A 24-year-old woman comes to the office due to a painful lesion in her mouth. She has had similar lesions once or twice a year over the last several years that caused significant discomfort with chewing and lasted 6-7 days. She has no associated rashes, joint pains or swelling, or genital lesions. She does not have any significant past medical history and does not use tobacco or alcohol. The patient is HIV-negative. Her mother has rheumatoid arthritis. Physical examination findings are shown in the image below.

Complete blood count and comprehensive metabolic panel are within normal limits. Erythrocyte sedimentation rate is 12 mm/hr.
Which of the following is the best next step in management of this patient?

Question

A 24-year-old woman comes to the office due to a painful lesion in her mouth. She has had similar lesions once or twice a year over the last several years that caused significant discomfort with chewing and lasted 6-7 days. She has no associated rashes, joint pains or swelling, or genital lesions. She does not have any significant past medical history and does not use tobacco or alcohol. The patient is HIV-negative. Her mother has rheumatoid arthritis. Physical examination findings are shown in the image below.

Complete blood count and comprehensive metabolic panel are within normal limits. Erythrocyte sedimentation rate is 12 mm/hr.
Which of the following is the best next step in management of this patient?

Complete blood count and comprehensive metabolic panel are within normal limits.  Erythrocyte sedimentation rate is 12 mm/hr.
Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_979f_269b_853d_939c06a2e721_MD0002_00 Recurrent aphthous stomatitis (RAS) is subdivided into minor, major, and herpetiform variants. The minor variant (also known as "canker sores") is the most common and presents with a few ulcers that are small in diameter (<1 cm). The lesions occur on the non-keratinized portions of the tongue, cheeks, and lips, and heal in 7-10 days without scarring. They typically recur every 1-4 months. Diagnosis of RAS is clinical, and further workup (if any) is aimed at identifying underlying conditions as suggested by the history and examination. On occasion, celiac disease may first present as aphthous ulcers, and so assay for anti-tissue transglutaminase antibodies may be considered. Oral ulcers may also be associated with conditions such as HIV, Crohn disease, and Behçet's syndrome. Topical glucocorticoids are the first-line treatment, but severe RAS that does not respond to steroids can be treated with systemic agents such as colchicine or thalidomide. (Choice A) Methotrexate therapy used in rheumatoid arthritis (RA) is associated with stomatitis, but RA itself is not associated with RAS. (Choice B) In the absence of other systemic symptoms, further evaluation for systemic lupus erythematosus is not indicated. (Choice C) Crohn disease should be considered in patients with recurrent oral ulcerations and other gastrointestinal symptoms such as diarrhea or abdominal pain. However, this patient's normal inflammatory markers and absence of anemia or leukocytosis make Crohn disease less likely. (Choice D) Thyroid disease is not associated with RAS. Educational objective: Minor variant recurrent aphthous stomatitis presents with a few ulcers that are small, occur on the non-keratinized portions of the tongue, cheeks, and lips, and heal in 7-10 days without scarring. They typically recur every 1-4 months. Topical glucocorticoids are the treatment of choice. __________ References: Recurrent aphthous stomatitis. (http://www.ncbi.nlm.nih.gov/pubmed/24655523) Treatment of recurrent aphthous stomatitis. A literature review. (http://www.ncbi.nlm.nih.gov/pubmed/24790718)

A 24-Year-Old Woman Comes to the Office Due to a Painful