MKSAP: A 21-year-old man is evaluated for painful mouth sores

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 21-year-old man is evaluated for painful sores in his mouth. Episodes of these sores have occurred two to three times yearly since he was 16 years old, and he believes they are associated with stress. They usually appear on the inside of his mouth as a single, round, painful lesion, lasting for 5 to 10 days and resolving without scarring. He now has concerns about whether he might have herpes.

MKSAP: A 21 year old man is evaluated for painful mouth soresHe has had no fever, chills, arthralgias, genital ulcers, rashes, eye problems, diarrhea, abdominal pain, or weight loss. He is sexually active and has had only a few sexual partners, although he is currently monogamous. All of his sexual interactions have been heterosexual. He does not use illicit drugs. Results of HIV testing for his sexual partner and him from 3 months ago were negative. The remainder of the history is noncontributory.

On physical examination, the vital signs are normal. The oral examination is significant for the lesion shown. The remainder of the physical examination is unremarkable.

MKSAP: A 21 year old man is evaluated for painful mouth sores

MKSAP image ©2006. American College of Physicians. Medical Knowledge Self-Assessment Program (MKSAP ®14)

Which of the following is the most appropriate management option for this patient?

A) Thalidomide
B) Herpes simplex testing
C) HIV testing
D) Reassurance
E) Candidiasis culture

Answer and Critique

The correct answer is D) Reassurance.

This patient should be reassured that he has recurrent aphthous ulcers, not herpes simplex virus infection. Recurrent aphthous ulcers usually begin to occur in the teenaged years and recur intermittently, and their etiology is unknown. Thalidomide has been found useful in treating severe stomatitis among patients with immunodeficiency, particularly those with HIV, but it is not indicated in this patient. Before treatment with thalidomide is initiated, clinicians are required by the manufacturer to register and ask patients to complete an informed consent, because this drug, even when transmitted by seminal fluids, can cause birth defects. Performing another HIV test is not indicated in this patient at this time. Patients with oropharyngeal candidiasis often describe a cottony sensation in the mouth, loss of taste, and, occasionally, pain induced by eating and swallowing, symptoms not present in this patient.

Key Point

* Recurrent aphthous ulcers usually begin to occur in the teenaged years and recur intermittently, and their etiology is unknown.

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  • Duncan Cross

    When I was a teenager, my dad had me dust the sores with alum powder. Hurt like heck for a moment, but solved the sore. I’m sure it’s not a good idea for any number of reasons, but it seemed to work at the time.

  • Tarl Neustaedter

    I’ll be darned. I finally know what those are, a picture is worth a thousand words. I’ve had that kind of sores for decades – probably once every couple of years, and never knew what they were. In my case, they were clearly forming at spots where sharp points in my canines or incisors rested against my lips, which is why I assumed they were simply slow-healing cuts.

  • Anonymous

    I’ve had them off and on for years. I’ve read they can often be a food allergy. Mine usually show up a couple of days after eating chocolate.

  • Chelsea

    I would still want to check for atypical or latent presentation of celiac sprue. I believe they’ve found that only 10% present with classical signs/symptoms.

  • apurvab

    A 45. year old patient of mine presented with a complaint of these painful ulcers that began in her teens. Over the course of her life, they were dismissed by several pcp’s and an ENT, who declined to biopsy the lesion. As I hadn’t encountered this condition before, I had to resort to novice thinking to rule out all of the other causes first. Against the advise of the chief of gastroenterology, I got a tissue transglutaminase, which turned out to be positive. An EGD with biopsy susequently found severe villous atrophy, consistant with celiac sprue. She’s doing well now on a gluten free diet, and is finally free of these painful recurrent mouth sores after 30 years of suffering. Moral of the story – recurrent apthous ulcers is a diagnosis of exclusion, and one needs to be methodical regarding its workup.

  • The Happy Hospitalist

    Send them to ENT. If it turns out to be something else, you’ll get sued, even though MKSAP says it’s OK to just reassure.

    Nobody wants reassurance. They want certainty. And a subspecialist offers certainty in the minds of Americans.

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