Teen girl admitted to hospital with painful, swollen lip

What’s your diagnosis?

James H. Brien

A previously healthy, 14-year-old girl is admitted to the hospital after complaints of painful swelling of her lower lip, with periodic spotty, blood-tinged drainage from several discrete areas with overlying dark scabs.

She was in her usual good state of health until 2 weeks earlier, when she noticed a stinging sensation with pain, mild swelling and development of a yellowish crust about the right corner and the midportion of her lower lip. She admitted picking at the areas periodically, which resulted in minimal bleeding. By the end of a week, most of her lower lip began swelling. As the swelling worsened, her lower lip soon developed spontaneous, blood-tinged drainage from several areas, with associated bloody scabs. She denies any prior infection, thermal injury or other trauma to the mouth area, and she has a history of normal dental and oral health. She denies any similar problems in the past and has no other health concerns or complaints. Her immunizations are up to date, and her family history is unremarkable.

Figure 1. Diffuse swelling of the lower lip. Image: James H. Brien, DO

Figure 2. Swelling of the oral mucosa near the lateral commissure with deep-appearing white spots and inflammation of the skin at the corner. Image: James H. Brien, DO

Her exam reveals normal vital signs and the findings noted earlier — specifically, the diffuse, painful swelling of the lower lip with some areas of periodic drainage of blood-tinged material (Figure 1). It is also noted that the gingival surface of her right lower lip mucosa is notably swollen and inflamed, and an area near the right commissure has a “rough, pinkish” appearance that extends to include a small area of skin beyond the lower left vermillion border, along with some yellowish overlying crust (Figures 2 and 3). There is an area of similar “rough inflammation” that extends beyond the lower vermillion border to the skin at the midline (Figure 4). The left side of the lower lip is normal (Figure 5), and so is the rest of her oral exam. The only other positive finding was some mild anterior cervical and submental lymphadenopathy.

Figure 3. Close-up of the right commissure area showing bloody drainage and dull-appearing tissue of the lip adjacent to the cutaneous border. Image: James H. Brien, DO

Figure 4. Inflammation of the skin beyond the vermillion border of the lip at the midline. Image: James H. Brien, DO

Figure 5. A normal-appearing lower lip shown from the left. Image: James H. Brien, DO

The day before admission, her primary care provider obtained some drainage from the right lower lip’s bloody scab site, revealing some thick, yellowish pus, and sent it for Gram stain, revealing “rare clusters of gram-positive cocci” with culture pending. After admission to the hospital, a swab is obtained of the oral mucosa and lower lip for herpes simplex by PCR, which were negative. No other lab tests are performed.

What’s your diagnosis (choices in alphabetical order)?

A. Atypical Stevens-Johnson syndrome
B. Herpes simplex labialis with Staphylococcus aureus cellulitis and abscesses
C. Staphylococcus aureus lip cellulitis with abscesses
D. Streptococcus pyogenes cellulitis with abscesses

Answer and discussion:

The best answer is B, herpes simplex virus (HSV) labialis (cold sore) with secondary S. aureus (MRSA identified by culture) cellulitis with abscesses. The patient had surgical drainage by oral surgery with good results (Figures 6 and 7). Seeing a case and solving it 2 weeks after the problem began obviously relies on a good history and medical common sense. The problem began like most common “cold sores” (herpes simplex labialis) with some mild pain and stinging sensation. As the herpetic lesions develop, it is not unusual for the patient to pick at the area. Considering that the normal mouth flora may include pathogens such as S. aureus and S. pyogenes, which just need an opportunity to get beyond the normal mucocutaneous barrier to result in a localized infection, it is easy to see how this patient’s problem may have occurred. Picking at a skin lesion is like plowing the field before planting a seed: it creates an environment that assists in the growth of the seed (or infectious organism). You may say, “But Dr. Brien, wait — how do you know it was a cold sore? The herpes PCR was negative.” Then I would say, “The problem with trying to detect the virus in this case was the delay in testing.” The lesion likely stopped shedding the virus by the time the patient was tested 2 weeks after onset. In this case, the clinical history of developing a classic “cold sore” is more sensitive than the lab.

Figure 6. Preop appearance. Image: James H. Brien, DO

Figure 7. Postop appearance. Image: James H. Brien, DO

The clue to S. aureus and not S. pyogenes is in the Gram stain. Staph is usually seen in clusters and not chains, like strep. Also, the characteristics of the infection may be a clue. Despite the name, “pyogenes,” meaning “pus producing,” S. pyogenes does not characteristically produce localized soft tissue abscesses, whereas S. aureus is known for abscess production. Having said that, keep in mind that S. pyogenes does produce pus and will fill your chest with it (empyema) if your pneumonia is caused by that organism, thus the name for the species. In addition to drainage, the patient received oral anti-MRSA therapy and recovered without complication.

Lastly, “atypical Stevens-Johnson syndrome (SJS)” describes a form of SJS that is provoked by a reaction to a Mycoplasma pneumoniae infection that involves only the mucous membranes with little to no skin involvement (Figures 8 and 9). Exactly 10 years ago (September 2014) I featured this topic, for those interested in dipping back into the archives to see more.

Figure 8. Lips in a patient with atypical Stevens-Johnson syndrome. Image: James H. Brien, DO

Figure 9. The same patient shown in Figure 8 with inflamed eyes due to atypical Stevens-Johnson syndrome. Image: James H. Brien, DO

Reviews of atypical SJS can be found in these two articles (the second can be accessed in full for free):

• Ravin KA, et al. Pediatrics. 2007;doi:10.1542/peds.2006-2401.
• Beheshti R, Cusack B. Cureus. 2022;doi:10.7759/cureus.21825.

Columnist comments:

For about 40 years, mixed viral and bacterial infections have become increasingly recognized. The first example I can recall was in the late 1970s, when it was found that cases of bacterial (S. aureus) tracheitis seemed to occur in the wake of typical viral croup (mostly parainfluenza virus). Then came Nelson and McCracken’s landmark bacterial meningitis studies in the 1980s, which showed that most cases of bacterial meningitis in children are preceded by a viral upper respiratory infection by an average of 4 days. All these early studies depended on identification of the organisms by culture techniques, which was laborious and time consuming. Then came the development of methods that do not depend on the growth of an organism on media or visualizing under a microscope; the most important of these being DNA amplification (PCR), which has revolutionized the approach to confirming unusual infections that are frequently altered and more severe, such as those caused by a combination of viral and bacterial pathogens that may potentiate their effects on the host. I have featured numerous mixed viral (mostly varicella and herpes simplex) and bacterial (usually staph, strep or Pneumococcus) infections in several prior columns over the last 32 years: January 1991, May 1991 (by Phil Brunell, MD), November 1991, April 1998, June 2000, January 2004, January 2009 (with guest columnist, Michael Cater, MD), April 2022 and July 2023. I have seen plenty of cases of herpes simplex stomatitis and labialis over the years, but I have never seen a case like the one shown here, with such dramatic involvement of most of the lower lip with S. aureus cellulitis and abscess formation. While it would have been nice to have laboratory confirmation of herpes simplex as well as S. aureus, the history and residual appearance of the lip leaves little doubt as to the prior presence of herpes simplex.

Please keep in touch and let me know if you have a good case to consider for this column — and GET YOUR FLU SHOTS!

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Brien is a member of the Healio Pediatrics Peer Perspective Board and an adjunct professor of pediatric infectious diseases at McLane Children's Hospital, Baylor Scott & White Health, in Temple, Texas. He can be reached at jhbrien@aol.com.