higher, the tendency of this population to display atypical features is unclear and warrants further investigation.

Herpes zoster of the trigeminal nerve with multi-dermatomal involvement: a case report of an unusual presentation

BackgroundHerpes zoster, also known as shingles, results from reactivation of the varicella-zoster virus. It commonly presents with burning pain and vesicular lesions with unilateral distribution and affects the thoracic and cervical sites in up to 60 and 20% of cases, respectively. The branches of the trigeminal nerves are affected in up to 20% of cases. Multidermatomal involvement of the trigeminal nerves has been only anecdotally described in immunocompetent subjects.Case presentationA 71-year-old previously healthy male presented with grouped vesicular and impetiginized lesions with crusts on the left half of the face of two-weeks duration. The lesions first developed on the left nasal tip and progressively worsened with unilateral appearance of vesicular lesions on the left forehead, face, ala nasi, nasal vestibulum and columella, as well as on the left side of hard and soft palate. The affected edematous erythematous areas corresponded to the distribution of the left ophthalmic (V1) and maxillary (V2) branches of the trigeminal nerve, including the infraorbital and nasopalatine nerves of the maxillary branch responsible for the oral cavity involvement. Viral DNA amplification by polymerase chain reaction confirmed the presence of Varicella zoster virus. The patient was started on oral valaciclovir with rapid recovery.ConclusionsAmong immunocompetent patients, herpes zoster is considered a self-limited localized infection. Our observation provides a rare but paradigmatic example of herpes zoster with involvement of both the ophthalmic and maxillary divisions of the trigeminal nerve in an immunocompetent patient. Immunocompetence status and age-specific screening should be warranted in case of atypical involvement and according to the patient’s history, while treatment with antiviral drugs should be rapidily initiated in patients at risk.