Oral Signs of Bacterial Disease

  • Emily W. Shelley
  • Rochelle R. TorgersonEmail author


The oral manifestations of bacterial diseases are varied ranging from nonspecific ulcers to the nearly pathognomonic strawberry tongue of scarlet fever. The bacterial diseases with oral manifestations range from the highly prevalent gingivitis/periodontitis to the much rarer diphtheria, a disease physicians in North America would not expect to encounter. This chapter covers the salient features of the following bacterial diseases with emphasis on their oral manifestations: syphilis, gonorrhea, tuberculosis, acute necrotizing ulcerative gingivitis, scarlet fever, diphtheria, staphylococcal scalded skin, leprosy, gingivitis/periodontitis, granuloma inguinale, tularemia, and cat scratch disease.


Bacterial disease Oral manifestations Syphilis Acute necrotizing ulcerative gingivitis Scarlet fever 


  1. 1.
    Goldman L, Schafter AI, editors. Cecil medicine: expert consult – online. Philadelphia: Elsevier Health Sciences; 2011.Google Scholar
  2. 2.
    Goldman L, Schafter AI, editors. Goldman’s Cecil medicine. 24th ed. Philadelphia: Elsevier Saunders; 2012.Google Scholar
  3. 3.
    James WD, Berger T, Elston D. Andrew’s diseases of the skin: clinical dermatology. Philadelphia: Elsevier Health Sciences; 2011.Google Scholar
  4. 4.
    Mandell GL, Bennett JE, Dolin R. Mandell, Douglas, and Bennett’s principles and practice of infectious diseases. Philadelphia: Churchill Livingstone/Elsevier; 2010.Google Scholar
  5. 5.
    Bolognia JL, Jorizzo JL, Schaffer JV. Dermatology. UK: Elsevier Health Sciences; 2012.Google Scholar
  6. 6.
    Andreoli TE, et al. Andreoli and Carpenter’s Cecil essentials of medicine. Philadelphia: Elsevier Health Sciences; 2010.Google Scholar
  7. 7.
    Schwarzenberger K, Werchniak AE, Ko CJ, editors. General dermatology. Edinburgh: Elsevier Limited; 2009.Google Scholar
  8. 8.
    Goering RV, Mims CA. Mims’ medical microbiology. Philadelphia: Mosby Elsevier; 2008.Google Scholar
  9. 9.
    Leuci S, Martina S, Adamo D, Ruoppo E, Santarelli A, Sorrentino R, et al. Oral syphilis: a retrospective analysis of 12 cases and a review of the literature. Oral Dis. 2013;19(8):738–46. Scholar
  10. 10.
    Kent ME, Romanelli F. Reexamining syphilis: an update on epidemiology, clinical manifestations, and management. Ann Pharmacother. 2008;42(2):226–36. Scholar
  11. 11.
    Drago F, Ciccarese G, Cogorno L, Tomasini CF, Cozzani EC, Riva SF, et al. Primary syphilis of the oropharynx: unusual location of a chancre. Int J STD AIDS. 2014;
  12. 12.
    Hertel M, Matter D, Schmidt-Westhausen AM, Bornstein MM. Oral syphilis: a series of 5 cases. J Oral Maxillofac Surg. 2014;72(2):338–45. Scholar
  13. 13.
    Ficarra G, Carlos R. Syphilis: the renaissance of an old disease with oral implications. Head Neck Pathol. 2009;3(3):195–206. Scholar
  14. 14.
    Captline AM, White NS, Merkow LP, Snyder SP. Atrophic luetic glossitis. Report of a case. Oral Surg Oral Med Oral Pathol. 1970;30(2):192–5. Scholar
  15. 15.
    Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines. MMWR Morb Mortal Wkly Rep. 2010;59(RR-12):1–110.Google Scholar
  16. 16.
    Bolognia JL, Jorizzo JL, Schaffer JV, editors. Dermatology. 3rd ed. London: Elsevier Limited; 2012.Google Scholar
  17. 17.
    Skerlev M, Culav-Koscak I. Gonorrhea: new challenges. Clin Dermatol. 2014;32(2):275–81. Scholar
  18. 18.
    Randle HW. Treatment of oral ulcers. Dermatol Clin. 1993;11(4):801–8.PubMedCrossRefGoogle Scholar
  19. 19.
    Bruce AJ, Rogers RS 3rd. Oral manifestations of sexually transmitted diseases. Clin Dermatol. 2004;22(6):520–7. Scholar
  20. 20.
    Centers for Disease Control and Prevention (CDC). Update to CDC’s sexually transmitted diseases treatment guidelines, 2010: oral cephalosporins no longer a recommended treatment for gonococcal infections. MMWR Morb Mortal Wkly Rep. 2012;61(31):590–4.Google Scholar
  21. 21.
    Bignell C, Fitzgerald M. UK national guideline for the management of gonorrhoea in adults, 2011. Int J STD AIDS. 2011;22(10):541–7. Scholar
  22. 22.
    Centers for Disease Control and Prevention (CDC). Tuberculosis outbreak associated with a homeless shelter – Kane County, Illinois, 2007–2011. MMWR Morb Mortal Wkly Rep. 2012;61(11):186–9.Google Scholar
  23. 23.
    Centers for Disease Control and Prevention (CDC). Notes from the field: tuberculosis cluster associated with homelessness – Duval County, Florida, 2004–2012. MMWR Morb Mortal Wkly Rep. 2012;61(28):539–40.Google Scholar
  24. 24.
    Kaplan JE, Benson C, Holmes KK, Brooks JT, Pau A, Masur H, et al. Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. MMWR Recomm Rep. 2009;58(Rr-4):1–207.. quiz CE1-4PubMedGoogle Scholar
  25. 25.
    Toossi Z, Mayanja-Kizza H, Hirsch CS, Edmonds KL, Spahlinger T, Hom DL, et al. Impact of tuberculosis (TB) on HIV-1 activity in dually infected patients. Clin Exp Immunol. 2001;123(2):233–8. Scholar
  26. 26.
    Brighenti S, Andersson J. Local immune responses in human tuberculosis: learning from the site of infection. J Infect Dis. 2012;205(Suppl 2):S316–24. Scholar
  27. 27.
    Mignogna MD, Muzio LL, Favia G, Ruoppo E, Sammartino G, Zarrelli C, et al. Oral tuberculosis: a clinical evaluation of 42 cases. Oral Dis. 2000;6(1):25–30.PubMedCrossRefGoogle Scholar
  28. 28.
    Verma S, Prakash R, Mohan S, Singh U, Agarwal N. Primary oral tuberculosis. BMJ Case Rep. 2013;
  29. 29.
    Ishikawa H, Hyo Y, Ono T. Tuberculous submandibular lymphadenitis. J Oral Maxillofac Surg. 1982;40(5):302–5. Scholar
  30. 30.
    Popowich L, Heydt S. Tuberculous cervical lymphadenitis. J Oral Maxillofac Surg. 1982;40(8):522–4. Scholar
  31. 31.
    Garg RK, Singhal P. Primary tuberculosis of the tongue: a case report. J Contemp Dent Pract. 2007;8(4):74–80. Scholar
  32. 32.
    Centers for Disease Control and Prevention (CDC). Recommendations for use of an isoniazid-rifapentine regimen with direct observation to treat latent Mycobacterium tuberculosis infection. MMWR Morb Mortal Wkly Rep. 2011;60(48):1650–3.Google Scholar
  33. 33.
    American Thoracic Society, CDC, Infectious Diseases Society of America. Treatment of tuberculosis. MMWR Recomm Rep. 2003;52(Rr-11):1–77.Google Scholar
  34. 34.
    Melnick SL, Roseman JM, Engel D, Cogen RB. Epidemiology of acute necrotizing ulcerative gingivitis. Epidemiol Rev. 1988;10:191–211.PubMedCrossRefGoogle Scholar
  35. 35.
    Wade DN, Kerns DG. Acute necrotizing ulcerative gingivitis-periodontitis: a literature review. Mil Med. 1998;163(5):337–42.PubMedCrossRefGoogle Scholar
  36. 36.
    Osuji OO. Necrotizing ulcerative gingivitis and cancrum oris (noma) in Ibadan. Niger J Periodontol. 1990;61(12):769–72. Scholar
  37. 37.
    Listgarten MA. Electron microscopic observations on the bacterial flora of acute necrotizing ulcerative gingivitis. J Periodontol. 1965;36:328–39. Scholar
  38. 38.
    Turnbull RS. Periodontal disease part IV: periodontal infections. Can Fam Physician. 1988;34:1399–400.PubMedPubMedCentralGoogle Scholar
  39. 39.
    Cogen RB, Stevens AW Jr, Cohen-Cole S, Kirk K, Freeman A. Leukocyte function in the etiology of acute necrotizing ulcerative gingivitis. J Periodontol. 1983;54(7):402–7. Scholar
  40. 40.
    Claffey N, Russell R, Shanley D. Peripheral blood phagocyte function in acute necrotizing ulcerative gingivitis. J Periodontal Res. 1986;21(3):288–97. Scholar
  41. 41.
    Horning GM, Cohen ME. Necrotizing ulcerative gingivitis, periodontitis, and stomatitis: clinical staging and predisposing factors. J Periodontol. 1995;66(11):990–8. Scholar
  42. 42.
    Zitelli BJ, McIntire SC, Nowalk AJ. Zitelli and Davis’ atlas of pediatric physical diagnosis: expert consult – online. Philadelphia: Elsevier Health Sciences; 2012.Google Scholar
  43. 43.
    Pindborg JJ, Bhat M, Roed-Petersen B. Oral changes in South Indian children with severe protein deficiency. J Periodontol. 1967;38(3):218–21.PubMedCrossRefGoogle Scholar
  44. 44.
    Uohara GI, Knapp MJ. Oral fusospirochetosis and associated lesions. Oral Surg Oral Med Oral Pathol. 1967;24(1):113–23. Scholar
  45. 45.
    Falkler WA Jr, Martin SA, Vincent JW, Tall BD, Nauman RK, Suzuki JB. A clinical, demographic and microbiologic study of ANUG patients in an urban dental school. J Clin Periodontol. 1987;14(6):307–14. Scholar
  46. 46.
    Kliegman R. Nelson textbook of pediatrics. Philadelphia: Elsevier/Saunders; 2011.Google Scholar
  47. 47.
    Habif TP. Clinical dermatology. Philadelphia: Elsevier Health Sciences; 2009.Google Scholar
  48. 48.
    Ferri FF. Ferri’s color atlas and text of clinical medicine. Philadelphia: Saunders/Elsevier; 2009.Google Scholar
  49. 49.
    Baren JM, Rothrock S, Brennan J, Brown L. Pediatric emergency medicine. Philadelphia: Elsevier Health Sciences; 2007.Google Scholar
  50. 50.
    Murray PR, Rosenthal KS, Pfaller MA. Medical microbiology. Philadelphia: Elsevier Health Sciences; 2012.Google Scholar
  51. 51.
    Berk DR, Bayliss SJ. MRSA, staphylococcal scalded skin syndrome, and other cutaneous bacterial emergencies. Pediatr Ann. 2010;39(10):627–33. Scholar
  52. 52.
    Braunstein I, Wanat KA, Abuabara K, McGowan KL, Yan AC, Treat JR. Antibiotic sensitivity and resistance patterns in pediatric staphylococcal scalded skin syndrome. Pediatr Dermatol. 2014;31(3):305–8. Scholar
  53. 53.
    Marx J, Hockberger R, Walls R. Rosen’s emergency medicine – concepts and clinical practice. Philadelphia: Elsevier Health Sciences; 2013.Google Scholar
  54. 54.
    Global leprosy update, 2013; reducing disease burden. Wkly Epidemiol Rec 2014;89(36):389–400.Google Scholar
  55. 55.
    Cohen J, Opal SM, Powderly WG. Infectious diseases. Philadelphia: Elsevier – Health Sciences Division; 2010.Google Scholar
  56. 56.
    Rodrigues LC, Lockwood D. Leprosy now: epidemiology, progress, challenges, and research gaps. Lancet Infect Dis. 2011;11(6):464–70. Scholar
  57. 57.
    Motta AC, Komesu MC, Silva CH, Arruda D, Simão JC, Zenha EM, et al. Leprosy-specific oral lesions: a report of three cases. Med Oral Pathol Oral Cir Bucal. 2008;13(8):E479–82.Google Scholar
  58. 58.
    de Abreu MA, Michalany NS, Weckx LL, Neto Pimentel DR, Hirata CH, de Avelar Alchorne MM. The oral mucosa in leprosy: a clinical and histopathological study. Braz J Otorhinolaryngol. 2006;72(3):312–6.PubMedCrossRefGoogle Scholar
  59. 59.
    Dhawan AK, Verma P, Sharma S. Oral lesions in leprosy revisited: a case report. Am J Dermatopathol. 2012;34(6):666–7. Scholar
  60. 60.
    Girdhar BK, Desikan KV. A clinical study of the mouth in untreated lepromatous patients. Lepr Rev. 1979;50(1):25–35.PubMedGoogle Scholar
  61. 61.
    Bucci F Jr, Mesa M, Schwartz RA, McNeil G, Lambert WC. Oral lesions in lepromatous leprosy. J Oral Med. 1987;42(1):4–6.PubMedGoogle Scholar
  62. 62.
    Scheepers A, Lemmer J, Lownie JF. Oral manifestations of leprosy. Lepr Rev. 1993;64(1):37–43.PubMedGoogle Scholar
  63. 63.
    Costa A, Nery J, Oliveira M, Cuzzi T, Silva M. Oral lesions in leprosy. Indian J Dermatol Venereol Leprol. 2003;69(6):381–5.PubMedGoogle Scholar
  64. 64.
    Swain JP, Soud A, Agarwal SK. Necrotic erythema nodosum leprosum with oral mucosal involvement. Indian J Lepr. 2008;80(2):175–8.PubMedGoogle Scholar
  65. 65.
    Scheepers A, Lemmer J. Erythema nodosum leprosum: a possible cause of oral destruction in leprosy. Int J Lepr Other Mycobact Dis. 1992;60(4):641–3.. doi: 1299716PubMedGoogle Scholar
  66. 66.
    Martinez TS, Figueira MM, Costa AV, Gonçalves MA, Goulart LR, Goulart IM. Oral mucosa as a source of Mycobacterium leprae infection and transmission, and implications of bacterial DNA detection and the immunological status. Clin Microbiol Infect. 2011;17(11):1653–8. Scholar
  67. 67.
    Chimenos Kustner E, Pascual Cruz M, Pinol Dansis C, Vinals Iglesias H, Rodríguez de Rivera Campillo ME, López López J. Lepromatous leprosy: a review and case report. Med Oral Patol Oral Cir Bucal. 2006;11(6):E474–9.PubMedGoogle Scholar
  68. 68.
    Ishii N, Barua S, Mori S, Nagaoka Y, Suzuki K. Report of the tenth meeting of the WHO Technical Advisory Group on Leprosy Control. Nihon Hansenbyo Gakkai Zasshi. 2010;79(1):37–42.PubMedCrossRefGoogle Scholar
  69. 69.
    Chemotherapy of leprosy. Report of a WHO Study Group. World Health Organ Tech Rep Ser 1994;847:1–24.Google Scholar
  70. 70.
    Petersen PE, Bourgeois D, Ogawa H, Estupinan-Day S, Ndiaye C. The global burden of oral diseases and risks to oral health. Bull World Health Organ. 2005;83(9):661–9.PubMedPubMedCentralGoogle Scholar
  71. 71.
    Tomar SL, Asma S. Smoking-attributable periodontitis in the United States: findings from NHANES III. National Health and Nutrition Examination Survey. J Periodontol. 2000;71(5):743–51. Scholar
  72. 72.
    Pihlstrom BL, Michalowicz BS, Johnson NW. Periodontal diseases. Lancet. 2005;366(9499):1809–20. Scholar
  73. 73.
    Slots J. Systemic antibiotics in periodontics. J Periodontol. 2004;75(11):1553–65. Scholar
  74. 74.
    Robinson PG. The significance and management of periodontal lesions in HIV infection. Oral Dis. 2002;8(Suppl 2):91–7. Scholar
  75. 75.
    Newman MG, et al. Carranza’s clinical periodontology. Philadelphia: Elsevier – Health Sciences Division; 2014.Google Scholar
  76. 76.
    Quick CRG, et al. Essential surgery: problems, diagnosis, and management. Philadelphia: Elsevier – Health Sciences Division; 2013.Google Scholar
  77. 77.
    Marshall RI, Bartold PM. A clinical review of drug-induced gingival overgrowths. Aust Dent J. 1999;44(4):219–32. Scholar
  78. 78.
    Pihlstrom BL. Measurement of attachment level in clinical trials: probing methods. J Periodontol. 1992;63(12 Suppl):1072–7. Scholar
  79. 79.
    Markle W, Conti T, Kad M. Sexually transmitted diseases. Prim Care. 2013;40(3):557–87. Scholar
  80. 80.
    Velho PE, Souza EM, Belda JW. Donovanosis. Braz J Infect Dis. 2008;12(6):521–5. Scholar
  81. 81.
    O’Farrell N. Donovanosis. Sex Transm Infect. 2002;78(6):452–7. Scholar
  82. 82.
    O’Farrell N, Moi H. European guideline for the management of donovanosis, 2010. Int J STD AIDS. 2010;21(9):609–10. Scholar
  83. 83.
    Rajendran R, Sivapathasundharam B. Shafer’s textbook of oral pathology. Philadelphia: Elsevier/Reed Elsevier; 2012.Google Scholar
  84. 84.
    Hanna CB, Pratt-Thomas HR. Extragenital granuloma venereum; report of six cases of lip, oral and cutaneous involvement with review of literature. S Med J. 1948;41(9):776–82.CrossRefGoogle Scholar
  85. 85.
    Doddridge M, Muirhead R. Donovanosis of the oral cavity. Case report. Aust Dent J. 1994;39(4):203–5. Scholar
  86. 86.
    Brain P. Granuloma inguinale with extensive oral involvement. S Afr Med J. 1951;25(33):581–2.PubMedGoogle Scholar
  87. 87.
    Veeranna S, Raghu TY. Oral donovanosis. Int J STD AIDS. 2002;13(12):855–6. Scholar
  88. 88.
    Hart G. Donovanosis. Clin Infect Dis. 1997;25(1):24–30.. quiz 31-2PubMedCrossRefGoogle Scholar
  89. 89.
    Coovadia YM, Steinberg JL, Kharsany A. Granuloma inguinale (donovanosis) of the oral cavity. A case report. S Afr Med J. 1985;68(11):815–7.PubMedGoogle Scholar
  90. 90.
    Wysocki GP, Brooke RI. Oral manifestations of chronic granulomatous disease. Oral Surg Oral Med Oral Pathol. 1978;46(6):815–9. Scholar
  91. 91.
    Workowski KA, Berman S. Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010;59(Rr-12):1–110.PubMedGoogle Scholar
  92. 92.
    Boyce JM. Recent trends in the epidemiology of tularemia in the United States. J Infect Dis. 1975;131(2):197–9.PubMedCrossRefGoogle Scholar
  93. 93.
    Tarnvik A, Sandstrom G, Sjostedt A. Epidemiological analysis of tularemia in Sweden 1931–1993. FEMS Immunol Med Microbiol. 1996;13(3):201–4. Scholar
  94. 94.
    Ellis J, Oyston PC, Green M, Titball RW. Tularemia. Clin Microbiol Rev. 2002;15(4):631–46. Scholar
  95. 95.
    Berdal BP, Mehl R, Meidell NK, Lorentzen-Styr AM, Scheel O. Field investigations of tularemia in Norway. FEMS Immunol Med Microbiol. 1996;13(3):191–5. Scholar
  96. 96.
    Ohara Y, Sato T, Fujita H, Ueno T, Homma M. Clinical manifestations of tularemia in Japan – analysis of 1,355 cases observed between 1924 and 1987. Infection. 1991;19(1):14–7. Scholar
  97. 97.
    Gurcan S. Epidemiology of tularemia. Balkan Med J. 2014;31(1):3–10. Scholar
  98. 98.
    Pilo P, Johansson A, Frey J. Identification of Francisella tularensis cluster in central and western Europe. Emerg Infect Dis. 2009;15(12):2049–51. Scholar
  99. 99.
    Tularemia – United States, 2001–2010. MMWR Morb Mortal Wkly Rep 2013;62(47):963–6.Google Scholar
  100. 100.
    Senel E, Satilmis O, Acar B. Dermatologic manifestations of tularemia: a study of 151 cases in the mid-Anatolian region of Turkey. Int J Dermatol. 2014;
  101. 101.
    Polat M, Kara SS, Tapısız A, Tezer H. Unusual presentation of oropharyngeal tularemia: a case report. Vector Borne Zoonotic Dis. 2013;13(5):337–9. Scholar
  102. 102.
    Dentan C, Pavese P, Pelloux I, Boisset S, Brion JP, Stahl JP, et al. Treatment of tularemia in pregnant woman. France Emerg Infect Dis. 2013;19(6):996–8. Scholar
  103. 103.
    Koc S, Gürbüzler L, Yaman H, Eyibilen A, Salman N, Ekici A. Tularaemia presenting as parapharyngeal abscess: case presentation. J Laryngol Otol. 2012;126(5):535–7. Scholar
  104. 104.
    Dlugaiczyk J, Harrer T, Zwerina J, Traxdorf M, Schwarz S, Splettstoesser W, et al. Oropharyngeal tularemia – a differential diagnosis of tonsillopharyngitis and cervical lymphadenitis. Wien Klin Wochenschr. 2010;122(3–4):110–4. Scholar
  105. 105.
    Boisset S, Caspar Y, Sutera V, Maurin M. New therapeutic approaches for treatment of tularaemia: a review. Front Cell Infect Microbiol. 2014;4:40. Scholar
  106. 106.
    Jackson LA, Perkins BA, Wenger JD. Cat scratch disease in the United States: an analysis of three national databases. Am J Public Health. 1993;83(12):1707–11.PubMedPubMedCentralCrossRefGoogle Scholar
  107. 107.
    Dehio C. Molecular and cellular basis of bartonella pathogenesis. Annu Rev Microbiol. 2004;58:365–90. Scholar
  108. 108.
    Cook GC, Zumla A. Manson’s tropical diseases. Philadelphia: Saunders; 2009.Google Scholar
  109. 109.
    Arisoy ES, et al. Hepatosplenic cat-scratch disease in children: selected clinical features and treatment. Clin Infect Dis. 1999;28(4):778–84.. NO DOIPubMedCrossRefGoogle Scholar
  110. 110.
    Jacobs RF, Schutze GE. Bartonella henselae as a cause of prolonged fever and fever of unknown origin in children. Clin Infect Dis. 1998;26(1):80–4.. NO DOIPubMedCrossRefGoogle Scholar
  111. 111.
    Farrar J, et al. Manson’s tropical diseases: expert consult – online. UK: Elsevier Health Sciences; 2013.Google Scholar
  112. 112.
    Margileth AM. Dermatologic manifestations and update of cat scratch disease. Pediatr Dermatol. 1988;5(1):1–9. Scholar
  113. 113.
    Moriarty RA, Margileth AM. Cat scratch disease. Infect Dis Clin N Am. 1987;1(3):575–90.Google Scholar
  114. 114.
    Steiner M, Gould A, Wilkie W, Porter K. Cat-scratch disease in the submandibular region: report of a case. J Oral Maxillofac Surg. 1994;52(6):614–8. Scholar
  115. 115.
    Mintz SM, Anavi Y. Cat scratch fever presenting as a submental swelling. J Oral Maxillofac Surg. 1988;46(11):1015–8. Scholar
  116. 116.
    Premachandra DJ, Milton CM. Cat scratch disease in the parotid gland presenting with facial paralysis. Br J Oral Maxillofac Surg. 1990;28(6):413–5. Scholar
  117. 117.
    Margileth AM. Recent advances in diagnosis and treatment of cat scratch disease. Curr Infect Dis Rep. 2000;2(2):141–6. Scholar
  118. 118.
    Brunetti E, Fabbi M, Ferraioli G, Prati P, Filice C, Sassera D, et al. Cat-scratch disease in Northern Italy: atypical clinical manifestations in humans and prevalence of Bartonella infection in cats. Eur J Clin Microbiol Infect Dis. 2013;32(4):531–4. Scholar
  119. 119.
    Conrad DA. Treatment of cat-scratch disease. Curr Opin Pediatr. 2001;13(1):56–9.PubMedCrossRefGoogle Scholar

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Authors and Affiliations

  1. 1.Cleveland Medical CenterUniversity HospitalsClevelandUSA
  2. 2.Departments of Dermatology and Obstetrics and GynecologyMayo ClinicRochesterUSA

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