Photo Quiz

Rash Inside the Mouth

 

Am Fam Physician. 2017 Jun 1;95(11):729-730.

A 40-year-old woman presented with a four-day history of sore throat, dry cough, malaise, and myalgia. She did not have red or watery eyes. One day before these symptoms began, she noted a rash on the inside of her mouth. She did not have constitutional symptoms such as fever, chills, or weight changes. She had not been exposed to sick contacts or unimmunized children.

On physical examination, she appeared well and was in no acute distress. There was mild tonsillar hypertrophy with mild erythema and no discharge. A greyish-white vesicular eruption with an erythematous background was noted on the buccal mucosa (Figure 1).

 Enlarge     Print

Figure 1.


Figure 1.

Question

Based on the patient's history and physical examination findings, which one of the following is the most likely diagnosis?

A. Fordyce spots.

B. Herpetic gingivostomatitis.

C. Koplik spots.

D. Oral candidiasis.

Discussion

The answer is C: Koplik spots. Koplik spots are considered a pathognomonic sign of measles, or rubeola. Measles has an incubation period of six to 21 days. The prodrome lasts two to four days but may persist for as long as eight days. Symptoms typically include fever, malaise, and anorexia, followed by conjunctivitis, coryza, and cough. Approximately 48 hours before the onset of the measles exanthem, patients may develop an enanthem or mucosal rash that is characterized by Koplik spots. The lesions are whitish, grayish, or bluish, 1- to 3-mm elevations with an erythematous base, and are typically seen on the buccal mucosa opposite the molar teeth. The measles exanthem arises two to four days after the onset of fever and consists of an erythematous, maculopapular, blanching rash, which classically begins on the face and spreads to the neck, upper trunk, lower trunk, and extremities. Clinical improvement typically begins within 48 hours of the appearance of the rash.1,2

Confirming the diagnosis of measles requires serologic testing with virus-specific immunoglobulin G titers and viral culture. All cases of measles must be reported to state health departments. Measles was eradicated from the United States in 2000, but there are an estimated 3 to 4 million cases globally each year. In 2014, there were 667 cases of measles in the United States, most of which were acquired outside of the country.3 Treatment is supportive, including monitoring for complications. Isolation is important because the virus is highly contagious.3

Fordyce spots are benign neoplasms of the sebaceous glands. They present as isolated or scattered papules that are discrete, white to yellow, and 1 to 2 mm in size. They are particularly prominent on the vermilion border or buccal mucosa.1

Herpetic gingivostomatitis presents as multiple intraoral vesicular lesions and erosions bordered by an inflammatory, erythematous base. The lesions are typically seen on the lips, gingiva, oral palate, or tongue.1

Oral candidiasis, or thrush, can present in several ways. The pseudomembranous form is the most common and appears as white plaques on the buccal mucosa, palate, tongue, or oropharynx.1

 Enlarge     Print

Summary Table

ConditionCharacteristics

Fordyce spots

Discrete, white to yellow, 1- to 2-mm papules

Herpetic gingivostomatitis

Multiple intraoral vesicular lesions and erosions with an inflammatory, erythematous base; typically seen on the lips, gingiva, oral palate, or tongue

Koplik spots

Whitish, grayish, or bluish 1- to 3-mm elevations with an erythematous base; typically seen on the buccal mucosa opposite the molar teeth

Oral candidiasis

White plaques on the buccal mucosa, palate, tongue, or oropharynx

Summary Table

ConditionCharacteristics

Fordyce spots

Discrete, white to yellow, 1- to 2-mm papules

Herpetic gingivostomatitis

Multiple intraoral vesicular lesions and erosions with an inflammatory, erythematous base; typically seen on the lips, gingiva, oral palate, or tongue

Koplik spots

Whitish, grayish, or bluish 1- to 3-mm elevations with an erythematous base; typically seen on the buccal mucosa opposite the molar teeth

Oral candidiasis

White plaques on the buccal mucosa, palate, tongue, or oropharynx

Author disclosure: No relevant financial affiliations.

Address correspondence to Joseph Aziz, MD, at jaziz@chcqca.org. Reprints are not available from the author.

REFERENCES

1. Gan H, Maldonado YA. Measles: clinical manifestations, diagnosis, and treatment [subscription required]. Updated February 2, 2017. http://www.uptodate.com/contents/measles-clinical-manifestations-diagnosis-treatment-and-prevention. Accessed April 28, 2017.

2. Richardson M, Elliman D, Maguire H, Simpson J, Nicoll A. Evidence base of incubation periods, periods of infectiousness and exclusion policies for the control of communicable diseases in schools and preschools [published correction appears in Pediatr Infect Dis J. 2001;20(7):653]. Pediatr Infect Dis J. 2001;20(4):380–391.

3. Centers for Disease Control and Prevention. Measles (rubeola). https://www.cdc.gov/measles/. Accessed January 26, 2017.

This series is coordinated by John E. Delzell Jr., MD, MSPH, Assistant Medical Editor.

A collection of Photo Quiz published in AFP is available at https://www.aafp.org/afp/photoquiz.

Previously published Photo Quizzes are now featured in a mobile app. Get more information at https://www.aafp.org/afp/apps.

The editors of AFP welcome submissions for Photo Quiz. Guidelines for preparing and submitting a Photo Quiz manuscript can be found in the Authors' Guide at http://www.aafp.org/afp/photoquizinfo. To be considered for publication, submissions must meet these guidelines. E-mail submissions to afpphoto@aafp.org.

 

 

Copyright © 2017 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions


More in AFP


Editor's Collections


Related Content


More in Pubmed

MOST RECENT ISSUE


Aug 15, 2018

Access the latest issue of American Family Physician

Read the Issue


Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article