Atypical herpetic ulcerations in COVID-19 positive patients: A report of three cases

Abstract

Since the global COVID-19 pandemic, numerous reports have been made regarding oral lesions seen in COVID-19 patients. It remains unclear whether or not these are true manifestations of COVID-19. Here we present 3 patients who were hospitalized for COVID-19 and who developed atypical herpetic ulcerations during their treatment with remdesivir (Veklury) and steroids. In healthy patients, recurrent infection by herpes simplex virus (HSV) presents as lesions only on the lips and the attached oral mucosa. Atypical herpetic ulcerations are seen in immunocompromised patients. They present as large, stellate shaped ulcerations with raised borders and may involve movable mucosa. The 3 cases presented in this report resembled the atypical herpetic ulcerations typically seen in patients with immunosuppression. Through our report, we aimed to introduce the possibility of atypical herpetic ulcers in patients being treated for COVID-19, to allow for their timely diagnosis and to raise awareness of the underlying immunocompromised state.

Fig. 1

(A) Stellate shaped ulcer with raised white border on the ventral surface of the tongue. (B) Irregular shaped ulcers with raised white borders on the lateral tongue.

Fig. 2

(A) Ulcers on the anterior tip of the tongue. (B) Large ulcer on the labial mucosa. The patient also had candidiasis.

Fig 3

(A) Ulcer on the anterior tip of the tongue. (B) Ulcer on the labial mucosa.

Fig. 4

Representative cytologic smear of the lower labial mucosa of patient 3. Papanicolaou stain demonstrates virally altered epithelial cells with multiple molded nuclei exhibiting ballooning degeneration.