Oral ulcers and mucosal disease — formative SAQs

SAQ 1 — The drooling febrile toddler with painful gums (10 marks, 15 minutes)

A two-year-old boy has three days of high fever, drooling and progressive refusal of all fluids. On examination his temperature is 39.2 degrees Celsius, the gingiva is diffusely swollen, red and bleeding, and there are shallow vesicles and ulcers across the gingiva, tongue and lips with tender cervical lymphadenopathy. He has passed no urine for eight hours and his capillary refill is three seconds. [1]

a) What is the diagnosis, and which two clinical features make dehydration the practical threat? (2 marks) [1]

b) Give the antiviral regimen you would use, including drug, dose, route, frequency, duration and the window of onset within which it should start, and cite the evidence. (3 marks) [1] [2]

c) Outline your immediate fluid and analgesia management, including the route you would choose if he cannot maintain oral hydration. (3 marks) [2]

d) Give two circumstances in which you would choose intravenous rather than oral aciclovir. (2 marks) [2]

SAQ 2 — The child with recurrent scarring oral ulcers (10 marks, 15 minutes)

A ten-year-old girl has recurrent oral ulcers, several larger than ten millimetres, that last three to four weeks and heal with scarring. She has no genital, eye, skin or joint symptoms, and growth is normal, but the recurrence has worsened over the last year. [9]

a) Classify her aphthous stomatitis by type, and give two features that distinguish it from herpetic gingivostomatitis. (2 marks) [9] [10]

b) List the panel of investigations you would send to look for a systemic driver, naming the cytopenia and the malabsorption condition you are screening for. (4 marks) [9]

c) Outline your stepwise topical management, naming a topical corticosteroid, an antiseptic mouthwash and a topical analgesic. (2 marks) [10]

d) Give two systemic diagnoses you must consider if she later develops genital ulcers or eye inflammation, and state the subspecialty to whom you would refer. (2 marks) [9] [3]