CHAPTER IV

DISCUSSION

One week ago, the patient had pain at the border of the tongue, then two days

later ulcers appeared on the floor of the mouth, posterior of right cheek and upper

inner lip, worsening when eating hard of spicy food. The patient claims that she

frequently experiences oral ulcers, but cannot think of any specific cause, other

than her use of Listerine. However, she favours spicy and fried food, instant

noodles, and rarely consumes fruits and vegetables. Furthermore, she does have

the habit of one sided chewing and lip biting.

Extraorally, the submandibular and submental lymph nodes were swollen, firm

and tender. The patient had febris. Two round, hyperpigmented macules at the

lower lip, measuring 1mm in diameter. It was black, and had regular and clear

margins with a flat base. In the upper lip, there were multiple papules at >0.5mm

in diameter, round, convex with regular margins.

During intraoral examination, the left, posterior buccal mucosa presented an

atrophic lesion; the labial mucosa presented multiple atrophic lesions at the border

of mucosa and vermillion of lower lip. There was another atrophic lesion at region

11. The tongue presented bite lines on both sides and multiple atrophic lesions on

the tongue; the floor of the mouth had one atrophic lesion on the left side.

Based on the anamnesis, physical and clinical examination performed, the the

patient was suspected of having recurrent herpes simplex virus type 1 and was

asked to do a lab test for further supporting evidence. The immunoserology test

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for the Anti- HSV 1 IgG (method: ELISA) found the patient to be positive of

HSV-1.

Based on the sign and symptoms presented, it is confirmed to be recurrent

herpes simplex virus type 1. HSV can cause either primary or reactivation (recurrent)

infections. The clinical course depends on the age and immune status of the host, the

anatomic site of involvement, and the antigenic virus type. Primary HSV-1 infections are

accompanied by systemic signs, longer duration of symptoms, and higher rate of

complications. Recurrent infections are typically milder and shorter. The patient claimed

to have frequent and recurrent ulcerations previously. Not only that, patient reported that

the current ulcers are less severe than the previous condition. The short interval between

the recurrences of the ulcers is due to the psychological status of the patient where she

was repeatedly stressed out. Besides that, the patient was constantly exposed to the sun

for a long period of time and this is a predisposing factor of this condition. The nutritional

status of the patient is rather low due to the less intakes of vegetables and fruits which

subsequently decreases the immune system. These factors contribute to the recurrent

HSV-1 and support the diagnosis.