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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Multiple clinical manifestations of coronavirus disease 2019 &#40;COVID-19&#41; have gradually come to light since the early reports of respiratory and thrombotic symptoms&#44; and include loss of smell&#44; taste disturbances&#44; and neurological and digestive disorders&#46; Cutaneous manifestations of COVID-19 have been classified into 5 clinical patterns&#58; acro-ischemic &#40;pseudo-chilblain&#41;&#44; vesicular&#44; urticarial&#44; maculopapular&#44; and livedoid or necrotic&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Oral mucosal changes have also been reported&#44; but much less frequently&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Severe acute respiratory syndrome coronavirus 2 &#40;SARS-CoV-2&#41;&#44; which causes COVID-19&#44; binds to angiotensin converting enzyme 2 &#40;ACE-2&#41; receptors&#44; which were recently identified on the dorsum of the tongue and in the salivary glands&#44; confirming that the virus can infect the oral mucosa&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In this article&#44; we describe oral mucosal findings observed in patients with COVID-19 pneumonia at the IFEMA field hospital in Madrid&#44; Spain&#46; Some of these cases are already described in the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The specific aim of this study was to describe all the oral mucosal changes observed in this series of patients and discuss the possible pathophysiological mechanisms of SARS-CoV-2 infection of the oral cavity&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patients and methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">During the first wave of the COVID-19 pandemic in Spain&#44; the country&#8217;s hospitals were so overstretched that it was necessary to open field hospitals&#46; The Community of Madrid installed a provisional hospital at the IFEMA trade show and conference center that provided care to over 4500 COVID-19 patients between March 21 and April 30&#44; 2020&#46; A group of voluntary dermatologists conducted a cross-sectional study in which they examined the mucous membranes of all patients admitted to IFEMA from other hospitals in Madrid&#46; They included patients with pneumonia and a positive polymerase chain reaction test for SARS-CoV-2 or radiological images of COVID-19 without evidence of other causes of pneumonia&#46; The examination of patients was facilitated by the fact that the investigators did not need to change personal protective equipment &#40;PPE&#41; between contacts&#44; as all the patients were examined in a dedicated COVID-19 room&#46; The study was approved by the ethics committee of Hospital La Paz&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0030" class="elsevierStylePara elsevierViewall">The mucous membranes of 715 patients were examined&#46; Of these&#44; 666 met the inclusion criteria&#46; The results are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Seventy-eight patients &#40;11&#46;7&#37;&#41; had changes involving the oral mucosa&#46; The most common manifestation was transient U-shaped lingual papillitis&#44; present in 35 patients &#40;11&#46;5&#37;&#41;&#59; 20 of these patients &#40;6&#46;6&#37;&#41; also had tongue swelling &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Glossitis with patchy depapillation&#44; a characteristic inflammatory pattern of the tongue&#44; was observed in 12 patients &#40;3&#46;9&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; A fungal culture was performed in all cases and was negative&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Other common manifestations were aphthous stomatitis &#40;n&#160;&#61;&#160;21&#44; 6&#46;9&#37;&#41; and mucositis &#40;n&#160;&#61;&#160;12&#44; 3&#46;9&#37;&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Sixteen patients &#40;5&#46;3&#37;&#41; reported a burning sensation on the tongue or in the mouth&#59; 5 &#40;1&#46;6&#37;&#41; had white tongue and 2 &#40;0&#46;5&#37;&#41; had enanthema&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0055" class="elsevierStylePara elsevierViewall">The reported prevalence of cutaneous manifestations in patients with COVID-19 is variable&#44; and ranges from 7&#46;8&#37; in the study by Giorgi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> to 20&#37; in the study by Recalcati<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> and 45&#46;6&#37; in the first study of mucocutaneous manifestations in this series of patients from the IFEMA field hospital&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> There have been few reports&#44; however&#44; of oral manifestations&#44; probably because of fear of infection during examination or the shortage of PPE during the first wave&#46; Enanthema was among the first manifestations to be described&#46; Several cases were mentioned by Galv&#225;n-Casas et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> who classified the cutaneous manifestations of COVID-19 into 5 patterns&#46; Jimenez-Cahue et al&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> later described enanthema in 29&#37; of COVID-19 patients with a skin rash&#44; which mostly took the form of papulovesicular&#44; purpuric&#44; or erythema multiforme&#8211;like eruption&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The most frequently described oral manifestation associated with COVID-19 to date is dysgeusia&#44; with rates ranging from 5&#46;6&#37; in early reports from China<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> to 88&#46;8&#37; in a study conducted by ear&#44; nose&#44; and throat specialists&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Taste disturbances are highly specific to SARS-CoV-2 infection and may or not be accompanied by a loss of smell&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Dry mouth is also very common and is possibly linked to the destruction of salivary glands caused by the binding of the virus to ACE-2 receptors on the glands&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">We also observed what we consider to be tongue-specific manifestations&#44; such as swelling with characteristic indentation on both sides due to the increased size of the tongue and its pressing against the teeth&#46; This swelling also causes inflammation of the anterior papillae&#44; leading to what we have termed <span class="elsevierStyleItalic">transient U-shaped lingual papillitis</span>&#46; One group of authors reported a case of macroglossia associated with COVID-19 that required treatment with corticosteroids&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Tongue swelling and irritated papillae can be caused by multiple factors&#44; including direct inflammation of the oral mucosa by SARS-CoV-2&#44; drying of the mucosa due to viral activity or oxygen therapy&#44; or even poor oral hygiene due to the patient&#8217;s situation&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Another highly characteristic finding was glossitis with patchy depapillation&#44; observed in 3&#46;9&#37; of patients in our series&#46; D&#237;az Rodr&#237;guez et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> also reported a case of depapillation&#44; interestingly associated with a burning sensation in the mouth&#46; Another more recently described oral manifestation is COVID tongue&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> which is similar to geographic tongue but characterized by an increased incidence in patients with SARS-CoV-2 infection&#46; It might be caused by direct binding of the virus to ACE-2 receptors on the tongue or by an increased expression of interleukin 6&#44; which has been described in patients with COVID-19 and patients with geographic tongue&#46; Further studies are needed to better understand this association and its possible etiology and pathogenesis&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Mouth ulcers and aphthous stomatitis have also been described in patients with COVID-19&#44; and in some cases as an early sign of infection<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;17</span></a>&#59; mucositis and aphthous lesions in the mouth have been linked to infections by other viruses&#44; such as herpes simplex and cytomegalovirus&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The sensation of a burning tongue or burning mouth syndrome has also been previously described in association with COVID-19&#46; One Italian study of oral manifestations in 20 COVID-19 patients found that 15&#37; had the sensation of a burning mouth<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>&#59; this rate is somewhat higher than that of 5&#46;3&#37; detected in our series&#46; The authors of an Iranian study reported a prevalence rate of 68&#37; for oral manifestations of COVID-19 classified into pain&#44; burning&#44; and pruritus&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> These manifestations could have a neurological origin as palmoplantar erythrodysesthesia has also been described in COVID-19&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> A burning sensation in the mouth or on the palms and soles could be a sign of SARS-CoV-2 infection&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Oral manifestations in patients with COVID-19 might be due to SARS-CoV-2-mediated hemolysis &#40;erythrocytes have ACE-2 receptors&#41;&#46; The virus might compete with hepcidin&#44; causing increased levels of serum ferritin and&#44; paradoxically&#44; anemia and iron deficiency&#46; Like patients with iron deficiency&#44; they could experience ulcers and a burning sensation in the mouth&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">There have also been reports of new-onset halitosis in patients with COVID-19&#46; Using a halimeter&#44; one group of authors found that patients had increased sulphur compound levels during active SARS-CoV-2 infection and normal levels afterwards&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> As possible reasons&#44; the authors proposed primary&#44; virus-mediated&#44; alterations to the oral mucosa or secondary alterations related to dry mouth and decreased salivary flow&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Possible sources of bias in our study are its cross-sectional design &#40;we do not know the history or outcomes of the lesions identified&#41; and our exclusive focus on patients with pneumonia &#40;we do not know whether patients with few or no symptoms might have developed similar lesions&#41;&#46; We also did not find any reports of oral manifestations in hospitalized COVID-19 patients being treated with antibodies&#44; fluid therapy&#44; or mechanical ventilation&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusions</span><p id="par0100" class="elsevierStylePara elsevierViewall">Oral cavity lesions are associated with COVID-19 and may be an early sign of disease&#46; Apart from dysgeusia&#44; dry mouth&#44; ulcers&#44; and enanthema&#44; clinicians should also check for tongue alterations&#44; such as transient U-shaped tongue papillitis with or without tongue swelling and glossitis with patchy depapillation&#46; Burning mouth syndrome might also be a sign of COVID-19&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicts of interest</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "identificador" => "xres1542273"
          "titulo" => "Abstract"
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              "titulo" => "Background"
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              "titulo" => "Introducci&#243;n"
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              "titulo" => "Pacientes y m&#233;todos"
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              "titulo" => "Conclusi&#243;n"
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          "titulo" => "Palabras clave"
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          "titulo" => "Introduction"
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          "titulo" => "Conclusions"
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    "fechaRecibido" => "2021-01-13"
    "fechaAceptado" => "2021-02-15"
    "PalabrasClave" => array:2 [
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1395159"
          "palabras" => array:12 [
            0 => "Coronavirus"
            1 => "COVID-19"
            2 => "Oral manifestations"
            3 => "Oral changes"
            4 => "Swollen tongue"
            5 => "Macroglossia"
            6 => "Papillitis"
            7 => "Anterior lingual papillitis"
            8 => "Aphthae"
            9 => "Enanthema"
            10 => "Mucositis"
            11 => "Dysgeusia"
          ]
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      ]
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1395158"
          "palabras" => array:12 [
            0 => "Coronavirus"
            1 => "COVID-19"
            2 => "Manifestaciones orales"
            3 => "Alteraciones orales"
            4 => "Edema lingual"
            5 => "Macroglosia"
            6 => "Papilitis"
            7 => "Papilitis lingual anterior"
            8 => "Aftas"
            9 => "Enantema"
            10 => "Mucositis"
            11 => "Disgeusia"
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    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Coronavirus disease 19 &#40;COVID-19&#41; has many manifestations&#44; including respiratory&#44; thrombotic&#44; neurologic&#44; digestive&#44; and cutaneous ones&#46; Cutaneous manifestations have been classified into 5 clinical patterns&#58; acro-ischemic &#40;pseudo-chilblain&#41;&#44; vesicular&#44; urticarial&#44; maculopapular&#44; and livedoid&#46; Oral manifestations have also been reported&#44; but much less frequently&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients and methods</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">We performed a cross-sectional study in which we examined the oral mucosa of 666 patients with COVID-19 at the IFEMA field hospital in Madrid in April 2020&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Seventy-eight patients &#40;11&#46;7&#37;&#41; had changes involving the oral mucosa&#46; The most common were transient anterior U-shaped lingual papillitis &#40;11&#46;5&#37;&#41; accompanied or not by tongue swelling &#40;6&#46;6&#37;&#41;&#44; aphthous stomatitis &#40;6&#46;9&#37;&#41;&#44; a burning sensation in the mouth &#40;5&#46;3&#37;&#41;&#44; mucositis &#40;3&#46;9&#37;&#41;&#44; glossitis with patchy depapillation &#40;3&#46;9&#37;&#41;&#44; white tongue &#40;1&#46;6&#37;&#41;&#44; and enanthema &#40;0&#46;5&#37;&#41;&#46; Most of the patients also reported taste disturbances&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">COVID-19 also manifests in the oral cavity&#46; The most common manifestations are transient U-shaped lingual papillitis&#44; glossitis with patchy depapillation&#44; and burning mouth syndrome&#46; Mucositis with or without aphthous ulcers or enanthema may also be observed&#46; Any these findings may be key clues to a diagnosis of COVID-19&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Background"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Patients and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La enfermedad por coronavirus-19 &#40;COVID-19&#41; se ha relacionado con m&#250;ltiples s&#237;ntomas&#58; respiratorios&#44; tromb&#243;ticos&#44; neurol&#243;gicos&#44; digestivos o cut&#225;neos&#46; Estos &#250;ltimos se han clasificado en 5 tipos&#58; lesiones acroisqu&#233;micas&#44; lesiones vesiculares&#44; erupci&#243;n urticarial&#44; exantema maculopapular o lesiones livedoides&#46; Sin embargo&#44; se han descrito mucho menos las alteraciones orales asociadas a COVID-19&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pacientes y m&#233;todos</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Presentamos un estudio transversal realizado durante abril de 2020 en el Hospital de Campa&#241;a de IFEMA examinando la mucosa oral de 666 pacientes con COVID-19&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">En total&#44; 78 pacientes &#40;11&#46;7&#37;&#41; presentaron alteraciones en la mucosa oral&#46; La m&#225;s frecuente fue papilitis lingual transitoria anterior en forma de U &#40;11&#46;5&#37;&#41; asociada o no a edema lingual &#40;6&#44;6&#37;&#41;&#59; estomatitis aftosa &#40;6&#46;9&#37;&#41;&#44; mucositis &#40;3&#46;9&#37;&#41; glositis con depapilaci&#243;n en parches &#40;3&#46;9&#37;&#41;&#44; boca urente &#40;5&#46;3&#37;&#41;&#44; lengua saburral &#40;1&#44;6&#37;&#41; y enantema &#40;0&#46;5&#37;&#41;&#46; La mayor&#237;a refer&#237;a disgeusia asociada&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">La cavidad oral se puede alterar por la enfermedad COVID-19&#44; el edema lingual con papilitis lingual transitoria en forma de U o la glositis con depapilaci&#243;n en parches son los signos encontrados con mayor frecuencia&#44; al igual que la sensaci&#243;n de ardor en la cavidad oral o boca urente&#46; Otras manifestaciones orales que se pueden asociar a COVID-19 son mucositis con o sin aftas o el enantema&#46; Todos pueden ser signos clave para un diagn&#243;stico de esta enfermedad&#46;</p></span>"
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            "titulo" => "Pacientes y m&#233;todos"
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            "titulo" => "Resultados"
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            "identificador" => "abst0040"
            "titulo" => "Conclusi&#243;n"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Nu&#241;o Gonz&#225;lez A&#44; Magaletskyy K&#44; Mart&#237;n Carrillo P&#44; Lozano Masdemont B&#44; Mayor Ibarguren A&#44; Feito Rodr&#237;guez M&#44; et al&#46;&#44; &#191;Son las alteraciones en la mucosa oral un signo de COVID-19&#63; Estudio transversal en un Hospital de Campa&#241;a&#44; ACTAS Dermo-Sifiliogr&#225;ficas&#44; 2021&#59;112&#58;640&#8211;644&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Characteristic tongue swelling or macroglossia &#40;6&#46;6&#37;&#41; associated with transient U-shaped lingual papillitis &#40;11&#46;5&#37;&#41; in patients with COVID-19&#46; A&#44; Illustration showing tongue changes with indentation on both sides of the tongue and inflammation of anterior papillae&#44; probably caused by friction&#46; B&#8211;E&#44; Tongue swelling and transient U-shaped lingual papillitis during COVID-19&#46; COVID-19 indicates coronavirus disease 2019&#46;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Glossitis and patchy depapillation &#40;3&#46;9&#37;&#41; in patients with COVID-19&#46; A&#44; Illustration showing glossitis with patchy depapillation observed in patients with COVID-19&#46; B&#8211;D&#44; Patients with glossitis and patchy depapillation&#46; Fungal culture and serology were negative&#46; COVID-19 indicates coronavirus disease 2019&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">No&#46; &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Oral mucosal changes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">78 &#40;11&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Transient U-shaped lingual papillitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35 &#40;11&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tongue swelling&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20 &#40;6&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Glossitis with patchy depapillation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12 &#40;3&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mucositis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12 &#40;3&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Aphthous ulcers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21 &#40;6&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Burning mouth&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;5&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">White tongue&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;1&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Candidiasis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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Original Article
Are Oral Mucosal Changes a Sign of COVID-19? A Cross-Sectional Study at a Field Hospital
¿Son las alteraciones en la mucosa oral un signo de COVID-19? Estudio transversal en un Hospital de Campaña
A. Nuño Gonzáleza,
Autor para correspondencia
, K. Magaletskyya, P. Martín Carrillob, B. Lozano Masdemontc, A. Mayor Ibargurena, M. Feito Rodrígueza, P. Herranz Pintoa
a Servicio de Dermatología, Hospital Universitario La Paz, Madrid, Spain
b SERMAS, Centro de Salud de Colmenarejo, Colmenarejo, Madrid, Spain
c Servicio de Dermatología, Hospital Universitario de Móstoles, Móstoles, Madrid, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Multiple clinical manifestations of coronavirus disease 2019 &#40;COVID-19&#41; have gradually come to light since the early reports of respiratory and thrombotic symptoms&#44; and include loss of smell&#44; taste disturbances&#44; and neurological and digestive disorders&#46; Cutaneous manifestations of COVID-19 have been classified into 5 clinical patterns&#58; acro-ischemic &#40;pseudo-chilblain&#41;&#44; vesicular&#44; urticarial&#44; maculopapular&#44; and livedoid or necrotic&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Oral mucosal changes have also been reported&#44; but much less frequently&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Severe acute respiratory syndrome coronavirus 2 &#40;SARS-CoV-2&#41;&#44; which causes COVID-19&#44; binds to angiotensin converting enzyme 2 &#40;ACE-2&#41; receptors&#44; which were recently identified on the dorsum of the tongue and in the salivary glands&#44; confirming that the virus can infect the oral mucosa&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In this article&#44; we describe oral mucosal findings observed in patients with COVID-19 pneumonia at the IFEMA field hospital in Madrid&#44; Spain&#46; Some of these cases are already described in the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The specific aim of this study was to describe all the oral mucosal changes observed in this series of patients and discuss the possible pathophysiological mechanisms of SARS-CoV-2 infection of the oral cavity&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patients and methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">During the first wave of the COVID-19 pandemic in Spain&#44; the country&#8217;s hospitals were so overstretched that it was necessary to open field hospitals&#46; The Community of Madrid installed a provisional hospital at the IFEMA trade show and conference center that provided care to over 4500 COVID-19 patients between March 21 and April 30&#44; 2020&#46; A group of voluntary dermatologists conducted a cross-sectional study in which they examined the mucous membranes of all patients admitted to IFEMA from other hospitals in Madrid&#46; They included patients with pneumonia and a positive polymerase chain reaction test for SARS-CoV-2 or radiological images of COVID-19 without evidence of other causes of pneumonia&#46; The examination of patients was facilitated by the fact that the investigators did not need to change personal protective equipment &#40;PPE&#41; between contacts&#44; as all the patients were examined in a dedicated COVID-19 room&#46; The study was approved by the ethics committee of Hospital La Paz&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0030" class="elsevierStylePara elsevierViewall">The mucous membranes of 715 patients were examined&#46; Of these&#44; 666 met the inclusion criteria&#46; The results are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Seventy-eight patients &#40;11&#46;7&#37;&#41; had changes involving the oral mucosa&#46; The most common manifestation was transient U-shaped lingual papillitis&#44; present in 35 patients &#40;11&#46;5&#37;&#41;&#59; 20 of these patients &#40;6&#46;6&#37;&#41; also had tongue swelling &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Glossitis with patchy depapillation&#44; a characteristic inflammatory pattern of the tongue&#44; was observed in 12 patients &#40;3&#46;9&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; A fungal culture was performed in all cases and was negative&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Other common manifestations were aphthous stomatitis &#40;n&#160;&#61;&#160;21&#44; 6&#46;9&#37;&#41; and mucositis &#40;n&#160;&#61;&#160;12&#44; 3&#46;9&#37;&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Sixteen patients &#40;5&#46;3&#37;&#41; reported a burning sensation on the tongue or in the mouth&#59; 5 &#40;1&#46;6&#37;&#41; had white tongue and 2 &#40;0&#46;5&#37;&#41; had enanthema&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0055" class="elsevierStylePara elsevierViewall">The reported prevalence of cutaneous manifestations in patients with COVID-19 is variable&#44; and ranges from 7&#46;8&#37; in the study by Giorgi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> to 20&#37; in the study by Recalcati<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> and 45&#46;6&#37; in the first study of mucocutaneous manifestations in this series of patients from the IFEMA field hospital&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> There have been few reports&#44; however&#44; of oral manifestations&#44; probably because of fear of infection during examination or the shortage of PPE during the first wave&#46; Enanthema was among the first manifestations to be described&#46; Several cases were mentioned by Galv&#225;n-Casas et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> who classified the cutaneous manifestations of COVID-19 into 5 patterns&#46; Jimenez-Cahue et al&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> later described enanthema in 29&#37; of COVID-19 patients with a skin rash&#44; which mostly took the form of papulovesicular&#44; purpuric&#44; or erythema multiforme&#8211;like eruption&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The most frequently described oral manifestation associated with COVID-19 to date is dysgeusia&#44; with rates ranging from 5&#46;6&#37; in early reports from China<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> to 88&#46;8&#37; in a study conducted by ear&#44; nose&#44; and throat specialists&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Taste disturbances are highly specific to SARS-CoV-2 infection and may or not be accompanied by a loss of smell&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Dry mouth is also very common and is possibly linked to the destruction of salivary glands caused by the binding of the virus to ACE-2 receptors on the glands&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">We also observed what we consider to be tongue-specific manifestations&#44; such as swelling with characteristic indentation on both sides due to the increased size of the tongue and its pressing against the teeth&#46; This swelling also causes inflammation of the anterior papillae&#44; leading to what we have termed <span class="elsevierStyleItalic">transient U-shaped lingual papillitis</span>&#46; One group of authors reported a case of macroglossia associated with COVID-19 that required treatment with corticosteroids&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Tongue swelling and irritated papillae can be caused by multiple factors&#44; including direct inflammation of the oral mucosa by SARS-CoV-2&#44; drying of the mucosa due to viral activity or oxygen therapy&#44; or even poor oral hygiene due to the patient&#8217;s situation&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Another highly characteristic finding was glossitis with patchy depapillation&#44; observed in 3&#46;9&#37; of patients in our series&#46; D&#237;az Rodr&#237;guez et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> also reported a case of depapillation&#44; interestingly associated with a burning sensation in the mouth&#46; Another more recently described oral manifestation is COVID tongue&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> which is similar to geographic tongue but characterized by an increased incidence in patients with SARS-CoV-2 infection&#46; It might be caused by direct binding of the virus to ACE-2 receptors on the tongue or by an increased expression of interleukin 6&#44; which has been described in patients with COVID-19 and patients with geographic tongue&#46; Further studies are needed to better understand this association and its possible etiology and pathogenesis&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Mouth ulcers and aphthous stomatitis have also been described in patients with COVID-19&#44; and in some cases as an early sign of infection<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;17</span></a>&#59; mucositis and aphthous lesions in the mouth have been linked to infections by other viruses&#44; such as herpes simplex and cytomegalovirus&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The sensation of a burning tongue or burning mouth syndrome has also been previously described in association with COVID-19&#46; One Italian study of oral manifestations in 20 COVID-19 patients found that 15&#37; had the sensation of a burning mouth<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>&#59; this rate is somewhat higher than that of 5&#46;3&#37; detected in our series&#46; The authors of an Iranian study reported a prevalence rate of 68&#37; for oral manifestations of COVID-19 classified into pain&#44; burning&#44; and pruritus&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> These manifestations could have a neurological origin as palmoplantar erythrodysesthesia has also been described in COVID-19&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> A burning sensation in the mouth or on the palms and soles could be a sign of SARS-CoV-2 infection&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Oral manifestations in patients with COVID-19 might be due to SARS-CoV-2-mediated hemolysis &#40;erythrocytes have ACE-2 receptors&#41;&#46; The virus might compete with hepcidin&#44; causing increased levels of serum ferritin and&#44; paradoxically&#44; anemia and iron deficiency&#46; Like patients with iron deficiency&#44; they could experience ulcers and a burning sensation in the mouth&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">There have also been reports of new-onset halitosis in patients with COVID-19&#46; Using a halimeter&#44; one group of authors found that patients had increased sulphur compound levels during active SARS-CoV-2 infection and normal levels afterwards&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> As possible reasons&#44; the authors proposed primary&#44; virus-mediated&#44; alterations to the oral mucosa or secondary alterations related to dry mouth and decreased salivary flow&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Possible sources of bias in our study are its cross-sectional design &#40;we do not know the history or outcomes of the lesions identified&#41; and our exclusive focus on patients with pneumonia &#40;we do not know whether patients with few or no symptoms might have developed similar lesions&#41;&#46; We also did not find any reports of oral manifestations in hospitalized COVID-19 patients being treated with antibodies&#44; fluid therapy&#44; or mechanical ventilation&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusions</span><p id="par0100" class="elsevierStylePara elsevierViewall">Oral cavity lesions are associated with COVID-19 and may be an early sign of disease&#46; Apart from dysgeusia&#44; dry mouth&#44; ulcers&#44; and enanthema&#44; clinicians should also check for tongue alterations&#44; such as transient U-shaped tongue papillitis with or without tongue swelling and glossitis with patchy depapillation&#46; Burning mouth syndrome might also be a sign of COVID-19&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicts of interest</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "clase" => "keyword"
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            0 => "Coronavirus"
            1 => "COVID-19"
            2 => "Oral manifestations"
            3 => "Oral changes"
            4 => "Swollen tongue"
            5 => "Macroglossia"
            6 => "Papillitis"
            7 => "Anterior lingual papillitis"
            8 => "Aphthae"
            9 => "Enanthema"
            10 => "Mucositis"
            11 => "Dysgeusia"
          ]
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          "palabras" => array:12 [
            0 => "Coronavirus"
            1 => "COVID-19"
            2 => "Manifestaciones orales"
            3 => "Alteraciones orales"
            4 => "Edema lingual"
            5 => "Macroglosia"
            6 => "Papilitis"
            7 => "Papilitis lingual anterior"
            8 => "Aftas"
            9 => "Enantema"
            10 => "Mucositis"
            11 => "Disgeusia"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Coronavirus disease 19 &#40;COVID-19&#41; has many manifestations&#44; including respiratory&#44; thrombotic&#44; neurologic&#44; digestive&#44; and cutaneous ones&#46; Cutaneous manifestations have been classified into 5 clinical patterns&#58; acro-ischemic &#40;pseudo-chilblain&#41;&#44; vesicular&#44; urticarial&#44; maculopapular&#44; and livedoid&#46; Oral manifestations have also been reported&#44; but much less frequently&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients and methods</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">We performed a cross-sectional study in which we examined the oral mucosa of 666 patients with COVID-19 at the IFEMA field hospital in Madrid in April 2020&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Seventy-eight patients &#40;11&#46;7&#37;&#41; had changes involving the oral mucosa&#46; The most common were transient anterior U-shaped lingual papillitis &#40;11&#46;5&#37;&#41; accompanied or not by tongue swelling &#40;6&#46;6&#37;&#41;&#44; aphthous stomatitis &#40;6&#46;9&#37;&#41;&#44; a burning sensation in the mouth &#40;5&#46;3&#37;&#41;&#44; mucositis &#40;3&#46;9&#37;&#41;&#44; glossitis with patchy depapillation &#40;3&#46;9&#37;&#41;&#44; white tongue &#40;1&#46;6&#37;&#41;&#44; and enanthema &#40;0&#46;5&#37;&#41;&#46; Most of the patients also reported taste disturbances&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">COVID-19 also manifests in the oral cavity&#46; The most common manifestations are transient U-shaped lingual papillitis&#44; glossitis with patchy depapillation&#44; and burning mouth syndrome&#46; Mucositis with or without aphthous ulcers or enanthema may also be observed&#46; Any these findings may be key clues to a diagnosis of COVID-19&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Background"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Patients and methods"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La enfermedad por coronavirus-19 &#40;COVID-19&#41; se ha relacionado con m&#250;ltiples s&#237;ntomas&#58; respiratorios&#44; tromb&#243;ticos&#44; neurol&#243;gicos&#44; digestivos o cut&#225;neos&#46; Estos &#250;ltimos se han clasificado en 5 tipos&#58; lesiones acroisqu&#233;micas&#44; lesiones vesiculares&#44; erupci&#243;n urticarial&#44; exantema maculopapular o lesiones livedoides&#46; Sin embargo&#44; se han descrito mucho menos las alteraciones orales asociadas a COVID-19&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pacientes y m&#233;todos</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Presentamos un estudio transversal realizado durante abril de 2020 en el Hospital de Campa&#241;a de IFEMA examinando la mucosa oral de 666 pacientes con COVID-19&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">En total&#44; 78 pacientes &#40;11&#46;7&#37;&#41; presentaron alteraciones en la mucosa oral&#46; La m&#225;s frecuente fue papilitis lingual transitoria anterior en forma de U &#40;11&#46;5&#37;&#41; asociada o no a edema lingual &#40;6&#44;6&#37;&#41;&#59; estomatitis aftosa &#40;6&#46;9&#37;&#41;&#44; mucositis &#40;3&#46;9&#37;&#41; glositis con depapilaci&#243;n en parches &#40;3&#46;9&#37;&#41;&#44; boca urente &#40;5&#46;3&#37;&#41;&#44; lengua saburral &#40;1&#44;6&#37;&#41; y enantema &#40;0&#46;5&#37;&#41;&#46; La mayor&#237;a refer&#237;a disgeusia asociada&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">La cavidad oral se puede alterar por la enfermedad COVID-19&#44; el edema lingual con papilitis lingual transitoria en forma de U o la glositis con depapilaci&#243;n en parches son los signos encontrados con mayor frecuencia&#44; al igual que la sensaci&#243;n de ardor en la cavidad oral o boca urente&#46; Otras manifestaciones orales que se pueden asociar a COVID-19 son mucositis con o sin aftas o el enantema&#46; Todos pueden ser signos clave para un diagn&#243;stico de esta enfermedad&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Nu&#241;o Gonz&#225;lez A&#44; Magaletskyy K&#44; Mart&#237;n Carrillo P&#44; Lozano Masdemont B&#44; Mayor Ibarguren A&#44; Feito Rodr&#237;guez M&#44; et al&#46;&#44; &#191;Son las alteraciones en la mucosa oral un signo de COVID-19&#63; Estudio transversal en un Hospital de Campa&#241;a&#44; ACTAS Dermo-Sifiliogr&#225;ficas&#44; 2021&#59;112&#58;640&#8211;644&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Characteristic tongue swelling or macroglossia &#40;6&#46;6&#37;&#41; associated with transient U-shaped lingual papillitis &#40;11&#46;5&#37;&#41; in patients with COVID-19&#46; A&#44; Illustration showing tongue changes with indentation on both sides of the tongue and inflammation of anterior papillae&#44; probably caused by friction&#46; B&#8211;E&#44; Tongue swelling and transient U-shaped lingual papillitis during COVID-19&#46; COVID-19 indicates coronavirus disease 2019&#46;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Glossitis and patchy depapillation &#40;3&#46;9&#37;&#41; in patients with COVID-19&#46; A&#44; Illustration showing glossitis with patchy depapillation observed in patients with COVID-19&#46; B&#8211;D&#44; Patients with glossitis and patchy depapillation&#46; Fungal culture and serology were negative&#46; COVID-19 indicates coronavirus disease 2019&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">No&#46; &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Oral mucosal changes&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">78 &#40;11&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Transient U-shaped lingual papillitis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">35 &#40;11&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Tongue swelling&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20 &#40;6&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Glossitis with patchy depapillation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12 &#40;3&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mucositis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12 &#40;3&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Aphthous ulcers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21 &#40;6&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Burning mouth&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;5&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">White tongue&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;1&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Candidiasis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Enanthema&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;0&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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