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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 4  |  Issue : 2  |  Page : 87-90

Lingual tuberculosis mimicking malignant lesion: A rare manifestation of a common disease


1 Department of Pulmonary Medicine, Sardar Patel Medical College and Associated Group of Hospitals, Bikaner, Rajasthan, India
2 Department of Radiation Oncology, Acharya Tulsi Regional Cancer Treatment and Research Institute, Bikaner, Rajasthan, India

Date of Web Publication10-Jun-2016

Correspondence Address:
Akhil Kapoor
Room No. 73, PG Boys Hostel, PBM Hospital Campus, Bikaner - - 334 003, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2320-8775.159875

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  Abstract 

We report a rare case of tuberculosis (TB) of base of the tongue following pulmonary TB. Patient presented to us with chief complaints of sore throat, dysphagia, and hoarseness of voice for 20 days. Examination with 90° telescope revealed ulcerative lesion in the base of the tongue on the left side of size 0.5 cm and another lesion in the left arytenoid and inter arytenoid area extending to the false vocal cord of the left side with undermined edges along with whitish slough at the center of the ulcer. Infection of the oral cavity with Mycobacterium tuberculosis is rare, however, it should be considered among the differential diagnosis of the lesions of the oral cavity. The biopsy is necessary to confirm the diagnosis.

Keywords: Base of tongue, oral ulcer, tuberculosis


How to cite this article:
Saugat R, Soni G, Shivranjani R, Gujrani M, Thakral P, Kapoor A. Lingual tuberculosis mimicking malignant lesion: A rare manifestation of a common disease. J Assoc Chest Physicians 2016;4:87-90

How to cite this URL:
Saugat R, Soni G, Shivranjani R, Gujrani M, Thakral P, Kapoor A. Lingual tuberculosis mimicking malignant lesion: A rare manifestation of a common disease. J Assoc Chest Physicians [serial online] 2016 [cited 2019 Sep 15];4:87-90. Available from: http://www.jacpjournal.org/text.asp?2016/4/2/87/159875


  Introduction Top


Tuberculosis (TB) can involve any organ system in the body and TB of the oral cavity is very rare. It can occur as primary infection without involving other organs or can occur as a secondary infection following pulmonary TB. Tongue TB is very rarely described in the literature. It was reported that it occurred in only one of 5094 patients who were diagnosed as having pulmonary TB.[1] The main presenting symptom is a painful oral ulcer.

The resistance of the intact oral mucosa to tubercular infection stems from the cleansing action of saliva, presence of saprophytes, antagonism of the striated musculature to bacterial invasion and the thickness of a protective epithelial covering. Predisposing factors include poor oral hygiene, trauma, tobacco, irritation, dental extraction, pyogenic foci, and leukoplakia. Tongue is the commonest site for oral TB.[2],[3] It may also occur at gingiva, floor of mouth, palate, lips, and buccal mucosa.[4]


  Case Report Top


A 65-year-old male carpenter from a village of Western Rajasthan, India; presented with complaints of sore throat, dysphagia, hoarseness of voice and difficulty in swallowing for 20 days. Patient also complained of cough with expectoration, low-grade fever, and night sweats for 10 days. There was no history of loss of weight, loss of appetite or hemoptysis. There was no history of trauma, toothache or sharp tooth. The patient came from low socioeconomic status and was a chronic smoker with 20 pack-years. He was started on anti-TB drugs DOTS Cat I for 6 months 2 years before and completed the treatment as scheduled.

No lymphadenopathy could be elicited. Local examination with 90° telescope revealed ulcerative lesion in the base of the tongue left side [Figure 1] about size 0.5–1 cm; another lesion in the left arytenoid and inter arytenoid area extending to the false vocal card of left side [Figure 2] with undermined edges with whitish slough at the center of the ulcer.
Figure 1: Photograph with 90° telescope showing ulcerative lesion in the base of the tongue on the left side (shown by arrow)

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Figure 2: Photograph with 90° telescope showing lesion in left arytenoid and inter arytenoid area extending to the false vocal card of left side (shown by arrow)

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Laboratory investigation revealed elevated erythrocyte sedimentation rate 80 mm/h, white blood cell count 19,200 cells/cm, hemoglobin 12.8 g/dl. The biochemical parameters were within normal limits. HIV test was negative. Chest X-ray showed multiple areas of consolidation with opacity in the right upper zone along with bilateral infiltrates [Figure 3]. Sputum microscopy was positive for acid-fast bacilli (AFB) 1+. Cartridge-based nucleic acid amplification test of sputum was performed which detected M. tuberculosis sensitive to rifampicin.
Figure 3: Chest X-ray showing multiple areas of consolidation with opacity in right upper zone (shown by arrow)

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A small biopsy from the margin and center of the ulcer was performed under local anesthesia and sent for histopathological examination which revealed features of granulomatous inflammation with areas of caseation necrosis. The granuloma was composed of epithelioid cells, langhan's giant cells [Figure 4] and lymphocytic infiltration suggestive of TB. The patient was started on anti-TB therapy DOTS Cat II injection. Streptomycin 0.75 g/day, rifampicin 600 mg/day (as patient's weight was >60 kg), isoniazide 600 mg/day, pyrazinamide 1500 mg/day, ethambutol 1200 mg/day (each given thrice a week); patient clinically improved in 15 days. The patient was followed as per the standard guidelines and was declared cured at 8 months of completion of treatment with negative sputum and no lesion at the base of the tongue.
Figure 4: Photomicrograph showing granulomatous inflammation with areas of caseation necrosis

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  Discussion Top


Tuberculosis is an infectious, chronic granulomatous disease that can involve almost any organ in the body, but primary lesions are usually confined to the lungs. Oral lesions are an infrequent occurrence in TB, and TB of the oral cavity is often a consequence of active pulmonary TB. Although primary TB in the oral cavity has been documented, it is a rare occurrence.[5] It is reported to have an incidence rate of 1.4–2%.[5] It can occur as the only manifestation or in conjunction with pulmonary or extrapulmonary TB. Morgagni described the first case of lingual TB in the year 1761.[6] Since the tongue of every patient with the active TB is exposed to positive sputum, the relative infrequency of TB must be explained. It is probably due to combination of the reasons like, the thickness of mucous membrane, the resistance of the striated muscle of tongue, the cleansing action of saliva, and the well-nigh perpetual motion of the tongue.[7]

Tubercular infection of the tongue usually occurs due to contact with the infected sputum, but it may also occur by blood spread, lymphatic spread or by direct contamination from the neighboring tuberculous focus in the oral cavity.[7] TB of the tongue is more common among males than females.[8] Secondary TB of the tongue is usually observed in patients aged over 30 years. Primary TB, on the other hand, is very unusual and is seen in younger patients; may be associated with cervical lymphadenopathy.[8],[9] TB of the tongue may occur in various forms as ulcers, nodule, fissures, plaques or vesicles. The other oral manifestations of TB can be indurated soft tissue lesions or even lesions within the jaw that may be in the form of TB osteomyelitis or simple bony radiolucencies. The lesions are almost always painful. The most frequently occurring lesion is an ulcer, characterized by irregular edges with minimal induration. The base of an ulcer may be granular or covered with pseudomembrane. The dorsal surface of the tongue is affected most commonly followed by the palate, buccal mucosa, and lips. The salivary glands, tonsils, and uvula also are involved frequently. Secondary lesions of the mandibular ridge (alveolar mucosa) are extremely rare.[10]

A breach in the mucosa due to any reason is one of the important predisposing factors.[11] Weaver reported that 1–1.5% cases of pulmonary TB show TB of the oral cavity, the sites most frequently affected are the tongue, palate, tonsil, pharynx, and buccal mucosa.[12] Nagar et al. also reported a case of primary TB of palate [13] Panek et al. described a case of TB of the tongue associated with the pulmonary lesion, diagnosed by thin-needle biopsy.[14] Identification of AFB by ZN stain is confirmatory, but this is frequently negative in tissue sections.[13],[15]

The pathogenesis of oral TB usually is self-inoculation with infected sputum, resulting from the constant coughing up of bacteria that seed themselves in the oral tissue along their line of discharge through the mouth. Hematogenous spread of TB bacteria also occurs. In addition, direct inoculation of M. tuberculosis also has been reported. It is believed that an intact squamous epithelium of the oral mucosa serves as barriers to the penetration of TB bacilli.[16],[17],[18] However, small tears in the mucosa caused by chronic irritation or inflammation may be favorable sites for the colonization of organisms even if the onset is by hematogenous spread, since injured or inflamed tissues tend to localize blood borne bacteria.[19] The differential diagnosis of such lesion includes malignancy, foreign body granulomas, major aphthous ulcer, syphilis, sarcoidosis, and fungal infection, Wegener's granuloma.[4],[20]

The clinical presentation of extrapulmonary TB is atypical. The most common symptoms of lingual TB are pain on deglutition, burning sensation otalgia.[1] The constitutional symptoms of extrapulmonary TB are fever, anorexia, weight loss, malaise, and fatigue. Lymph nodes are the most common sites of extrapulmonary TB followed by pleural effusion. Lymph node TB may occur at the time of primary infection or due to reinfection or reactivation.[21] The diagnosis of oral cavity TB is based on sputum culture by the presence of AFB, chest X-ray, and biopsy.


  Conclusion Top


Tuberculosis of oral cavity is a rarely reported manifestation. 1–1.5% cases of pulmonary TB show infection of the oral cavity and TB of the tongue should be considered among one of the differential diagnoses of oral lesions. Biopsy is necessary to exclude any underlying malignancy. The physicians need to be aware of this condition for early diagnosis and treatment. Patient with tongue TB responds well to anti-TB therapy because the tongue is highly vascular.[1] In most cases, tongue lesions heal completely within 2 months of treatment.

 
  References Top

1.
Von Arx DP, Husain A. Oral tuberculosis. Br Dent J 2001;190:420-2.  Back to cited text no. 1
    
2.
Jawad J, El-Zuebi F. Primary lingual tuberculosis: A case report. J Laryngol Otol 1996;110:177-8.  Back to cited text no. 2
    
3.
Gupta A, Shinde KJ, Bhardwaj I. Primary lingual tuberculosis: A case report. J Laryngol Otol 1998;112:86-7.  Back to cited text no. 3
    
4.
Hathirum BT, Grewal DS, Irani DK, Tankwae PM, Patankar M. Tuberculosis of the cheek: A case report. Primary lingual TB: A case report. J Laryngol Otol 1997;111:872-3.  Back to cited text no. 4
    
5.
Garg RK, Singhal P. Primary tuberculosis of the tongue: A case report. J Contemp Dent Pract 2007;8:74-80.  Back to cited text no. 5
    
6.
Kakar PK, Sood VP. Primary lingual tuberculoma. The Journal of Laryngology and Otology 1971;85:89-91.  Back to cited text no. 6
    
7.
Titche LL. Tuberculosis of the tongue. Am Rev Tuberc 1945;52:377.  Back to cited text no. 7
    
8.
Rauch DM, Friedman E. Systemic tuberculosis initially seen as an oral ulceration: Report of case. J Oral Surg 1978;36:387-9.  Back to cited text no. 8
    
9.
Pande TK, Hiran S, Rao VV, Pani S, Vishwanathan KA. Primary lingual tuberculosis caused by M. bovis infection. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;80:172-4.  Back to cited text no. 9
    
10.
Haddad NM, Zaytoun GM, Hadi U. Tuberculosis of the soft palate: An unusual presentation of oral tuberculosis. Otolaryngol Head Neck Surg 1987;97:91-2.  Back to cited text no. 10
    
11.
Ghose SM. Ulcers of tongue. J Indian Med Assoc 1966;41:377.  Back to cited text no. 11
    
12.
Weaver RA. Tuberculosis of the tongue. JAMA 1976;235:2418.  Back to cited text no. 12
    
13.
Nagar RC, Joshi CP, Kanwar DL. Tuberculosis of oral cavity. Indian J Tuberc 1985;32:158-9.  Back to cited text no. 13
    
14.
Panek B, Chyczewska E, Mróz RM. Tuberculosis of the tongue. Pneumonol Alergol Pol 1999;67:477-80.  Back to cited text no. 14
    
15.
Aguirre García F, Fuertes Martín A, Guillén Guerrero VS, Santa Cruz Ruiz S, Fernández-Matamoros García I, Pérez Liedo C, et al. Tongue tuberculosis as the first expression of the lung process. An Otorrinolaringol Ibero Am 2000;27:111-8.  Back to cited text no. 15
    
16.
Dimitrakopoulos I, Zouloumis L, Lazaridis N, Karakasis D, Trigonidis G, Sichletidis L. Primary tuberculosis of the oral cavity. Oral Surg Oral Med Oral Pathol 1991;72:712-5.  Back to cited text no. 16
    
17.
Hashimoto Y, Tanioka H. Primary tuberculosis of the tongue: Report of a case. J Oral Maxillofac Surg 1989;47:744-6.  Back to cited text no. 17
    
18.
Yusuf H. Oral tuberculosis. Two case reports. Br Dent J 1975;138:470-2.  Back to cited text no. 18
    
19.
Fujibayashi T, Takahashi Y, Yoneda T, Tagami Y, Kusama M. Tuberculosis of the tongue. A case report with immunologic study. Oral Surg Oral Med Oral Pathol 1979;47:427-35.  Back to cited text no. 19
    
20.
Das P, Suri V, Arora R, Kulkarni K, Kumar K. Primary lingual tuberculosis mimicking malignancy: A report of two cases and review of literature. Internet J Pathol 2007;6. Available from: https://ispub.com/IJPA/6/2/8951. [Last cited on 2012 Jan 12].   Back to cited text no. 20
    
21.
Sharma SK, Mohan A. Extrapulmonary tuberculosis. Indian J Med Res 2004;120:316-53.  Back to cited text no. 21
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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