In reply to Joe Gallagher:

Aphthous ulcers are an interesting "phenomenon"
Who remembers the time in our first years of practice when patients or
parents would say they or their child had been "run down" lately and had
several bouts of these ulcers ? I suspect I use to politely ridicule such
observations with superior and recently ordained MBChB Robbins-styled ("The
Pathologic Basis of Disease") arrogance. We seemed content in the mystical
belief that such things were proven to be "random events" because no
ivory-towered Professors of Oral Medicine had yet designed and conducted the
gold-standard "diagnostic proof" study and passed them on to their collegial
pathologists.
A decade or two downstream one has the benefit of that undocumented
volume-derived hindsight (aka "experience") and the scientific powers of
simple observation. For example it is of interest that people who get
recurrent or frequent aphthous ulceration do not (as a general rule) get
oral cold sores (labial) - and vice versa.
And while I must admit to not having seen studies on the prevalence of HSV I
in the general population, it is known to be highly prevalent (in the form
of substantial IgG titres to HSV I in perhaps 80% of children by the age of
10 years). One can extrapolate that the ubiquitous neuropathic herpes
viruses - in particular the recurrent HSV I, HZV, CMV and probably the
herpes hominis (HHV 6 etc) are indeed endemic, and also that they may
manifest in a variety of ways depending upon which nerve fibres have been
blessed with their presence.
Furthermore the frequency of recurrence varies enormously. The human immune
response is a variable as the human fingerprint.
While a number present with labial cold sores or recurrent unilateral nasal
cold sores others present with aphthous ulceration - with recurrences most
often in the same area - proof at least in my own mind of the cause.
A careful history will indeed confirm the observations of all those parents
and patients (whom I used to label subconsciously as hypochondriacs!) who
had been "run down" for some time. The recurrence rates of dormant viruses
may be up to 10 episodes per annum - that works out at perhaps up to 25-30
weeks of fatigue, and a variety of other associated systemic symptoms
through to depression and cerebritis (as a 10 year old I saw yesterday
observed quite appropriately "my brain doesn't seem to be working properly
today")
Interestingly the only patient who I have really been able to truly label as
Chronic Fatigue Syndrome despite a vast number of tests over 10 -12 years,
over the last 15 years or so in practice finally presented late last year
with genital herpes.
Sick building syndrome .. Chronic fatigue syndrome.. Perhaps there really is
truth in the old maxim "it's healthier living in the countryside"
As far as treatment goes - I don't have any EBM answers apart from
supportive. How about flavouring the valciclovir tablets into a lozenge? Or
grinding a Valtrex tablet up into Kenalog in Orabase maybe ? In any case I
thought EBM was Expressed Breast Milk
Jon Wilcox
Auckland


-----Original Message-----
From: Joe Gallagher <[log in to unmask]>
To: none <[log in to unmask]>
Date: Saturday, March 14, 1998 9:34 AM
Subject: Aphthous Ulcers


>Anyone else experience the phenomenon I did going through medical school
>whereby you would get to cover topics and subjects adequetely  up to
>about 80% and you would not have a bulls notion on the other 20%.  A
>case in point would be the Gonads in Anatomy.  It always seemed to be
>tackled at the end of term when all that histology and Islets of
>Langerballs was all just too complex to deal with.
>
>Aphthous Ulcers are  the Gonads of my post student days.  Where was I
>when this was covered in lectures?  What the hell do you treat them with
>anyway?  Are the treatments EBM  maaan.
>
>



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