SAEM Clinical Images Series: Spicy Gum Leads to Spicy Gums


A 32-year-old male with a past medical history of asthma presents with a two-day history of cracked lips and progressively worsening oral pain, associated with white discharge, foul smell, and a metallic taste. The patient presented to urgent care and was sent to the Emergency Department (ED) for a sepsis workup. The worsening sores caused him to eat and drink less, including the gum he normally chews. He endorses oral sex with one female partner one week ago. No recent dental work. He recently completed a prednisone course for the same issue. Denies fevers, tooth pain, tongue pain, dysphagia, odynophagia, chest pain, difficulty breathing, abdominal pain, genitourinary discharge or lesions, sick contacts, trismus, facial swelling, or voice changes.

Vitals: T 102°F; HR 125; BP 114/81; RR 19; SPO2 94%

General: No distress. Alert and oriented.

Skin: Warm and dry, no rash.

Ears: Hearing grossly intact.

Nose: Bilateral nares patent, no bleeding.

Neck: Soft, symmetric, no adenopathy, non-tender.

Extraoral: Ulcerations on upper and lower lips.

Intraoral: 1 small ulcer on tip of the tongue on the right. Inflamed, erythematous and bleeding gingiva and interdental papilla. Uvula midline. Maximal interincisal opening ~ 40 mm. Teeth intact.

Heart: Regular rate and rhythm, no murmur.

Lungs: Clear to auscultation, air entry to bases.

Abdomen: Soft, non-tender, no guarding.

GU: Patient denied symptoms and declined exam.

White blood cell (WBC) count: 11.4

pH: 7.386

Lactic Acid: 1.7

Urinalysis (UA): Negative Blood. Culture sent.

STI workup including HSV titers and HIV testing obtained and pending.

The differential is broad, including ANUG (acute necrotizing ulcerative gingivitis) also known as “trench-mouth” and, more commonly, primary herpes gingivostomatitis and candidal infection. Consideration of periodontitis and dental abscess/pulpitis is necessary. The spectrum of erythema multiforme, Stevens-Johnson syndrome, and toxic epidermal necrolysis is important to include, as well as autoimmune disorders which commonly have mucosal involvement such as systemic lupus erythematosus (SLE), Behcet’s, and Crohn’s disease. Scurvy, although uncommon, can also present with gingival erythema and pain.

Consider the presence of a known autoimmune disorder, chronic systemic disease, or an immunocompromised state. History should include new sexual partners, dietary changes, and changes in dental hygiene. We were concerned given this patient’s vital signs on presentation, and alongside a sepsis workup, called dental to the bedside. They immediately asked the patient about the recent use of chewing gum and its flavor, and the patient described a recent preference for cinnamon gum, which he had been using for about 1-2 weeks. The dental consultant came to the diagnosis immediately. A literature search reveals a phenomenon called “cinnamon-contact stomatitis” which is believed to be caused by a delayed T-cell-mediated hypersensitivity reaction. It is characterized by white patches on the mucosa with erythema and erosions on the buccal mucosa and lateral tongue. Treatment consists of discontinuation of the offending agent, and corticosteroids in patients with severe symptoms. Lesions can take up to two weeks to heal, and appropriate follow-up with dental is needed to monitor for resolution.

Take-Home Points

  • The differential for ulcerated, painful gums is broad, and one must consider any history of systemic disease or an immunocompromised state.
  • Consider cinnamon-contact stomatitis in patients that present with extensive oral ulcerations in the absence of other risk factors.

  • Georgakopoulou EA. Cinnamon contact stomatitis. J Dermatol Case Rep. 2010 Nov 19;4(2):28-9. doi: 10.3315/jdcr.2010.1047. PMID: 21886744; PMCID: PMC3157809.
  • Vivas AP, Migliari DA. Cinnamon-induced Oral Mucosal Contact Reaction. Open Dent J. 2015 Jul 31;9:257-9. doi: 10.2174/1874210601509010257. PMID: 26312097; PMCID: PMC4541332.

SAEM Clinical Image Series: Facial Burn


A 50-year-old female with a history of bipolar disorder, ADHD, anxiety, depression, and alcoholism presented to the ED after her family found her at home agitated, restless, and with a “large black burn” on her face. Her husband reported that she had been “picking” at this area of her face earlier in the day; at that time it appeared only slightly red. Per her husband, the patient had also felt “bugs crawling on her legs” and had been picking at and grabbing her legs on the day of presentation.


SAEM Clinical Image Series: Flu-like symptoms, oral ulcers, and rash

palmar rash erythema multiforme

[Click for larger view]

Chief Complaint: Flu-like symptoms, lip pain/swelling, mouth pain, eye redness, and rash

History of Present Illness: Patient is a 35-year-old transgender male with a history of bipolar disorder (taking seroquel/lamotrigine) who presents with 2 days of:

  • Flu-like symptoms
  • Progressive lip pain/swelling
  • Mouth pain
  • Oral ulcers
  • Eye redness
  • New erythematous rash involving the palms/soles and lower extremities

The patient initially noted myalgias, fever, and malaise 2 days ago. Yesterday, the patient woke up with bilateral eye redness and itching, and he developed lip swelling/discoloration and mouth pain throughout the day. He presented to an outside emergency department (ED) 12 hours prior, where he was told that he had a viral infection, given pain medication, and discharged home. He has not taken any other medications. The patient presents to this ED due to progression of symptoms, including the development of a pruritic rash on his palms, soles, and lower extremities. Upon further questioning, the patient also reports vaginal itching and a fishy odor. He has a history of bacterial vaginosis and states that these symptoms feel similar. The patient denies genital sores, vaginal discharge, and vaginal bleeding. He is currently sexually active with men and women, and does not regularly use barrier protection.


60 Second Soapbox: Autoimmune Disease, Ultrasound Teaching, 3rd Nerve Palsy

60 second soapboxIt’s time for another installment of 60 Second Soapbox! Each episode, 1 lucky individual gets exactly 1 minute to present their rant-of-choice to the world. Any topic is on the table – clinical, academic, economic, or whatever else may interest an EM-centric audience. We carefully remix your audio to add an extra splash of drama and excitement. Even more exciting, participants get to challenge 3 of their peers to stand on a soapbox of their own! 


AIR Series: Immunology 2017

air series traumaWelcome to the Immunology Module! After carefully reviewing all relevant posts from the top 50 sites of the Social Media Index, the ALiEM AIR Team is proud to present the highest quality online immunology content. Below we have listed our selection of the highest quality blog posts within the past 12 months (as of July 2017) related to immunology emergencies. These are curated and approved for residency training by the AIR Series Board. We have identified 0 AIRs and Honorable Mentions. We recommend programs give 1 hour (about 15 minutes per article) of III credit for this module.


The Dirty Epi Drip: IV Epinephrine When You Need It

PeanutAllergyBraceletYou’re a recent graduate picking up an extra shift in a small ED somewhere north of here. At 3 AM an obese 47 year-old woman presents with shortness of breath and difficulty speaking after eating a Snickers bar an hour earlier. She admits to history of hypertension, peanut allergy, and a prior intubation for a similar presentation. She is becoming more obtunded in the resuscitation room as you are collecting your history. A glance at the monitor shows:

  • HR 130
  • BP 68/40
  • O2 saturation 89% on room air


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