Tuberculosis of the tongue: A rare case

Devidas B Dahiphale; Abhijeet Nagarpurkar; Harshul Sharma; Shivaji Pole; Prasanna S Mishrikotkar

doi:10.4103/mgmj.mgmj_197_22

CASE REPORT

Year : 2022 | Volume : 9 | Issue : 4 | Page : 591-595

Tuberculosis of the tongue: A rare case

Devidas B Dahiphale, Abhijeet Nagarpurkar, Harshul Sharma, Shivaji Pole, Prasanna S Mishrikotkar
Department of Radio-Diagnosis, MGM Medical College and Hospital, Aurangabad, Maharashtra, India

Date of Submission	14-Oct-2022
Date of Acceptance	21-Nov-2022
Date of Web Publication	29-Dec-2022

Correspondence Address:
Dr. Harshul Sharma
Department of Radio-Diagnosis, MGM Medical College and Hospital, N-6, CIDCO, Aurangabad 431003, Maharashtra
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mgmj.mgmj_197_22

Abstract

Introduction: Tuberculosis mostly affects the lungs, but may also affect the central nervous system, lymphatic system, circulatory system, genitourinary system, bones, joints, and skin. Extrapulmonary involvement in tuberculosis is rare, accounting for just 10 to 15% of cases. The lymph nodes are the second most common site of tuberculosis infection. Oral tuberculosis has long been thought to be an unusual phenomenon. Oral manifestations are thought to occur in just 0.05 to 5% of all tuberculosis cases. Surface ulcers, patches, papillomatous lesions, and indurated soft tissue lesions are the most common oral manifestations. Case Presentation: A 69-year-old man presented to the Department of Ear, Nose, Throat at MGM Hospital in Aurangabad, India, with a painful ulcer and tiny nodules on the tongue’s tip and lateral surface. The ulcer appeared 3–4 weeks ago without any obvious trigger with a prickling feeling and increased soreness over the area., Onintraoral inspection multiple small nodules is measuring about 0.1 cm and multiple circular ulcer measuring about 0.2 x 0.1 cm in diameter at the tip and lateral border of the tongue. A granulomatous center and a whitish, well-defined border with mild elevation characterized the ulcer. Conclusion: Despite the rarity of tuberculosis evidence in the oral cavity, oral tuberculosis should be included in the differential diagnosis of chronic oral lesions. To prevent ineffective oral therapy, accurate diagnosis is crucial for successful care by concentrating on the pathological source.

Keywords: Oral tuberculosis, oral ulceration, tongue, tongue oral ulceration

How to cite this article:
Dahiphale DB, Nagarpurkar A, Sharma H, Pole S, Mishrikotkar PS. Tuberculosis of the tongue: A rare case. MGM J Med Sci 2022;9:591-5

How to cite this URL:
Dahiphale DB, Nagarpurkar A, Sharma H, Pole S, Mishrikotkar PS. Tuberculosis of the tongue: A rare case. MGM J Med Sci [serial online] 2022 [cited 2023 Feb 7];9:591-5. Available from: http://www.mgmjms.com/text.asp?2022/9/4/591/365989

Introduction

Tuberculosis (TB) is a chronic infectious disease caused by the bacteria Mycobacterium tuberculosis (M. tuberculosis) and spread by infectious aerosol droplets expelled by patients with active tuberculosis. However, in the vast majority of cases, such infections are suppressed by the host’s successful immune response; TB frequently goes unnoticed in its latent phase and is not contagious.^[1]Tuberculosis mostly affects the lungs, but may also affect the central nervous system, lymphatic system, circulatory system, genitourinary system, bones, joints, and skin. Which can spread to the oral cavity through infected sputum or a hematogenous route.^[2]

Extrapulmonary involvement in tuberculosis is rare, accounting for just 10 to 15% of cases. The lymph nodes are the second most common site of tuberculosis infection. Oral TB has long been thought to be an unusual phenomenon. Oral manifestations are thought to occur in just 0.05 to 5% of all tuberculosis cases. Surface ulcers, patches, papillomatous lesions, and indurated soft tissue lesions are the most common oral manifestations.^[3]

The oral manifestation of tuberculosis can affect people of all ages but is most common in the elderly. It typically manifests as an ulcer. Autoinoculation is thought to occur when infected pulmonary mucus interacts with damaged, vulnerable areas of the mucosa, resulting in the appearance of lesions.^[4]

Case presentation

A 69-year-old man presented to the Department of Ear, Nose, Throat (ENT) at MGM Hospital in Aurangabad, India, with a painful ulcer and several tiny nodules on the tongue’s tip and lateral surface. The ulcer appeared 3–4 weeks ago without any obvious trigger, There is a prickling feeling and increased soreness over the area. On intraoral inspection, multiple small nodules measuring about 0.1 cm x 0.1 cm and multiple circular ulcer measuring about 0.2 cm x 0.1 cm in diameter at the tip and lateral border of the tongue. A granulomatous center and a whitish, well-defined border with mild elevation characterized the ulcer [Figure 1]. On palpation, the lesion’s base was firm and consistent. For the last 30 years, the patient has had a history of tobacco chewing and smoking. The complete blood count (CBC) was within normal limits, and serologic studies for the human immunodeficiency virus and hepatitis C were also negative. The important differential diagnoses considered were major aphthous ulcer, traumatic ulcer, and infections based on the clinical history. Initial treatments such as amoxicillin 1.0 gm, prednisolone 30 mg, and a topical mouthwash were used with careful instructions to prevent potential triggers, and triamcinolone acetonide 5 mg was administered twice into the lesion for 2 months. However, no substantial progress has been made.

Figure 1: Patient presented with multiple tongue nodular ulcers

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On High-resolution computed tomography (HRCT), cavitary lesions in the apicoposterior segment of the left upper lobe with patchy nodular air space opacities and centrilobular nodules arranged in a linear branching pattern giving tree-in-bud appearance in the bilateral lung parenchyma, necrotic mediastinal lymphadenopathy, and apical pleural thickening on the left side of the lung, all of which were suggestive of reactivation of old tubercular disease [Figure 2]. But as a patient does not give a history of taking Anti Tubercular Treatment (ATT), Magnetic resonance imaging (MRI) of the tongue was recommended for better understanding. The MRI report revealed an altered signal intensity lesion in the right half of the anterior tongue, as well as cervical lymphadenopathy indicative of a neoplastic etiology [Figure 3]. A biopsy was recommended to confirm the diagnosis, and an incisional biopsy of the ulcer was performed (2 percent lidocaine with epinephrine 1:100,000). An abundant inflammatory infiltrate composed of lymphocytes and epitheliod cells forming well-defined granulomas is seen, plenty of Langhans giant cells are also seen, and few granulomas show the caseous type of necrosis, Findings suggestive of granulomatous inflammation of the tongue favors tubercular etiology[Figure 4].

Figure 2: HRCT chest suggests a cavitary lesion in the apicoposterior segment of the left upper lobe with patchy nodular air space opacities and centrilobular nodules arranged in a linear branching pattern giving tree-in-bud appearance in the bilateral lung parenchyma, necrotic mediastinal lymphadenopathy, and apical pleural thickening on the left side of the lung

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Figure 3: MRI STIR images reveal an altered signal intensity lesion in the right half of the anterior tongue findings of the patient

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Figure 4: Abundant inflammatory infiltrate composed of lymphocytes and epitheliod cells forming well-defined granuloma, plenty of Langan’s type giant cells are also seen, few granulomas show the caseous type of necrosis, Findings suggestive of Tubercular etiology

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Based on histological findings, the oral ulcer was finally diagnosed as lingual TB. The patient was immediately referred to a pulmonologist for further examination and management. Acid-fast bacillus (AFB) stains of the lesion were positive for M. tuberculosis. AFB cultures were positive for the M. tuberculosis complex. Polymerase chain reaction (PCR) was conducted on his sputum, and analysis confirmed the presence of M. tuberculosis. Additional blood biochemistry revealed the increased values of erythrocyte sedimentation rate (ESR) (103 mm/h) and C-reactive protein (CRP) (2.54 mg/dL).^[1]After about 3 months of drug therapy, the oral ulcer of the patient almost disappeared [Figure 5], and after another 2 months, the AFB culture showed no growth of tuberculosis. Currently, the patient is on ATT without any complications.

Figure 5: Post ATT presentation of the patient with resolved nodules and ulcer

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Discussion

TB is the world’s ninth leading cause of death and the leading cause of death caused by a single infectious agent, surpassing human immunodeficiency virus infection/ acquired immune deficiency syndrome(HIV/AIDS). According to the World Health Organization, 10.4 million people were infected with tuberculosis in 2016: 90 percent were adults, 65 percent were men, 10% were HIV-positive (74 percent in Africa), and 56 percent resided in one of five countries: India, Indonesia, China, the Philippines, and Pakistan. Although the global incidence of tuberculosis is decreasing at a rate of about 2% per year.^[5]

The pulmonary system is the most susceptible to tuberculosis, and infection rarely spreads to other areas of the body in most patients. Progressive pulmonary TB, on the other hand, can spread by self-inoculation through infected sputum, blood, or lymphatic system to cause secondary TB lesions in organs other than the lung.^[6]Extrapulmonary tuberculosis (TB) of the pleura, lymphatics, bone, genitourinary system meninges, peritoneum, or skin affects around 15% of TB patients.^[7] The oral cavity, as well as the head and neck area, may be affected by tuberculosis. Lesions in the mouth may be either primary or secondary to pulmonary tuberculosis, with secondary lesions being more common.^[8] However, primary lingual tuberculosis with a tongue ulcer as a presenting symptom is uncommon. The oral lesions are normally accompanied by a stellate ulcer on the dorsum of the tongue.^[9]

Ulcers, nodules, fissures, tuberculomas, and granulomas are all symptoms of lingual tuberculosis. A superficial ulcer is the most common lesion, with undermined margins, a granulating base, and occasional small tuberculous nodules around the periphery. The ulcer may be ragged and indurated, and it is often painful. The appearance of granulomatous inflammation with epithelioid cells and Langhans giant cells or AFB on Ziehl-Neelsen staining of biopsy specimens is one of the histological conditions for a diagnosis of oral TB.^[10]

Bacilli are phagocytosed and degraded by resident macrophages once they reach the lungs. Some bacilli, however, can evade lysosomal delivery and survive within the macrophage. M. tuberculosis is kept in check in macrophages by granulomas, which are clusters^[1]of immune cells containing mycobacteria-infected macrophages in the middle, surrounded by macrophages, T and B lymphocytes, dendritic cells, endothelial cells, fibroblasts, and granulocytes. As long as host immunity is successful, mycobacteria can exist in a so-called “dormant” state.^[7]As a result, the presence of granuloma as a distinct feature of latent pulmonary TB suggests a balance between host tolerance and M. tuberculosis virulence.

Many people with no symptoms have virulent bacteria in their granulomas. Granulomas control bacterial infection while also providing bacteria with a haven for long-term survival.^[11]

Once a patient has been diagnosed with tuberculosis, personalized anti-TB medications should be administered based on a clinical review. Treatment of latent tuberculosis infection is also needed to prevent active tuberculosis disease in people who have already been infected with M. tuberculosis.^[1] Oral lesions may be relieved after systemic TB is treated with medication.

The oral lesions of tuberculosis have a nonspecific clinical appearance and are often misdiagnosed. When oral lesions do not react adequately to local treatments, the doctor should consider TB as a possibility. Clinical and radiological examination, as well as careful anamnesis, can play a key role in the clinical diagnosis of tuberculosis. Based on the ulcer’s prolonged course and the lack of trauma in the past, aphthous ulcers and traumatic ulcers may be ruled out in this situation. Since other systemic diseases, such as Crohn’s disease, syphilis, blastomycosis infection, and even Langerhans cell histiocytosis, can cause different forms of oral ulcers, histopathological examination and microorganisms culture should be considered for a definitive diagnosis.^[12]

Since the patient had no other systemic symptoms other than a chronic oral ulcer that was not reacting to treatment, it was initially difficult to distinguish TB from other focal lesions in our case. Computed tomography (CT)chest and MRI results were conflicting, with the CT chest suggesting reactivation of tuberculosis, despite the patient’s denial of any previous history of ATT. An MRI was recommended, but the MRI suggested a neoplastic etiology. Finally, histopathology was recommended, and TB was confirmed on biopsies.

Even though the secondary TB tongue is extremely rare, and the primary TB tongue is even rarer, it is critical to consider the different oral forms of TB to prevent a delayed diagnosis and a poor prognosis.

Conclusion

In conclusion, despite the rarity of TB evidence in the oral cavity, oral TB should be included in the differential diagnosis of chronic oral lesions. To prevent ineffective oral therapy, accurate diagnosis is crucial for successful care by concentrating on the pathological source.

Ethical consideration

Institutional Ethics Committee (IEC) of MGM Medical College, Aurangabad, Maharashtra, India reviewed and approved the research study entitled: “Tuberculosis of the tongue: a rare case” in the ICE meeting held on 7 October 2022, communicated vide their letter no. MGM/PHARMAC/ERHS/2022/84 dated October 8, 2022.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initial will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.

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