RESUMEN
Ulceration of the oral cavity is common and a frequent reason for referral to secondary and tertiary centres. Epstein-Barr virus (EBV)-related mucocutaneous ulceration, however, is a rare cause of oral ulceration that has been described only recently. Histologically these lesions resemble lymphomas; however, their management and prognosis differ significantly. We present a case of EBV-induced oral ulceration and discuss the diagnosis and management of and available literature for the condition, which was treated successfully through conservative measures alone.
Asunto(s)
Infecciones por Virus de Epstein-Barr/complicaciones , Herpesvirus Humano 4 , Úlceras Bucales/etiología , Adulto , Biopsia , Infecciones por Virus de Epstein-Barr/diagnóstico , Infecciones por Virus de Epstein-Barr/patología , Infecciones por Virus de Epstein-Barr/terapia , Femenino , Humanos , Mucosa Bucal/patología , Mucosa Bucal/virología , Úlceras Bucales/diagnóstico , Úlceras Bucales/terapia , Úlceras Bucales/virologíaRESUMEN
Abstract Coronavirus disease 2019 (COVID-19) is a new disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus. China reported the first case of COVID-19 in December 2019, and a few months later, the World Health Organization declared it as a pandemic. Oral ulcers in adult patients have been associated with COVID-19. However, no cases have yet been documented in children. The angiotensin-converting enzyme-2 (ACE2) receptor has been identified in tissues of the oral cavity. Studies have identified the tongue as the site with the highest expression of ACE2, and the oral epithelium, gingival epithelium, and salivary glands as sites of lesser extent expression. ACE2 expression is lower in children and varies with age. SARS-CoV-2 in saliva has been identified in various studies, which suggests that this could be a useful sample for diagnosis. However, its presence in saliva would indicate the high risk of contagion of this fluid.
Resumen La COVID-19 es una nueva enfermedad causada por el SARS-CoV-2 (coronavirus tipo 2 del síndrome respiratorio agudo grave). El primer caso de COVID-19 se reportó en China en diciembre de 2019, y unos meses después la Organización Mundial de la Salud la declaró como una pandemia. En pacientes adultos se han asociado úlceras orales a la COVID-19; en niños aún no se han documentado casos. El receptor de la enzima convertidora de la angiotensina 2 (ECA2) se ha identificado en tejidos de la cavidad oral. Los estudios han identificado que la lengua es el sitio con mayor expresión del receptor de la ECA2, y el epitelio bucal, el epitelio gingival y las glándulas salivales lo son en menor medida. La expresión de la ECA2 es menor en los niños y va aumentando con la edad. En diversos estudios se ha identificado el SARS-CoV-2 en la saliva, lo que sugiere que podría ser una muestra útil para el diagnóstico de este virus. Sin embargo, su presencia en saliva indicaría un alto riesgo de contagio de este fluido.
Asunto(s)
Adulto , Niño , Humanos , Salud Bucal , Úlceras Bucales/virología , SARS-CoV-2/aislamiento & purificación , COVID-19/complicaciones , Saliva/virología , Factores de Edad , Enzima Convertidora de Angiotensina 2/metabolismo , Prueba de COVID-19 , COVID-19/diagnóstico , COVID-19/virología , Boca/virologíaRESUMEN
Epstein-Barr virus (EBV)-associated lymphoproliferative disorder may resemble nonspecific inflammation. We report 3 cases of immunosuppressed adult patients with small lymphocytic EBV ulcers in the skin and oral mucosa, characterized by a lack of atypical lymphocytic infiltration. All 3 cases were diagnosed in routine practice. For comparisons, cases of conventional Epstein-Barr virus-positive mucocutaneous ulcer (EBVMCU) were reviewed which were extracted from our pathology archives (n=11). The present patients were 2 females and 1 male, aged above 70 years. The primary disease was rheumatoid arthritis (n=2) and dermatitis herpetiformis (n=1). The main source of immunosuppression was prednisolone (n=2) and methotrexate (n=1). The ulcers were located in the oral cavity, buttock, and/or external genitalia. Histology evaluation revealed nonspecific lymphocytic infiltration. Epstein-Barr virus-encoded small RNA (EBER)-positive cells were small and coexpressed CD20. The number of EBER-positive cells ranged from 52 to 132/HPF, which was within the range of that observed in the reviewed conventional EBVMCUs (range, 48 to 1328; median, 121). All 3 cases regressed spontaneously or by the reduction of immunosuppressants. Although the present cases lacked cytologic atypia, those clinical course and loads of EBER-positive cells (>50/HPF) suggested EBV involvement. Current cases of EBVMCU with small lymphocytic infiltration underscore the need for EBER in situ hybridization when an etiology of ulcer with predominant lymphocytes in an immunosuppressed patient is unclear.
Asunto(s)
Infecciones por Virus de Epstein-Barr/patología , Herpesvirus Humano 4/patogenicidad , Linfocitos/patología , Mucosa Bucal/patología , Infecciones Oportunistas/patología , Úlceras Bucales/patología , Úlcera Cutánea/patología , Anciano , Infecciones por Virus de Epstein-Barr/inmunología , Infecciones por Virus de Epstein-Barr/virología , Femenino , Herpesvirus Humano 4/inmunología , Interacciones Huésped-Patógeno , Humanos , Huésped Inmunocomprometido , Inmunosupresores/efectos adversos , Linfocitos/inmunología , Linfocitos/virología , Masculino , Mucosa Bucal/inmunología , Mucosa Bucal/virología , Infecciones Oportunistas/inmunología , Infecciones Oportunistas/virología , Úlceras Bucales/inmunología , Úlceras Bucales/virología , Factores de Riesgo , Úlcera Cutánea/inmunología , Úlcera Cutánea/virología , Carga ViralAsunto(s)
Artritis Reumatoide/tratamiento farmacológico , Infecciones por Virus de Epstein-Barr/diagnóstico , Inmunosupresores/efectos adversos , Linfoma de Células B Grandes Difuso/diagnóstico , Metotrexato/efectos adversos , Úlceras Bucales/diagnóstico , Infecciones por Virus de Epstein-Barr/etiología , Infecciones por Virus de Epstein-Barr/metabolismo , Humanos , Linfoma de Células B Grandes Difuso/metabolismo , Úlceras Bucales/inducido químicamente , Úlceras Bucales/virología , Prevalencia , Receptores de Interleucina-2/metabolismoRESUMEN
The coronavirus disease 2019 (Covid-19) is a viral infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that clinically affects multiple organs of the human body. Cells in the oral cavity express viral entry receptor angiotensin-converting enzyme 2 that allows viral replication and may cause tissue inflammation and destruction. Recent studies have reported that Covid-19 patients present oral manifestations with multiple clinical aspects. In this review, we aim to summarise main signs and symptoms of Covid-19 in the oral cavity, its possible association with oral diseases, and the plausible underlying mechanisms of hyperinflammation reflecting crosstalk between Covid-19 and oral diseases. Ulcers, blisters, necrotising gingivitis, opportunistic coinfections, salivary gland alterations, white and erythematous plaques and gustatory dysfunction were the most reported clinical oral manifestations in patients with Covid-19. In general, the lesions appear concomitant with the loss of smell and taste. Multiple reports show evidences of necrotic/ulcerative gingiva, oral blisters and hypergrowth of opportunistic oral pathogens. SARS-CoV-2 exhibits tropism for endothelial cells and Covid-19-mediated endotheliitis can not only promote inflammation in oral tissues but can also facilitate virus spread. In addition, elevated levels of proinflammatory mediators in patients with Covid-19 and oral infectious disease can impair tissue homeostasis and cause delayed disease resolution. This suggests potential crosstalk of immune-mediated pathways underlying pathogenesis. Interestingly, few reports suggest recurrent herpetic lesions and higher bacterial growth in Covid-19 subjects, indicating SARS-CoV-2 and oral virus/bacteria interaction. Larger cohort studies comparing SARS-CoV-2 negative and positive subjects will reveal oral manifestation of the virus on oral health and its role in exacerbating oral infection.
Asunto(s)
COVID-19/complicaciones , Gingivitis Ulcerosa Necrotizante/complicaciones , Infecciones por Herpesviridae/complicaciones , Úlceras Bucales/complicaciones , Enfermedades Periodontales/complicaciones , Sialadenitis/complicaciones , Estomatitis Aftosa/complicaciones , Xerostomía/complicaciones , Enzima Convertidora de Angiotensina 2/genética , Enzima Convertidora de Angiotensina 2/inmunología , Anosmia/complicaciones , Anosmia/inmunología , Anosmia/patología , Anosmia/virología , COVID-19/inmunología , COVID-19/patología , COVID-19/virología , Disgeusia/complicaciones , Disgeusia/inmunología , Disgeusia/patología , Disgeusia/virología , Expresión Génica , Gingivitis Ulcerosa Necrotizante/inmunología , Gingivitis Ulcerosa Necrotizante/patología , Gingivitis Ulcerosa Necrotizante/virología , Infecciones por Herpesviridae/inmunología , Infecciones por Herpesviridae/patología , Infecciones por Herpesviridae/virología , Humanos , Boca/inmunología , Boca/patología , Boca/virología , Úlceras Bucales/inmunología , Úlceras Bucales/patología , Úlceras Bucales/virología , Enfermedades Periodontales/inmunología , Enfermedades Periodontales/patología , Enfermedades Periodontales/virología , SARS-CoV-2/inmunología , SARS-CoV-2/patogenicidad , Serina Endopeptidasas/genética , Serina Endopeptidasas/inmunología , Sialadenitis/inmunología , Sialadenitis/patología , Sialadenitis/virología , Estomatitis Aftosa/inmunología , Estomatitis Aftosa/patología , Estomatitis Aftosa/virología , Xerostomía/inmunología , Xerostomía/patología , Xerostomía/virologíaRESUMEN
Coronavirus disease 2019 (COVID-19) is a new disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus. China reported the first case of COVID-19 in December 2019, and a few months later, the World Health Organization declared it as a pandemic. Oral ulcers in adult patients have been associated with COVID-19. However, no cases have yet been documented in children. The angiotensin-converting enzyme-2 (ACE2) receptor has been identified in tissues of the oral cavity. Studies have identified the tongue as the site with the highest expression of ACE2, and the oral epithelium, gingival epithelium, and salivary glands as sites of lesser extent expression. ACE2 expression is lower in children and varies with age. SARS-CoV-2 in saliva has been identified in various studies, which suggests that this could be a useful sample for diagnosis. However, its presence in saliva would indicate the high risk of contagion of this fluid.
Asunto(s)
COVID-19/complicaciones , Salud Bucal , Úlceras Bucales/virología , SARS-CoV-2/aislamiento & purificación , Adulto , Factores de Edad , Enzima Convertidora de Angiotensina 2/metabolismo , COVID-19/diagnóstico , COVID-19/virología , Prueba de COVID-19 , Niño , Humanos , Boca/virología , Saliva/virologíaAsunto(s)
Úlceras Bucales/virología , Enfermedades de la Lengua/virología , Lengua/patología , Anciano , Infecciones por Citomegalovirus , Complicaciones de la Diabetes , Glucocorticoides/administración & dosificación , Humanos , Fallo Renal Crónico/complicaciones , Masculino , Poliangitis Microscópica/complicaciones , Poliangitis Microscópica/tratamiento farmacológico , Úlceras Bucales/patología , Enfermedades de la Lengua/patologíaRESUMEN
Epstein-Barr virus (EBV)-positive mucocutaneous ulcer (EBVMCU) is a unifocal mucosal or cutaneous ulcer that is histologically characterized by proliferating EBV-positive atypical B cells. While EBVMCU demonstrates a histology similar to that of EBV-positive diffuse large B-cell lymphoma (DLBCL), their clinical behavior differs. Thus, characterizing distinguishing features of EBVMCU and EBV-positive DLBCL is critical. To identify unique characteristics between EBVMCU and lymphoma, we analyzed the clinicopathological and genetic features of 34 Japanese patients with EBVMCU and compared them to those of 24 EBV-positive DLBCL patients and 25 EBV-negative DLBCL patients. All patients with EBVMCU had localized ulcerative lesions, and 31 patients (91%) were using immunosuppressants, such as methotrexate (MTX) or hydroxycarbamide. All patients that were followed up with exhibited good prognosis following immunosuppressant reduction or chemotherapy. In addition, 17 EBV-positive DLBCL patients, and 15 EBV-negative DLBCL patients, received chemotherapy (P < 0.001, P < 0.001, respectively). Our data showed that EBVMCU did not increase indicators associated with lymphoma prognosis, such as soluble interleukin 2 receptor (sIL-2R) and lactate dehydrogenase (LDH) compared to those in the EBV-positive DLBCL or EBV-negative DLBCL groups (sIL-2R, P < 0.001, P = 0.025; LDH, P = 0.018, P = 0.038, respectively). However, histologically, EBVMCU exhibited EBV-positive, variable-sized, atypical B-cell proliferation. Thus, EBVMCU was histologically classified as: (1) polymorphous; (2) large cell-rich; (3) classic Hodgkin lymphoma-like; and (4) mucosa-associated lymphoid tissue lymphoma-like. Moreover, genetic analysis showed that immunoglobin heavy chain (IGH) gene rearrangement did not differ significantly between EBVMCU and EBV-positive DLBCL (44% vs. 32%; P = 0.377), or between EBVMCU and EBV-negative DLBCL (44% vs. 58%; P = 0.280). Therefore, it is difficult to distinguish EBVMCU from EBV-positive DLBCL using only pathological and genetic findings, suggesting that clinical information is important in accurately distinguishing between EBVMCU and EBV-positive DLBCL.
Asunto(s)
Infecciones por Virus de Epstein-Barr/patología , Herpesvirus Humano 4/patogenicidad , Linfoma de Células B Grandes Difuso/patología , Úlceras Bucales/patología , Úlcera Cutánea/patología , Anciano , Anciano de 80 o más Años , Biomarcadores de Tumor/genética , Diagnóstico Diferencial , Infecciones por Virus de Epstein-Barr/genética , Infecciones por Virus de Epstein-Barr/inmunología , Infecciones por Virus de Epstein-Barr/virología , Femenino , Reordenamiento Génico , Genes de las Cadenas Pesadas de las Inmunoglobulinas , Genes Codificadores de los Receptores de Linfocitos T , Herpesvirus Humano 4/inmunología , Humanos , Huésped Inmunocomprometido , Inmunohistoquímica , Inmunosupresores/efectos adversos , Hibridación in Situ , Japón , Linfoma de Células B Grandes Difuso/genética , Linfoma de Células B Grandes Difuso/inmunología , Linfoma de Células B Grandes Difuso/virología , Masculino , Persona de Mediana Edad , Úlceras Bucales/genética , Úlceras Bucales/inmunología , Úlceras Bucales/virología , Reacción en Cadena de la Polimerasa , Valor Predictivo de las Pruebas , Úlcera Cutánea/genética , Úlcera Cutánea/inmunología , Úlcera Cutánea/virologíaRESUMEN
We describe a series of 9 patients with Epstein-Barr virus (EBV)-positive mucocutaneous lymphoproliferative lesions that broadens the concept of EBV-positive mucocutaneous ulcer. We report 5 female and 4 male patients, with an average age of 74 years (range, 55 to 87 y), 2 of whom were HIV-positive. The lesions were located in the oropharynx, skin, and rectal and/or genital mucosa. Histopathologically, 6 cases showed a polymorphic pattern and 3 had a monomorphic and diffuse one, with angiotropism in 4 cases (2 each with the polymorphic and monomorphic patterns). Three of the cases expressed PDL1. In addition to its presence in the neoplastic lymphoid cells, EBV was also detected in adjacent epithelial cells in an oropharyngeal lesion. All cases responded to local therapy or adapted systemic chemotherapy in selected cases. This series extends the spectrum of this disorder to include some HIV-positive cases, patients with multiple lesions confined to a single anatomic area, lesions with an angiocentric pattern, and some cases with monomorphous large-cell cytology. We discuss the differential clinicopathologic diagnosis of this disorder and that of classic EBV large B-cell lymphoma.
Asunto(s)
Infecciones por Virus de Epstein-Barr/complicaciones , Membrana Mucosa/virología , Úlceras Bucales/virología , Úlcera Cutánea/virología , Anciano , Anciano de 80 o más Años , Infecciones por Virus de Epstein-Barr/patología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Membrana Mucosa/patología , Úlceras Bucales/patología , Úlcera Cutánea/patologíaRESUMEN
A 65-year-old man with treatment-resistant psoriatic arthritis, hypertension, dyslipidaemia and benign prostatic hyperplasia (BPH) presented with herpes simplex virus (HSV) oral ulcers and a recent 15 lb weight loss due to reduced consumption. Five weeks previously, his methotrexate was tapered and he had begun taking azathioprine. The patient's thiopurine S-methyltransferase (TPMT) activity level was normal prior to starting azathioprine. He was found to have pancytopenia with normal folate levels and azathioprine was discontinued. His pancytopenia worsened, with a nadir 8 days after stopping azathioprine, before returning to normal levels. His oral ulcers improved and he was able to tolerate solid food. This case illustrates that decreased TPMT activity is not the only risk factor for pancytopenia as an adverse reaction to azathioprine. Furthermore, HSV stomatitis may be the presenting symptom of pancytopenia. The timeline of improvement in cell counts illustrated in this patient has implications for the management of suspected azathioprine-induced pancytopenia.
Asunto(s)
Azatioprina/efectos adversos , Herpes Simple/inducido químicamente , Inmunosupresores/efectos adversos , Úlceras Bucales/inducido químicamente , Pancitopenia/inducido químicamente , Anciano , Herpes Simple/virología , Humanos , Masculino , Metiltransferasas/metabolismo , Úlceras Bucales/virología , Pancitopenia/virología , SimplexvirusRESUMEN
The Epstein-Barr virus-positive mucocutaneous ulcer is a new phenomenon that was first described in 2014, and we know of only 67 reported cases. We describe a case in a patient who had had a renal transplant.
Asunto(s)
Infecciones por Virus de Epstein-Barr/diagnóstico , Trasplante de Riñón , Úlceras Bucales/virología , Biopsia , Diagnóstico Diferencial , Humanos , Huésped Inmunocomprometido , Masculino , Persona de Mediana Edad , Remisión EspontáneaAsunto(s)
Infecciones por Virus de Epstein-Barr , Herpesvirus Humano 4/metabolismo , Mucosa Bucal , Úlceras Bucales , Anciano , Infecciones por Virus de Epstein-Barr/metabolismo , Infecciones por Virus de Epstein-Barr/patología , Humanos , Masculino , Mucosa Bucal/metabolismo , Mucosa Bucal/patología , Mucosa Bucal/virología , Úlceras Bucales/metabolismo , Úlceras Bucales/patología , Úlceras Bucales/virología , Organización Mundial de la SaludRESUMEN
INTRODUCTION: oral lesions comprise significant clinical features of HIV infection and are often indicators of immune suppression. However, the advent of antiretroviral therapy has significantly reduced its prevalence. The aim of this study was to relate the prevalence of oral lesions of HIV to treatment outcome of Combined Antiretroviral Therapy (cART) in a Nigerian HIV adult population. METHODS: a cross- sectional study was conducted on 491 People Living with HIV (PLWHIV) on cART from two HIV centres in Lagos state, Nigeria. The EC-clearing house guidelines were employed to categorise oral lesions. Presence or absence of these lesions was reconciled with CD4+ cell count as a measure of efficacy of cART treatment. RESULTS: a total of 491 PLWHIV on cART were enrolled, 366 (74.5%) were females and 125 (25.5%) were males. Age ranged between 18-80 years, with a mean of 41.2 ± 9.1 years. On examination, 12 (2.4%) patients presented with HIV oral lesions. Oral hyperpigmentation (10, 2.0%) was the most common lesion seen, followed by oral ulcers (2,0.4%). Majority (75%) of the affected patients were on a Lamivudine containing regimen. 7 out of the 12 patients with oral lesions had CD4+ cell count between 200-500 cell/mm3 prior to cART initiation. Eleven (92%) of the patients with oral lesions had significant improvement of their CD4+ cell count after cART administration. CONCLUSION: the prevalence of oral lesions in HIV patients on cART therapy in Lagos is low. Oral hyperpigmentation and oral ulcers are the most frequent lesions seen. The presence or absence of oral lesions were not associated with CD4+ cell count. Therefore, we conclude that the oral lesions seen in HIV patients on cART may not be a direct manifestation of the disease.
Asunto(s)
Fármacos Anti-VIH/administración & dosificación , Infecciones por VIH/tratamiento farmacológico , Enfermedades de la Boca/epidemiología , Úlceras Bucales/epidemiología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Terapia Antirretroviral Altamente Activa/métodos , Recuento de Linfocito CD4 , Estudios Transversales , Quimioterapia Combinada , Femenino , Infecciones por VIH/complicaciones , Humanos , Hiperpigmentación/epidemiología , Hiperpigmentación/virología , Masculino , Persona de Mediana Edad , Enfermedades de la Boca/virología , Nigeria/epidemiología , Úlceras Bucales/virología , Prevalencia , Adulto JovenRESUMEN
Epstein-Barr virus-positive mucocutaneous ulcer (EBVMCU) is a newly recognized provisional entity included in mature B-cell neoplasm in the latest 2016 World Health Organization Classification. It has a self-limited growth potential with a high predilection for oral cavities and occurs in age-related or iatrogenic immunodeficiency with indolent clinical courses. However, it shares histological features with EBV-positive diffuse large B-cell lymphoma (DLBCL), and this often leads to diagnostic challenges and controversies in patients with an oral EBV-positive B-cell neoplasm. The aim of this study was to better characterize and comprehend the pathophysiology of DLBCL and EBVMCU in the oral cavity. We conducted clinicopathologic and recurrent gene mutation analysis of 49 cases (14 EBV positive, 35 EBV negative), including cases diagnosed as DLBCL or B-cell lymphoproliferative disorders with high-grade morphology in the oral cavity. All EBV-positive cases matched the criteria of EBVMCU, with significantly earlier clinical stages than the EBV-negative group (P=.0006). Besides, histological analysis showed that all EBV-positive cases presented polymorphous features, whereas 91.4% (32/35) of the EBV-negative cases showed diffuse and monotonous proliferation (P<.0001). Furthermore, EBV-positive cases presented favorable clinical outcomes without disease-related death or recurrence. Gene mutation analysis (MYD88, CD79A, CD79B, CARD11, and EZH2) revealed that 33.3% (9/27) of EBV-negative cases harbored at least 1 gene mutation, whereas no gene mutation was observed in the EBV-positive group (0/11). These results suggest that oral EBV-positive B-cell lymphoid proliferation with polymorphous features often fulfill the criteria for EBVMCU, with clinicopathologically and genetically distinctive properties.
Asunto(s)
Infecciones por Virus de Epstein-Barr/virología , Herpesvirus Humano 4/aislamiento & purificación , Linfoma de Células B Grandes Difuso/virología , Trastornos Linfoproliferativos/virología , Neoplasias de la Boca/virología , Úlceras Bucales/virología , Anciano , Anciano de 80 o más Años , Biomarcadores de Tumor/genética , Proliferación Celular , Diagnóstico Diferencial , Infecciones por Virus de Epstein-Barr/genética , Infecciones por Virus de Epstein-Barr/patología , Infecciones por Virus de Epstein-Barr/terapia , Femenino , Humanos , Linfoma de Células B Grandes Difuso/genética , Linfoma de Células B Grandes Difuso/patología , Linfoma de Células B Grandes Difuso/terapia , Trastornos Linfoproliferativos/genética , Trastornos Linfoproliferativos/patología , Trastornos Linfoproliferativos/terapia , Masculino , Persona de Mediana Edad , Neoplasias de la Boca/genética , Neoplasias de la Boca/patología , Neoplasias de la Boca/terapia , Mutación , Clasificación del Tumor , Úlceras Bucales/genética , Úlceras Bucales/patología , Úlceras Bucales/terapia , Valor Predictivo de las PruebasRESUMEN
OBJECTIVE: Viral oral ulcers are common presentations in pediatric clinics. Although self-limiting, painful ulcerative lesions and inflamed mucosa can decrease oral intake and lead to dehydration. Despite the widespread use of Chinese herbal medicine (CHM) for pediatric upper respiratory disease in Taiwan, there is little evidence for its effectiveness as an antipyretic or in aiding ulcer healing for children with viral oral ulcers. We report two cases of children who presented with viral oral ulcers to illustrate the potential efficacy of CHM treatment in recovery from herpangina (HA) and herpetic gingivostomatitis (HGS). CLINICAL FEATURES AND OUTCOME: A 10-year-old girl with HA presented with an acute febrile illness associated with small vesicular or ulcerative lesions on the posterior oropharyngeal structures. The family refused western medicine due to a prior anaphylactic skin rash when she had taken sulfa drugs. The other patient was a 4-year-old boy with complaints of painful ulcers and hemorrhagic crusts on the lips. He was diagnosed with HGS and had received ibuprofen and supportive treatments such as hydration and local anesthesia spray for days, characterized by fever, anorexia, and nausea to no effect. Because the patients were suffering from the damp-heat syndrome according to Traditional Chinese Medicine (TCM) differentiation, both were treated using the same herbal formulas powder prescription, named Liang Ge San (LGS) and Gan Lu Xiao Du Dan (GLXDD). After several days of CHM treatment, the oral ulcers were in regression. Follow-up of the frontal view in both patients showed satisfactory disappearance of the sick furred tongue. CONCLUSIONS: The results of these case reports show that the early prescription of CHM is an effective modality of alternative treatment for viral oral ulcers. To our knowledge, this is the first report of CHM treatment hastening the recovery from febrile disease with viral oral ulcers in Taiwan. Future experimental studies to determine the definitive mechanism and clinical trials are warranted.