Pediatric emergency medicine trisk 1034 1034
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hyperpigmentations should prompt consideration of Peutz–Jeghers syndrome, an
autosomal-dominant condition which requires referral to a gastroenterologist
because of an increased risk of gastric malignancies.
EVALUATION AND DECISION
When evaluating patients with complaints of oral lesions, it is important to
consider a myriad of associated signs and symptoms while taking a complete
history and performing the physical examination. The patient’s age, general
health and appearance, presence of an exanthem or fever, and whether the lesions
are painful must be considered. Once the presence of lesions is noted, they should
be further characterized by color, type, and location and considered in the context
of any additional physical findings.
Toxic-appearing patients require immediate evaluation for potentially lifethreatening disease. Patients with Kawasaki disease or toxic shock syndrome (
Table 52.3 ) present with findings such as fever, diffuse cutaneous rash,
hyperemia of other mucous membranes, or poor perfusion indicative of shock. In
contrast, Stevens–Johnson syndrome may cause isolated oral lesions initially and
then rapidly progress to systemic involvement.
Once life-threatening causes have been considered, careful history and physical
examination may lead to the diagnosis of other systemic diseases. Weight loss,
abdominal pain, and diarrhea with or without blood loss suggest Crohn disease,
whereas genital ulceration in an adolescent boy points to Behỗet syndrome or
secondary syphilis.
The presence of rash and fever makes disorders of infectious etiology more
likely. Measles, varicella, scarlet fever, and hand–foot–mouth disease are
generally diagnosed by history and physical examination alone. Laboratory
evaluation might include a throat culture for streptococci and serologic testing for
measles or HIV when these infections are suspected.
Infectious causes of oral lesions without exanthem may display obvious
findings such as cachexia and alopecia in the neutropenic patient with mucositis,
or they may be relatively localized to the oropharynx as in herpangina, herpes
gingivostomatitis or labialis, and dental infections, which may or may not cause
fever and lymphadenopathy.
Oral lesions without overt signs of systemic disease are mostly congenital or
tumorous in nature. With the exception of candidiasis, lesions found in the
newborn and during infancy are largely self-limited. A few congenital lesions,
including lymphangioma, hemangioma, and congenital epulis, may require
intervention.
