Palpitations in a young patient: are we always sure about the diagnosis?

Sir, Recently, De Giorgi V et al. published an interesting clinical picture titled ‘Hyperplastic oral candidiasis of the tongue’. I read this article with great interest and compliment the authors for their clinical report. However, I would like to highlight several important issues. We should analyze carefully when the authors state, ‘Clinically, it is nearly impossible to differentiate such lesions from a squamous cell carcinoma or a verrucous form of oral leukoplakia, except for the fact that they disappear after appropriate antifungal therapy’. Despite being an uncommon subtype (or manifestation) of oral candidiasis when compared to pseudomembranous and erythematous types, the careful clinical examination might be helpful to distinguish the lesions, avoiding surgical procedures. First, once the tongue intermittently contacts the palate, a ‘kissing’ lesion may be seen on the palate surface opposing the tongue lesion. It is more often reported in erythematous candidiasis, but can be observed in hyperplastic lesions either. Thus, it is important to mention if this relation was clinically verified or if the patient wore complete dentures. Second, the authors did not mention if there was anything relevant in the medical records of the patient. Once the oral candidiasis is an opportunist infection, this information is relevant for the establishment of the final diagnosis. Third, the occurrence of oral cancer in the dorsum of the tongue, especially in the median line is rare. Moreover, a one-year malignant lesion would not present such indolent behavior. Therefore, the presumptive diagnosis of hyperplatic candidiasis or another benign condition would be first hypothesized. Fourth, despite some authors suggest that hyperplastic candidiasis is a premalignant condition, this issue remains controversial. If the biopsied candidiasis with epithelial dysplasia was developed due to the carcinogen potential of the fungus, or if the dysplasia was already established and the infection by the fungus came later, is an unsolved question. However, the World Health Organization does not consider the hyperplastic candidiasis a premalignant condition. Finally, I believe that a careful clinical examination is essential to lead to a less invasive and effective treatment, reduction of the costs and improvement of the patient’s quality of life.