Today we discussed the differential of oral ulcers in an immunocompromised host (metastatic adenocarcinoma with unknown primary with recent chemoXRT) that ultimately was found to be a case of Ramsay Hunt Syndrome.
The differential we discussed for oral lesions includes the following etiologies:
- Infectious: Viral (HSV, VZV, Coxsackie-Hand Foot & Mouth disease, primary HIV, EBV, CMV), Bacterial (secondary syphilis, Bartonella-Bacillary Angiomatosis), and Fungal (Candidasis, mucormycosis, histoplasmosis, Crypto, aspergillosis)
- Neoplastic: Squamous Cell Carcinoma, Kaposi's sarcoma, melanoma
- Autoimmune: Behcets, Systemic Lupus Erythematosus, Bullous Pemphigoid, Pemphigous Vulgaris, Sjogrens, IBD, Celiacs disease
- Drug reactions: Toxic Epidermal Necrolysis-Steven's Johnson's Syndrome, chemotherapeutics (mucositis)
- Other: mechanical trauma, vitamin deficiencies (Niacin, zinc, B12), Amalgam tattoos (stains from fillings), lichen planus, familial, hereditary hemorrhagic telegantasia
An illness script for Ramsay Hunt Syndrome:
Varicella zoster virus infection of the geniculate nucleus leads to a clinical syndrome of peripheral unilateral facial nerve palsy (severe facial paralysis including the forehead and decreased taste on the anterior 2/3 of the tongue) accompanied by an erythematous vesicular rash on the ear (zoster oticus) or in the mouth. Patients can have vestibulocochlear nerve symptoms (nausea, vomiting, hearing loss, vertigo, nystagmus) as a result of the close proximity of the geniculate nucleus to the 8th cranial nerve.
For treatment, consideration should be given to early treatment of all patients with Ramsay Hunt syndrome or Bell’s palsy with a 7–10 day course of acyclovir and oral prednisone. A nice review of this is here.