Oral Ulcers — MCQs
All the following can cause mouth ulcers except ?
A 40 year old male reported with recurrent episodes of oral ulcers, large areas of denuded skin and flaccid vesiculo-bullous eruptions. Which is the most important bedside investigation helpful in establishing the diagnosis -
A 30-year-old with recurrent ulcers on lips and genitalia, and positive pathergy test. Diagnosis?
All of the following are found in SLE except
A 30-year-old with recurrent ulcers on lips and genitalia, and positive pathergy test. Diagnosis?
Which of the following is not typically associated with Reiter's syndrome?
A 42 year old man presented with recurrent oral ulcers since one year, episodes of redness of eye and genital ulcers. Which one of the following tests is of diagnostic value?
A patient presents with hoarseness of voice and a clinical condition as shown in the image. Identify the lesion:
A 45 year old male, known case of Rheumatoid arthritis is on a monotherapy since many years. Symptoms of RA are controlled but suddenly patient develops blurring of vision. Which of the following drug is responsible for sudden effect on vision?
A 26 year old female patient presented with fever, oral ulcers, sensitivity to light and rash over the malar area of the face sparing the nasolabial folds of both side. Which of the following indicates the condition associated with these manifestations?
Oral Ulcers Indian Medical PG Practice Questions and MCQs
Question 1: All the following can cause mouth ulcers except ?
- A. Sickle cell anemia
- B. Psoriasis (Correct Answer)
- C. Mouth washes
- D. Lichen planus
Explanation: ***Psoriasis*** - While psoriasis is an inflammatory condition affecting the skin, nails, and joints, it typically does **not cause mouth ulcers** [3], [4]. Oral lesions in psoriasis are rare and atypical, presenting as geographic tongue-like lesions or plaques rather than ulcerations. - The primary lesions of psoriasis are **erythematous plaques with silvery scales**, not aphthous-like ulcers found in the oral cavity [3]. *Sickle cell anemia* - Individuals with sickle cell anemia can experience **oral manifestations** due to chronic hypoxia and impaired microcirculation, including delayed healing and increased susceptibility to infections. - **Recurrent aphthous ulcers** are reported to be more common in patients with sickle cell disease, possibly due to their compromised immune status and tissue perfusion [1]. *Mouth washes* - Certain ingredients in **mouthwashes**, especially those containing strong detergents like **sodium lauryl sulfate (SLS)** or high concentrations of alcohol, can cause irritation and breakdown of the oral mucosa. - This irritation can lead to the development of **chemical burns** or **ulcerations**, particularly with prolonged or frequent use in sensitive individuals. *Lichen planus* - **Oral lichen planus** commonly presents with various lesions in the mouth, including reticular (Wickham's striae), atrophic, erythematous, bullous, and ulcerative forms [2]. - **Erosive and ulcerative forms** of lichen planus are especially painful and can mimic recurrent aphthous ulcers, making it a direct cause of mouth ulcers [1], [2].
Question 2: A 40 year old male reported with recurrent episodes of oral ulcers, large areas of denuded skin and flaccid vesiculo-bullous eruptions. Which is the most important bedside investigation helpful in establishing the diagnosis -
- A. Tzanck smear from the floor of bulla (Correct Answer)
- B. Gram staining of blister fluid
- C. Culture and sensitivity of blister fluid
- D. Skin biopsy with immunofluorescence
Explanation: ***Tzanck smear from the floor of bulla*** - A Tzanck smear from the floor of a bulla will reveal **acantholytic cells** (rounded keratinocytes that have lost their intercellular connections), which are characteristic of pemphigus, consistent with recurrent oral ulcers, denuded skin, and flaccid vesiculobullous eruptions. - This **bedside test** provides a rapid diagnosis by demonstrating the cytological features of acantholysis, differentiating it from other blistering disorders. *Gram staining of blister fluid* - This test is primarily used to identify **bacterial infections** and would show the morphology and Gram-staining characteristics of any bacteria present. - It would not provide information about the **acantholysis** or autoimmune nature of the blistering condition described. *Culture and sensitivity of blister fluid* - This investigation identifies **specific bacterial pathogens** and their antibiotic susceptibilities, which is useful for treating bacterial infections. - It would not help in diagnosing **autoimmune blistering diseases** like pemphigus, where bacteria are not the primary cause of the lesions. *Skin biopsy with immunofluorescence* - While a **skin biopsy with direct immunofluorescence** is the gold standard for confirming pemphigus by detecting autoantibodies, it is an **invasive procedure** requiring laboratory processing and is not considered a rapid bedside investigation. - The question specifically asks for the "most important **bed-side investigation**" helpful in establishing the diagnosis rapidly.
Question 3: A 30-year-old with recurrent ulcers on lips and genitalia, and positive pathergy test. Diagnosis?
- A. Herpes simplex
- B. Behcet's disease (Correct Answer)
- C. Pemphigus vulgaris
- D. Syphilis
Explanation: Behcet's disease - The combination of recurrent oral and genital ulcers along with a positive pathergy test is highly characteristic of Behcet's disease. - Behcet's is a systemic vasculitis that can affect multiple organ systems, with mucocutaneous lesions being a hallmark [3]. Herpes simplex - While herpes simplex causes recurrent oral (cold sores) and genital ulcers, it does not typically involve a positive pathergy test [1]. - Herpes lesions are typically vesicular before ulcerating, and diagnosis is often confirmed by viral culture or PCR [1]. Pemphigus vulgaris - Characterized by painful oral blisters and erosions, but genital ulcers are less common, and it does not typically involve a positive pathergy test. - Pemphigus vulgaris is an autoimmune blistering disease due to antibodies against desmoglein, diagnosed by biopsy and immunofluorescence [2]. Syphilis - Can cause oral and genital ulcers (chancres in primary syphilis) and sometimes mucocutaneous lesions in secondary syphilis (e.g., mucous patches). - However, syphilis does not present with a positive pathergy test, and its diagnosis is made through serological tests (e.g., RPR, VDRL, FTA-ABS).
Question 4: All of the following are found in SLE except
- A. Psychosis
- B. Discoid rash
- C. Oral ulcers
- D. Leucocytosis (Correct Answer)
Explanation: ***Leucocytosis*** - **Leucopenia** (decreased white blood cell count) is a common hematological manifestation in SLE, not **leucocytosis**. - A persistent white blood cell count of **less than 4,000/mm³** on two or more occasions in the absence of other causes is a criterion for SLE. *Psychosis* - **Neuropsychiatric manifestations**, including psychosis, are recognized as a serious complication of SLE, categorized under **neuropsychiatric SLE (NPSLE)**. - These symptoms result from **inflammation, autoantibody production**, and other immune-mediated processes affecting the central nervous system [1]. *Oral ulcers* - **Oral or nasopharyngeal ulcers** are a common mucocutaneous manifestation of SLE. - These ulcers are typically **painless** and can be found on the **hard palate** or buccal mucosa. *Discoid rash* - A **discoid rash** is a specific skin manifestation of cutaneous lupus, often chronic and causing scarring [1]. - It presents as **erythematous raised patches with adherent keratotic scaling** and follicular plugging, which can lead to scarring alopecia [1].
Question 5: A 30-year-old with recurrent ulcers on lips and genitalia, and positive pathergy test. Diagnosis?
- A. Pemphigus vulgaris
- B. Herpes simplex
- C. Behcet's disease (Correct Answer)
- D. Syphilis
Explanation: ***Behcet's disease*** - The classic triad of recurrent **oral ulcers**, **genital ulcers**, and a **positive pathergy test** is highly characteristic of Behcet's disease. - This is a chronic, relapsing, inflammatory condition with systemic involvement, often affecting blood vessels. *Pemphigus vulgaris* - Characterized by **flaccid bullae** and erosions on the skin and mucous membranes due to **autoantibodies against desmoglein**. - While it can cause oral ulcers, genital ulcers are less common and it does not present with a positive pathergy test. *Herpes simplex* - Causes recurrent vesicular lesions, often on the lips (**cold sores**) or genitals (**genital herpes**) [1]. - These lesions are typically painful vesicles that rupture to form ulcers, but do not combine with a positive pathergy test and genital ulcers as seen in Behcet's [1]. *Syphilis* - Manifests in stages; **primary syphilis** presents with a single, painless chancre, often on the genitals or mouth [1]. - While it can cause ulcers, recurrent ulcers and a positive pathergy test are not features of syphilis [1].
Question 6: Which of the following is not typically associated with Reiter's syndrome?
- A. Circinate balanitis
- B. Oral ulcers
- C. Keratoderma blenorrhagicum
- D. Subcutaneous nodules (Correct Answer)
Explanation: ***Subcutaneous nodules*** - **Subcutaneous nodules** are characteristic of conditions like **rheumatoid arthritis** [1] and **rheumatic fever**, not Reiter's syndrome (reactive arthritis). - While Reiter's syndrome can present with a variety of extra-articular manifestations, these specific nodules are not part of its typical clinical picture. *Oral ulcers* - **Oral ulcers** (painless aphthous ulcers) are a known mucocutaneous manifestation that can occur in patients with Reiter's syndrome [2]. - They are one of the 'can't see, can't pee, can't climb a tree' symptoms often associated with the condition, though less common than arthritis. *Keratoderma blenorrhagicum* - **Keratoderma blenorrhagicum** is a specific skin lesion characterized by hyperkeratotic, waxy, yellow-brown papules and plaques, predominantly on the palms and soles [2]. - It is highly characteristic, though not universally present, in patients with Reiter's syndrome and is clinically and histologically indistinguishable from pustular psoriasis. *Circinate balanitis* - **Circinate balanitis** is a painless inflammation of the glans penis characterized by shallow, serpiginous erosions [2]. - It is a common mucocutaneous manifestation of Reiter's syndrome, particularly in uncircumcised males [2].
Question 7: A 42 year old man presented with recurrent oral ulcers since one year, episodes of redness of eye and genital ulcers. Which one of the following tests is of diagnostic value?
- A. Drug-sensitivity test
- B. Pathergy test (Correct Answer)
- C. Patch test
- D. Mantoux test
Explanation: ***Pathergy test*** - The constellation of **recurrent oral and genital ulcers** along with **ocular inflammation (redness of eye)** is highly suggestive of **Behçet's disease**. - The **pathergy test** assesses for a hyper-reactivity of the skin to needle prick, which is characteristic of Behçet's disease and thus of diagnostic value. *Drug-sensitivity test* - This test is primarily used to identify allergic reactions or sensitivities to specific medications. - It would not be indicated for diagnosing a systemic inflammatory condition like Behçet's disease. *Patch test* - A **patch test** is used to identify substances that cause allergic contact dermatitis by applying potential allergens to the skin. - It is not relevant for the diagnosis of Behçet's disease, which involves inflammatory rather than allergic reactions. *Mantoux test* - The **Mantoux test** (tuberculin skin test) is used to screen for **tuberculosis infection** [1]. - This patient's symptoms are not consistent with tuberculosis, and the Mantoux test has no role in diagnosing Behçet's disease [2].
Question 8: A patient presents with hoarseness of voice and a clinical condition as shown in the image. Identify the lesion:
- A. Diphtheria (Correct Answer)
- B. Follicular tonsillitis
- C. Aphthous ulcer
- D. Membranous tonsillitis
Explanation: ***Diphtheria*** - The image shows a **thick, grayish-white pseudomembrane** covering the tonsils and likely extending to other parts of the pharynx, which is a classic sign of diphtheria. - **Hoarseness** indicates laryngeal involvement, a severe complication of diphtheria due to pseudomembrane formation extending to the larynx, potentially causing airway obstruction. *Follicular tonsillitis* - This condition presents with **pus-filled follicles** or spots on the tonsils, which are typically yellow or white, rather than a confluent membrane. - While it causes throat pain and fever, it generally does not lead to the formation of a **firm, adherent pseudomembrane** or significant hoarseness from laryngeal obstruction as seen in diphtheria. *Aphthous ulcer* - An aphthous ulcer is a **small, painful, shallow sore** with a white or yellowish center and a red border, typically found on the non-keratinized oral mucosa. - It does not present as a widespread, thick membranous lesion covering the tonsils and causing hoarseness. *Membranous tonsillitis* - While "membranous tonsillitis" describes the presence of a membrane on the tonsils, this term is often used generally. However, the specific characteristics in the image (thick, grayish, adherent membrane with severe symptoms like hoarseness) are pathognomonic for **diphtheria**. - Other causes of membranous tonsillitis, such as infectious mononucleosis, typically present with a less adherent membrane and often lack the severe systemic toxicity and potential for rapid airway compromise seen in diphtheria.
Question 9: A 45 year old male, known case of Rheumatoid arthritis is on a monotherapy since many years. Symptoms of RA are controlled but suddenly patient develops blurring of vision. Which of the following drug is responsible for sudden effect on vision?
- A. Methotrexate
- B. Hydroxychloroquine (Correct Answer)
- C. Sulfasalazine
- D. Leflunomide
Explanation: ***Hydroxychloroquine*** - **Hydroxychloroquine** [1] is known to cause **retinal toxicity** (maculopathy) as a dose-dependent, long-term side effect, leading to **blurring of vision** and other visual disturbances. - Patients on long-term hydroxychloroquine therapy require regular **ophthalmological screening** to detect and prevent irreversible vision loss. *Methotrexate* - **Methotrexate** is a common DMARD used in RA [1], but its ocular side effects are typically rare and less severe, usually involving **conjunctivitis** or **periorbital edema**. - It does not commonly cause **maculopathy** or sudden profound blurring of vision. *Sulfasalazine* - **Sulfasalazine** [1] can cause a range of side effects, including gastrointestinal issues and various hypersensitivity reactions. - Ocular side effects are infrequent and generally mild, such as **conjunctivitis** or **periorbital edema**, and not severe blurring of vision due to retinal damage. *Leflunomide* - **Leflunomide** is an immunosuppressive DMARD [1] whose common adverse effects include hepatotoxicity, gastrointestinal upset, and hypertension. - Significant **ocular toxicity** leading to blurring of vision, particularly retinal damage, is not a characteristic side effect of **leflunomide**.
Question 10: A 26 year old female patient presented with fever, oral ulcers, sensitivity to light and rash over the malar area of the face sparing the nasolabial folds of both side. Which of the following indicates the condition associated with these manifestations?
- A. Rosacea
- B. Dermatomyositis
- C. Psoriasis
- D. SLE (Correct Answer)
Explanation: ***SLE*** - The combination of **fever**, **oral ulcers**, **photosensitivity**, and a **malar rash** (which typically spares the nasolabial folds), particularly in a young female, is classic for **Systemic Lupus Erythematosus (SLE)** [1]. - SLE is a **chronic autoimmune inflammatory disease** that can affect multiple organ systems [2]. *Rosacea* - Rosacea often presents with **facial erythema**, **telangiectasias**, and papulopustules, primarily on the central face, but it does not typically involve oral ulcers, fever, or photosensitivity in the same way as SLE [4]. - The rash of rosacea is usually not a classic malar rash sparing the nasolabial folds, and it is not an autoimmune systemic disease. *Dermatomyositis* - Dermatomyositis is characterized by **proximal muscle weakness** and specific skin manifestations like **Gottron's papules** (over joints), **heliotrope rash** (periorbital edema), and a **shawl sign**, which differ from the presented symptoms [3]. - While it can cause light sensitivity and a rash, the distribution and associated symptoms (like no mention of muscle weakness) are not typical for a primary presentation of dermatomyositis. *Psoriasis* - Psoriasis typically presents with **well-demarcated erythematous plaques** covered with **silvery scales**, commonly on extensor surfaces like elbows and knees, and can also affect nails and joints. - It does not typically cause fever, oral ulcers, or a malar rash with nasolabial fold sparing, which are hallmarks of SLE.
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