Oral plaques and dysphagia in a young man

A 23-year-old man presents with a sore throat, dysphagia, and general malaise that began 1 week ago. He also reports a 5-pound weight loss. He has not recently taken antibiotics or inhaled glucocorticoids, and he has no history of tobacco use or trauma to his mouth. He has no personal or family history of oral cancer. He uses cocaine on occasion. He reports feeling feverish and having a decreased appetite.

An examination of his mouth reveals white plaques of varying sizes (Figure 1). The plaques are easily removed using a tongue blade, with no bleeding. No regional lymphadenopathy is noted.

Q: Based on the history, the symptoms, and the physical examination, which of the following is the most likely diagnosis in this patient?

• Oral hairy leukoplakia
• Squamous cell carcinoma
• Oral candidiasis
• Herpetic gingivostomatitis
• Streptococcal pharyngitis

A: Oral candidiasis is correct.

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Otherwise known as thrush, it is common in infants and in denture wearers, and it also can occur in diabetes mellitus, antibiotic therapy, chemotherapy, radiation therapy, and cellular immune deficiency states such as cancer or human immunodeficiency virus (HIV) infection.¹ Patients using inhaled glucocorticoids are also at risk and should always be advised to rinse their mouth out with water after inhaled steroid use.

Although Candida albicans is the species most often responsible for candidal infections, other candidal species are increasingly responsible for infections in immunocompromised patients. Candida is part of the normal flora in many adults.

Oral hairy leukoplakia is caused by the Epstein-Barr virus and is often seen in HIV infection. It is a white, painless, corrugated lesion, typically found on the lateral aspect of the tongue, and it cannot be scraped from the adherent surfaces. It can also be found on the dorsum of the tongue, the buccal surfaces, and the floor of the mouth. In an asymptomatic patient with oral hairy leukoplakia, HIV infection with moderate immunosuppression is most likely present.² Oral hairy leukoplakia is diagnosed by biopsy of suspected lesions. It is not a premalignant lesion, and how to best treat it is still being investigated.³

Squamous cell carcinoma of the oral cavity can present as nonhealing ulcers or masses, dental changes, or exophytic lesions with or without pain.¹ They may be accompanied by cervical nodal disease. Malignancies of the oral cavity account for 14% of all head and neck cancers, with squamous cell carcinoma the predominant type.⁴ Alcohol and tobacco use increase the risk. Alcohol and tobacco together have a synergistic effect on the incidence of oral carcinoma.^1,4 Predisposing lesions are leukoplakia, lichen planus of the erosive subtype, submucosal fibrosis, and erythroplakia. Oral infection with human papillomavirus has been shown to increase the risk of oral cancer by a factor of 14, and papillomavirus type 16 is detected in 72% of patients with oropharyngeal cancer.⁵

Herpetic gingivostomatitis is a manifestation of herpes simplex virus infection. The initial infection may be asymptomatic or may produce groups of vesicles that develop into shallow, painful, and superficial ulcerations on an erythematous base.^1,3 If the gingiva is involved, it is erythematous, boggy, and tender.³ Infections are self-limited, lasting up to 2 weeks, but there is potential for recurrence because of the ability of herpes simplex virus to undergo latency. Recurrence is usually heralded by prodromal symptoms 24 hours before onset, with tingling, pain, or burning at the infected site. The diagnosis can be made clinically, but the Tzanck smear test, viral culture, direct fluorescent antibody test, or polymerase chain reaction test can be used to confirm the diagnosis. In patients who are immunocompromised, infections tend to be more severe and to last longer.

Streptococcal pharyngitis, most often caused by group A beta-hemolytic streptococci, is the most common type of bacterial pharyngitis in the clinical setting. The bacteria incubate for 2 to 5 days. The condition mainly affects younger children.⁶ Patients with “strep throat” often present with a sore throat and high-grade fever. Other symptoms include chills, myalgia, headache, and nausea. Findings on examination may include petechiae of the palate, pharyngeal and tonsillar erythema and exudates, and anterior cervical adenopathy.⁶ Children often present with coinciding abdominal complaints. A rapid antigen detection test for streptococcal infection can be performed in the office for quick diagnosis, but if clinical suspicion is high, a throat culture is necessary to confirm the diagnosis. Treatment is to prevent complications such as rheumatic fever.⁶