The novel coronavirus disease (COVID-19), caused by the severe respiratory syndrome coronavirus 2 (SARS-CoV-2) coronavirus, poses an urgent threat to the global health. Initially named as 2019-nCOV and officially as SARS-COV-2. The most affected site is the lungs wherein the patient present symptoms ranging from mild flu-like to fulminant pneumonia and potential lethal respiratory distress.
This emerging respiratory infection has a possible zoonotic association with bats and pangolins, the most probable origin and intermediate host. The most common mode of transmission of COVID-19 is the direct mode in which close person-to-person contact (about 2 m), a distance at which the respiratory droplets from person's cough or sneeze can spread to another person who do not have an adequate barrier. Indirectly transmission occurs when saliva falls off on the ground or other hard surfaces and people come in contact as the virus remains viable for 15 min.
The COVID-19 has elaborated itself in the form of varied number of oral and extraoral symptoms. These include fever, chills, cough, shortness of breath, difficulty in breathing, muscle fatigue, body ache, headaches, altered taste and smell, and sore throat.
The less common extrapulmonary manifestations include cutaneous manifestations, i.e., maculopapular rashes in the form of COVID toe, acral urticariform, and vesicular vascular obstruction.
There are a myriad of oral manifestations observed in COVID-19 which include lesions on the tongue (also known as COVID tongue), alveolar mucosa, soft and hard palate, and buccal gingiva.
The COVID tongue is one of the most encountered oral symptoms usually presents as a typical bald, red areas of varying size that is surrounded by an irregular white border. There is a characteristic behavioral change in shape and size of the affected area resembling the geographic tongue.
The COVID tongue apart from its characteristic depapillated appearance is characterized by other intraoral complaints of loss of taste, ulceration, burning sensation, dry mouth, red or white patch lesions, petechiae, and a whitish coating on the surface.
Till now, the exact etiology behind the COVID tongue is unclear, but different mechanisms are proposed. First, either it could result due to the binding of the virus to the oral epithelial cells angiotensin-converting enzyme-2 (ACE2) receptor which induces changes at the cellular level. The other could be due to the growth of opportunistic infections such as viruses, bacteria, fungi in the oral cavity due to the COVID-19-induced stress, medications, and other related immunosuppression and compromised immune system unlike seen in healthy state.
In the present case report, a male patient aged 58 years, reported to the department with a complaint of some unusual appearance on the surface of his tongue. The patient was tested positive for SARS-CoV-2 in the April 1st week by reverse transcription–polymerase chain reaction (RT-PCR). In this, the nasopharyngeal and throat swab sample was collected. The patient had symptoms of fever, slight respiratory distress, and malaise. Apart from this, the patient also reported the gustatory and olfactory dysfunction and hypogeusia during the infection period which later on subsided with the improvement in the condition after a period of approximately 10 days. In the medical history, the patient reported that he is known cardiac patient for 10 years and is on medication for the same.
The patient gave the history of acquiring the infection after getting the both doses of the vaccine (Covishield) which he has taken in the month of March. The doses were taken at an interval of 6 weeks.
As reported by the patient in his history, the need of hospitalization did not arise and home quarantine was sufficient. The patient reported that he took tablet azithromycin 500 mg (od)* 3 days, capsule doxycycline 100mg (bid)* 10 days, tablet paracetamol 500mg (tid)*3 days, tablet ascorbic acid 500mg (od)*10 days, calcirol sachet, and tablet Vitamin D3-once in a week for 6 weeks. He was kept under physician observation, till the improvement in his symptoms. The patient was also tested for the D-dimer quantitative, which reported an increase in the value. The symptoms took approximately 2 weeks to subside, after which the patient was tested negative by RT-PCR. Following the COVID-19 negative report, the patient complained of slight body fatigue and weakness. Along with this, the patient also reported the “characteristic lesion” on the dorsal surface of the tongue, for which he came to the department.
The differential diagnosis of the present condition includes herpetic glossitis, Melkersson–Rosenthal syndrome, lichen planus, and fungal infection of the tongue. On careful examination, a positive COVID-19 history, increased D-dimer values, positive signs, and symptoms such as fever, loss of taste and smell, and difficulty in breathing rule out the possibility of the aforementioned conditions and a final diagnosis of COVID tongue [Figure 1]. The patient also complained of dryness of oral mucosa but no other significant symptom with respect to depapillated tongue was reported by the patient. The patient gave a negative history with respect to tobacco chewing, smoking, alcohol drinking, etc., The patient was asked for any other medications which he might have taken apart from the once prescribed by the physician for the treatment of COVID-19, but no such relevant drug history was procured.
Further, in detail, the patient was asked about the time of appearance of the depapillation of the tongue, whether he felt any discomfort, pain while eating food. The patient stated that he noticed the depapillation of the tongue in the 1st week of his illness.
Upon complete evaluation, supplements containing multivitamins and multiminerals and chlorhexidine mouthwash were given. He was instructed to take the supplements once daily for 1 month and rinse his mouth with mouthwash for 15 days twice daily. Simultaneously, the patient was reassured and was advised to wait and watch for improvement in the condition. Along with this, improvement in diet and lifestyle was advised. The patient was recalled after 1 month for postoperative evaluation. Upon examination, complete healing of the tongue was observed and a significant resolution of dryness of the oral mucosa was achieved [Figure 2].
Due to the novel nature of the SARS-COV-2 virus and a dynamic nature of it, the impact of the virus in humans is unveiling fold by fold. The effect of virus apart from the oral cavity, i.e., the cutaneous lesion has been well described and reported by the dermatologists but the oral lesion associated with COVID-19 is yet to be described and proven.
In the present study, it highlighted the occurrence of post-COVID symptoms in which mucocutaneous lesion forms one of the important sites where a number of lesions are observed in the patients. This puts the dental follow-up of patients after COVID of utmost important.
As per the current research and studies in describing the exact role and mechanisms of SARS COV 2 virus in causing any systemic/local alterations in functions of the body, a number of lesions/conditions have been attributed to it such as i)COVID toe ii)Kawasaki like lesions such as red and swollen tongue and iii)swollen feet, iv) aphthous stomatitis, v)angular cheilitis, vi)oral dryness, vii) dysgeusia, viii)angular cheilitis, ix)COVID tongue like lesion and x)anosmia. Increased occurrence of such conditions have been found in the COVID positive patients.
Although a clear relationship and a etiology between COVID-19 and any of these lesions have not been established due to the absence of sufficient evidence reports, lack of access to tests, leading to the improper diagnosis, a much-needed research is required to establish the virus role.
As per the current established studies, it is thus known that coronavirus causes a damage to the respiratory and other organs which are related to the ACE-2 receptors in the human system. These mainly include salivary glands, tongue, and oral mucosa having the receptors for ACE-2 enzyme leading to the inflammatory reactions in these sites.
Due to the acute nature of the infection and empirical pharmaceutical measures used in the symptomatic treatment of these patients, in a study by Amorim et al., 2020, they found that the COVID-19 patient presented with white plaque on the tongue dorsum, located centrally. These white plaques had a close resemblance with the late stage of recurrent herpetic lesion as seen in candidiasis, characterized by the presence of several small, circle-shaped yellowish ulcers. In their study, apart from this, they also reported the presence of nodule on the lower lip.
In another study by Corchuelo et al. 2020, they reported the presence of intense whitish discolored areas in the posterior area of the tongue and slightly diffused in the anterior part which he diagnosed as oral candidiasis. Along with the presence of multiple small petechiae on the mucosa of the lower lip.
In a study by Chaux-Bodard et al. 2020, they reported the presence of irregular oral ulcer on the tongue of a COVID-positive patient.
In another study by Díaz Rodríguez et al. 2020, they confirmed the occurrence of oral manifestations such as aphthous-like lesions, burning sensation, and tongue depapillation, commissural cheilitis in three COVID-positive patients.
In a study by Nuno-Gonzalez et al. 2020, they conducted in Spain in a hospital setup wherein 666 COVID-19-positive patients with varied mucocutaneous and dermatologic manifestations were seen. Out of 666 patients, 304 patients presented with mucocutaneous manifestations, which included either transient lingual papillitis (11.5%), glossitis with lateral indentations (6.6%), aphthous stomatitis (6.9%), glossitis with patchy depapillation (3.9%), and mucositis (3.9%). Burning sensation was reported in 5.3% of patients, and taste disturbances (dysgeusia) were also seen.
To draw the relation between the varied manifestations of SARS-COV-2, a correct history supplemented with the mechanisms of the virus causing it, is required which will need in-depth research on the evolving nature of the virus. In the current pandemic era, due to the ever-increasing rise in the number of oral infections attributed to SARS-COV-2 virus, interdisciplinary teleconsultation along with the support of information technologies available worldwide may prevent the spread of the virus among patients and health-care professionals.
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