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Snapshot diagnosis - what's causing these painful mouth ulcers?

A relatively healthy nursing home resident has suddenly developed very painful ulcers on her lips, tongue and palate. Dr Mike Wyndham describes another puzzling case

A relatively healthy nursing home resident has suddenly developed very painful ulcers on her lips, tongue and palate. Dr Mike Wyndham describes another puzzling case

The patient

She is an amazing 86-year-old lady who lives in a nursing home and is remarkably switched on. She had been suffering from symptoms that were felt to be angina for the last five years, but overall her medication seemed to be controlling things well. Her biggest problem was ulcerative colitis, which had flared up on two occasions in the last year but at that time she was well controlled on mesalazine.

I was called to see her one morning when she was in awful discomfort. She had been suffering from ulcers in her mouth. It was obvious from looking at them how painful they were. Clinically, there was ulceration on the lips, tongue and palate.

First instinct

Oral ulceration is pretty uncommon in primary care, but my first thought was that this was likely to be herpes simplex. However, there are other less common causes.

Differential diagnosis

• Coeliac disease

• Crohn's disease

• Drugs such as NSAIDs

• Erythema multiforme

• Pemphigus

• Behcet's disease

• Herpes simplex

• Low vitamin B12, folate or ferritin

Getting on the right track

A recent blood count ruled out a haematological cause. Previous colonoscopies had histologically confirmed ulcerative colitis rather than Crohn's disease or coeliac disease. Erythema multiforme would certainly fit with the rapid onset ulceration but there was a lack of blood crusting which may be found on the lips. There was no genital ulceration that would fit with Behcet's and no generalised blistering eruption suggestive of pemphigus. Ulcerative colitis tends to cause an aphthous stomatitis. She was not taking any incriminating drugs.

The hidden clue

The position and type of ulceration gave the biggest clue. The distribution of the ulceration was mostly affecting keratinised mucosa, which is usual for herpes simplex stomatitis. The ulcers were large and not looking like aphthous ulcers. In herpes simplex, the vesicles may join together to form large ulcers. She was started on a course of aciclovir with spectacular success.

Dr Mike Wyndham is a GP in Edgware, north London

What's causing these painful mouth ulcers? What's causing these painful mouth ulcers?

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