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Multiple Red Plaques with Severe Burning and Soreness on the Tongue

Case Challenge Number: 46

Diagnostic Information

History of Present Illness The patient presented with a chief complaint of burning tongue lesions existing for at least six months. She reported the lesions wax and wane and are aggravated by spicy foods, citrus, or acidic substances such as sodas, vinegar, and lemonade. Episodically her tongue is excruciatingly sore to the extent she is unable to touch the lesions. She also complained of a tingling of her extremities. Past Medical History The patient’s medical history was significant for breast cancer, treated 30 years ago, and a history of hypertension and asthma. Her medications include prednisone and steroid-based bronchodilators. She is a non-smoker and denies any alcohol use. Clinical and Cytologic Findings Intraoral examination revealed multiple red plaques with edema (Figures 1 and 2). Exquisite tenderness was encountered on palpation of the lesional areas of the ventral and dorsal surfaces of her tongue. The redness was particularly prominent on the ventral surface. The dorsal lesions were seen bilaterally. All other oral tissues appeared to be unaffected by the process. Her oral hygiene was excellent. A cytologic smear was taken and failed to reveal any fungal organisms.

case challenge 46 - Content - Diagnostic Information - Figure 1

Figure 1. The anterior ventral and tip of the tongue exhibiting a well demarcated and prominent erythema.

case challenge 46 - Content - Diagnostic Information - Figure 2

Figure 2. The dorsum and lateral borders of the tongue also demonstrating patchy erythema.

Laboratory Findings Complete blood work up was done with most findings within the normal range as shown in Table 1.

Table 1. Blood work up.

Vitamin B12L 55(243-894) pg/ml
Folate15.6(4.4-19.9) ng/ml
Complete Blood Count (with differential count)
HGB13.3(12.0-15.0) g/dl
HCT40.9(36.0-45.0) %
MCV92.4(80.0100.0)cu micron
MCH30.0(27.0-31.0) pg
MCHC32.4(32.0-37.0) g/dl
RDWH 16.0(11.5-14.5) %
PLT2639150-400)thou/cu mm
MPV9.2(7.4-10.4) fl
NEUTL 57.1(60-75) %
LYMPH34.9(25-40) %
MONO6.2(3.7) %
EOSL 1.7(3.5) %
BASO0.1(0-1) %
Differential Type (automatic differential)
NEUT ABS3.3(3.0-7.5) thou/cu mm
LYMPH ABS2.0(1.3-4.0) thou/cu mm
MONO ABS0.4(0.2-0.7) thou/cu mm
EOS ABS0.1(0.1-0.5) thou/cu mm
BASO ABS0.0(0.0-0.1) thou/cu mm
Abnormal parameters are indicated by “L” for below normal range and “H” for above normal range.

Histopathological Findings Microscopic examination of the biopsy specimen showed keratinized stratified squamous epithelium on the surface which was focally atrophic with areas of inflammatory cell infiltration. A moderately dense band of lymphocytes was noted immediately subjacent to the epithelium. Minor atypical changes were seen in the basal layers of the epithelium (Figures 3 and 4). No dysplasia or malignant features were noted. A second biopsy specimen was obtained for direct immunofluorescent antibody staining which revealed fibrinogen positivity along the basement membrane zone. IgG, C3, IgM, and IgA immunohistochemical studies proved to be negative. A diagnosis of chronic lichenoid mucositis with epithelial atrophy suggestive of a lichenoid reaction was rendered.

case challenge 46 - Content - Diagnostic Information - Figure 3
case challenge 46 - Content - Diagnostic Information - Figure 4

Figure 3 and 4. Histomicrographs using hematoxylin and eosin stain demonstrating keratinized surface epithelium with focal areas of atrophy and areas of inflammatory cell infiltration. A dense band of lymphocytes is seen immediately subjacent to the epithelium. Minor atypical changes were seen in the basal layers of the epithelium. Images are x10 and x20 magnification, respectively.