What is the diagnosis and treatment for a patient with bumps inside the mouth, gastrointestinal (GI) symptoms, and flu-like symptoms?

Diagnosis and Management of Oral Bumps with GI and Flu-Like Symptoms

Most Likely Diagnosis

The combination of non-painful oral bumps, gastrointestinal symptoms, and flu-like symptoms most likely represents oral candidiasis (thrush) in the context of a viral illness, potentially COVID-19 or influenza. 1, 2

Immediate Diagnostic Approach

Rule Out Life-Threatening Conditions First

• Obtain complete blood count urgently to exclude acute leukemia, which can present with yellowish-white pseudomembrane-covered oral lesions, particularly with neutropenia 3
• Check fasting blood glucose as hyperglycemia is a major predisposing factor for invasive fungal infections presenting as oral plaques 3
• Test for COVID-19 if symptoms include fever, cough, shortness of breath, chills, muscle pain, headache, sore throat, or new loss of taste or smell, as GI symptoms may precede respiratory symptoms by several days 1

Characterize the Oral Lesions

• White plaques that can be scraped off leaving an erythematous base indicate oral candidiasis 2
• Yellowish plaques that cannot be scraped off require fungal culture or KOH preparation 2, 3
• Multiple ulcers with yellowish-white pseudomembranes lasting weeks require biopsy to rule out extranodal NK/T-cell lymphoma or tuberculosis 3

Assess GI Symptoms in Context

• During active COVID-19 or influenza prevalence, assume GI symptoms (nausea, vomiting, diarrhea) are viral until proven otherwise 1
• Test stool for Clostridium difficile and other bacterial pathogens if patient has leukocytosis or recent antibiotic use 1
• Check HIV antibody and syphilis serology as baseline screening 3

Treatment Algorithm

For Confirmed or Suspected Oral Candidiasis

First-line therapy:

• Nystatin oral suspension (100,000 units) four times daily for 1 week, OR
• Miconazole oral gel 5-10 mL held in mouth after food four times daily for 1 week 2

For resistant or severe cases:

• Fluconazole 100 mg/day for 7-14 days 2

If diabetic or immunosuppressed with elevated fungal markers (1-3-β-D-glucan, galactomannan):

• Caspofungin infusion in hospital setting for invasive fungal infection 3

For Flu-Like Symptoms

If influenza is confirmed or suspected during community prevalence:

• Oseltamivir 75 mg twice daily for 5 days started within 48 hours of symptom onset reduces illness duration by 1.3 days in adults 4
• Zanamivir is an alternative if oseltamivir is contraindicated 1
• Treatment is particularly important for immunocompromised patients to reduce risk of complications 1

Supportive Oral Care (Implement Immediately)

• Rinse with alcohol-free, sodium bicarbonate-containing mouthwash upon awakening and at least four times daily 5
• Use soft toothbrush or tongue scraper to gently clean dorsal tongue surface twice daily 2, 5
• Apply viscous lidocaine 2% for immediate pain relief while awaiting diagnosis 3
• Avoid smoking, alcohol, spicy foods, hot beverages, and alcohol-based mouthwashes as they dry the mouth and cause irritation 2, 5
• Never use petroleum-based products chronically on oral mucosa as they promote dehydration and increase infection risk 2, 5

GI Symptom Management

• Optimize anti-emetics and antidiarrheals (loperamide) for symptomatic relief 1
• Monitor QTc interval carefully if using anti-emetics, especially with concurrent hydroxychloroquine or azithromycin 1
• Self-quarantine if COVID-19 is suspected and minimize household contact exposure 1

Critical Red Flags Requiring Urgent Evaluation

• Inability to tolerate sufficient liquid diet with ongoing dehydration or profound weight loss requires urgent endoscopy consideration 1
• Lesions persisting beyond 2 weeks despite appropriate antifungal therapy require biopsy to exclude malignancy or lymphoma 3, 6
• Neutropenia on CBC mandates immediate hematology consultation for possible acute leukemia 3
• Severe dysphagia with inability to tolerate secretions requires emergency evaluation 1

Follow-Up Strategy

• If oral lesions do not improve within 1 week of antifungal therapy, obtain fungal culture and consider biopsy 2, 3
• If GI symptoms persist beyond 1 week, consider endoscopy to rule out immune-mediated colitis or graft-versus-host disease in appropriate clinical contexts 1
• Monitor for development of respiratory symptoms for 30 days after initial presentation, as GI symptoms may precede COVID-19 respiratory manifestations 1