While this patient ’ s medical history did not necessarily suggest a deep fungal infection , such as histoplasmosis or blastomycosis , the clinical presentation of such lesions can closely resemble the ulcerated mass that this patient presented with . While deep fungal infections are rare , they are more commonly diagnosed in patients who are immunocompromised . Fungal infections have some geographic specificity , with histoplasmosis often being associated with the Ohio and Mississippi River regions of the United States . 2 When a specimen is stained with Grocott-Gomori methenamine silver ( GMS ) and viewed histologically , fungal organisms become evident . 6 Deep fungal infections require aggressive treatment with antifungal medications , such as amphotericin B , itraconazole , and ketoconazole .
Oral lesions associated with tuberculosis are a rare manifestation , and patients usually have a history of primary tuberculosis , a contagious chronic disease caused by Mycobacterium tuberculosis . 7 This patient did not have a previous diagnosis of tuberculosis , nor did she have symptoms suggestive of the disease . Diagnosis of tuberculosis is made by sputum culture and special mycobacterial stains using tissue samples , in which one would see chronic granulomatous inflammation with caseous necrosis . 2 If the patient is asymptomatic and does not have a history of tuberculosis infection or vaccination , a purified protein derivative ( PPD ) test is performed for initial diagnosis . If confirmed to be tuberculosis , treatment consists of a combination of drugs . The most widely used multi-agent protocol includes isoniazid , rifampicin , pyrazinamide , and ethambutol . 7 , 8
Syphilis is a bacterial infection , usually spread through sexual contact , caused by the spirochete Treponema pallidum . Syphilis has three stages , primary , secondary , and tertiary , which are separated by periods of latency . 4 In the primary stage , the spirochete enters the body , and , at the site of inoculation , a chancre forms between three days and three months later . Clinically , a chancre presents as a raised , ulcerated mass or nodule , which could be similar to the lesion that this patient displayed . A chancre will resolve without treatment in three to eight weeks ; however , a majority of patients will develop secondary syphilis weeks later , if not treated . 2 Administered parenterally , penicillin G is the preferred drug for treatment in all stages of syphilis . 9
A single , ulcerated lesion on the tongue is a presentation suggestive of the entities described above , whose etiologies range from traumatic injury to infectious diseases to a malignancy . Arriving at the correct diagnosis for the lesion is essential , as treatment varies tremendously between the possible causes . As a clinician , knowing , recognizing , and expeditiously acting on these types of lesions leads to improved outcomes and quality of life for the patients in our care .
REFERENCES
1 . Raman P . Tongue lesions as an oral diagnostic challenge for a primary care physician – a clinical case series . J Family Med Prim Care . 2020 Apr ; 11 ( 4 ): 1573-1579 .
2 . Neville , BW ; Damm , DD ; Allen , CM ; and Buoquot , JE . Oral and Maxillofacial Pathology . W . B . Saunders Company , 4th Edition , 2015 .
3 . Sharma B , Koshy , G , Kapoor S . Traumatic ulcerative granuloma with stromal eosinophilia : a case report and review of pathogenesis . J Clin Diagn Res , 2016 Oct ; 10 ( 10 ): ZD07-ZD09 .
4 . Chi AC , Day TA , Neville BW . Oral cavity and oropharyngeal squamous cell carcinoma-an update . CA Cancer J Clin . 2015 July 27 ; 65 ( 5 ): 401-421 . 5 . Johnson DE , Burtness B , Leemans CR , Lui VWY , Bauman JE , Grandis JR . Head and squamous cell carcinoma . Nat Rev Dis Primers . 2020 Nov 26 ; 6 ( 1 ): 92 .
6 . Sigera LSM , Gunawardane SR , Jayasekera PI . Histoplasma capsulatum caused a localized tongue ulcer in non-HIV patient – a case from non-endemic country . Ear Nose Throat J . 2019 May 7 ; 99 ( 6 ): 379-381 .
7 . Rodrigues BTG . Tuberculosis : primary diagnosis from an oral ulcer . J . Oral Diagn . 2020 Dec 23 ; 05 : e20200025 . 8 . Mumtaz S . Oral tuberculosis . Br Dent J . 2020 Nov 13 ; 229:571 . 9 . Syphilis – CDC basic fact sheet . 2022 Feb 10 . http :// www . cdc . gov / syphilis / stdfact -syphilis .
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