Our patient is a 49-year-old Hispanic immigrant female with a 24-year history of painful RAS in the oral cavity (Figure 1). Her symptoms were associated with nausea and odynophagia. She reports that the sores last approximately one week at a time and can present with as many as thirteen at a single time. There was never a period of time when she had not had an oral ulcer present for the past 20 years and often she would have an average of 5-6 oral ulcers at any given time. Within the past 20 years, she has seen many doctors before immigrating to the US, but it is unclear what kind of treatment she tried in the past and she never got a formal diagnosis of her problem as well. She has only been controlled with pain medication for symptom relief. She also reports a longstanding history of intermittent postprandial bloating and a history of constipation. She denies diarrhea, hematochezia, and personal or family history of colon cancer or gastric cancer. Other past medical history includes anxiety, history of stroke, and hypertension. Her anxiety is very well controlled. She denies drinking or smoking. Differentials such as lupus, Crohn's, ulcerative colitis, Behcet syndrome, HIV, deep mycosis, tuberculosis, syphilis, celiac disease, vasculitis, drug-induced injury (NSAIDs or alendronate), and genital ulcers were all considered. The patient had an extensive lab workup for her aphthous ulcers by her PCP (Table 1) including antinuclear antibody, tissue transglutaminase IgA, HIV 1&2 Ab, and HSV-1 IgM, which were all negative. HSV-1 IgG was positive, but the patient had received multiple courses of acyclovir without resolution of her symptoms. The nutrition panel revealed vitamin B and zinc deficiencies for which a three-month supplementation was given without improvement in her symptoms. Repeat vitamin levels were ordered, but the patient did not follow up. She was seen by a dermatologist who recommended triamcinolone paste to affected areas in her mouth without help. She was then referred to gastroenterology for further workup.
For her physical exam, oral cavity revealed normal lips, normal dentition, and occlusion; two aphthous ulcers on the right buccal mucosa, approximately 0.5 cm in size were seen. No drainage or purulent discharge was noted so the ulcer was not swabbed for examination. Other reviews of systems including skin, eye, lymphatics, cardiovascular, abdomen, thyroid, neurologic, and respiratory systems were all normal. Esophagogastroduodenoscopy was done and revealed erythematous gastric mucosa (Figure 2). The biopsy of this area was positive for H. Pylori infection and mild active chronic gastritis. She was then prescribed quadruple therapy consisting of a proton pump inhibitor, tetracycline, metronidazole, and bismuth subsalicylate. After completion of the therapy, she reported simultaneous resolution of RAS. H. pylori stool antigen was performed after completion of quadruple therapy and confirmed eradication. She was seen in follow-up five months later and denies the presence of RAS which has not happened for the last 20 years.