Endgames Case Review

An atypical, non-healing perioral lesion

BMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j3823 (Published 28 September 2017) Cite this as: BMJ 2017;358:j3823
  1. Vinay Naresh Mistry, longitudinal dental foundation trainee in oral and maxillofacial surgery1,
  2. Mohamed Imran Suida, specialty doctor in oral and maxillofacial surgery1,
  3. Deborah Kirkham, ST5 in genitourinary and HIV medicine2,
  4. Michael Wing Sung Ho, consultant in maxillofacial oncology1 3
  1. 1Oral and facial specialties, Mid Yorkshire Hospitals NHS Trust, Pinderfields Hospital, Wakefield, UK
  2. 2The Northern Sexual Health, Contraception and HIV Service, Central Manchester University Hospitals NHS Foundation Trust, The Hathersage Centre, Manchester, UK
  3. 3Oral and Maxillofacial Surgery, Leeds Teaching Hospitals NHS Trust, Leeds Dental Institute, Leeds, UK
  1. Correspondence to V N Mistry (vins_mistry{at}hotmail.com)

A 57 year old man was referred urgently to the oral and maxillofacial surgery clinic. He described a three month history of fatigue, recurrent sore throats, and a persistent “cold sore.” An irregular and indurated ulcer was present on the right oral commissure (fig 1), and an ipsilateral swelling was palpable in the submandibular triangle (fig 2). He had no relevant medical history. He drank little alcohol and was a non-smoker.

Fig 1 Irregular and indurated ulcer present on the right oral commissure

Fig 2 Ipsilateral swelling palpable in the submandibular triangle

Questions

  • 1. What are the most important differential diagnoses to consider?

  • 2. What investigations would be required to confirm the diagnosis?

  • 3. How would you manage a patient with this diagnosis?

Answers:

1. What are the most important differential diagnoses to consider?

Short answer

The most important differential diagnoses to consider include herpes labialis, primary syphilis, and squamous cell carcinoma.

Discussion

Primary syphilis should be considered alongside herpes simplex labialis if the symptoms do not resolve in 10-14 days.1 Association with other red flags such as induration, bleeding, and concurrent cervical lymphadenopathy should prompt fast track referral to the local head and neck oncology clinic. Malaise is a common feature of syphilis that would not normally be seen at an early stage of squamous cell carcinoma.

Cases of syphilis have risen dramatically in recent years. In the UK, USA, and other Western countries, this rise has been most marked in men who have sex with men, so taking a targeted sexual history is essential.2 Syphilis is classified into primary, secondary, latent (early …

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