Pathology · patient case with 1 question
A palatal lesion that will not clear
Patient: Female, 68 years old
Chief Complaint: “The sore on the roof of my mouth is still there after the medicine.”
Background: Diagnosed clinically with oral candidiasis six weeks ago and prescribed nystatin oral suspension, which she reports using as directed for the full course. Non-smoker. No dentures. No inhaled steroid.
Vital Signs: BP 134/82 mmHg · HR 76 bpm
Findings: A persistent erythematous area on the hard palate with a slightly raised, indurated margin. It does not wipe away. No improvement since the initial visit.
Question 1
The lesion has not responded to antifungal therapy. What is the most appropriate next step?
Show answer and explanation
Correct answer: D. Incisional biopsy
- A. Escalating to a systemic azole is reasonable when a genuine candidiasis fails topical therapy, but not when the lesion is indurated and does not wipe away. And a further month of watching is a month lost.
- B. Extending the same failed therapy is the error the question is testing. Two weeks of adequate antifungal treatment should produce visible improvement; six weeks without any is a diagnostic signal, not a dosing problem.
- C. A topical steroid without a diagnosis is actively dangerous — it may suppress inflammation, mask progression, and worsen an undiagnosed fungal or neoplastic process.
- D. CORRECT. The governing rule is that any oral lesion which fails to resolve after removal of the presumed cause and an adequate course of appropriate therapy requires a BIOPSY. Six weeks of nystatin with no change, plus induration and a raised margin, moves malignancy to the top of the differential. Continuing to treat empirically only delays the diagnosis of a potentially curable cancer.