Oral lesions in patients with SARS-CoV-2 infection: could the oral cavity be a target organ?

Abstract

Several viruses transmitted through saliva, such as herpes simplex virus, cytomegalovirus, and Zika virus, are capable of infecting and replicating in the oral mucosa, leading to painful oral ulcers. Few studies have described the oral manifestations of coronavirus disease 2019 (COVID-19). There is growing evidence that angiotensin-converting enzyme 2 (ACE2), the main host cell receptor of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is highly expressed on the epithelial cells of the tongue and of the salivary glands, which may explain the development of dysgeusia in patients with COVID-19. Hence, it is important to understand if SARS-CoV-2 can infect and replicate in oral keratinocytes and fibroblasts, causing oral ulcerations and superficial necrosis. Here, we report a series of 8 cases of COVID-19 infection, with oral necrotic ulcers and aphthous-like ulcerations which developed early in the course of disease after the development of dysgeusia and affected the tongue, lips, palate, and oropharynx. A short review of the literature regarding the important role of ACE2 in SARS-CoV-2 cellular entry is also provided, bringing new insights into oral keratinocytes and minor salivary glands as potential targets.

Fig. 1

A, Clustered ulcers 1 to 1.5 cm in diameter covered with crusts occurring on the lower lip (vermilion). Ulcerative painful lesions with superficial necrosis affecting the anterior dorsal tongue. B, Lower lip mucosal ulcers covered with a mucopurulent membrane and the so-called aphthous-like pattern.

Fig. 2

Small hemorrhagic ulcerations affecting the upper and lower lips (vermilion) and focal ulcerative areas of necrosis affecting the anterior dorsal tongue.

Fig. 3

A, Painful ulcer on the right lateral border of the tongue. B, Focal erythema/petechia and a shallow necrotic area on the anterior hard palate.

Fig. 4

A, Hemorrhagic ulcerations affecting the upper and lower lip vermilions. B, Painful “aphthous-like” necrotic ulceration affecting the right lower lip mucosa.

Fig. 5

Lesions presenting an aphthous-like pattern. A, B, Patient 3 presenting with multiple shallow ulcers at the apex and anterior lateral border of the tongue. C, Patient 4 with an isolated peritonsillar major aphthous-like ulcer. D, Patient 5. Isolated painful ulcer in the ventral portion of the tongue. E, Patient 6. Ulcerated lesion with slightly elevated and a marked erythematous halo. F, Patient 6. Aphthous-like ulcer covered by a necrotic membrane on the lateral border of the tongue.