Diagnostic Information

History of Present Illness Kim is 13-year-old female who was referred to your clinic by the juvenile court for evaluation of “bumps” on her tongue. She is accompanied by her foster-mother who is concerned she may have a sexually transmitted disease. Kim became a ward of the state after her parents were killed 5 years ago (murder-suicide). The bumps were discovered by a local dentist who immediately reported her findings to Child Protective Services. She appears to be in no acute distress and denies any sexual activity or abusive encounters. Medical History - Adverse drug effects: none

- Medications: escitalopram 20 mg qd

- Pertinent medical history: depression x 5 years

- Pertinent family history: paternal – depression, death by suicide age 34, maternal - DM type 2, death by murder age 31; no siblings

- Social history: admits to smoking 5-10 cigarettes / day x 3 years, denies alcohol and recreational drug exposure Clinical Findings Extraoral examination reveals normal TMJ function, no facial muscle tenderness, and no cervical lymphadenopathy. Intraoral examination reveals an intact dentition with mild fluorosis. There is no evidence of active caries or periodontal disease. The posterior left side of the tongue is slightly enlarged and pebbly and exhibits multiple translucent intact vesicles (Figures 1 & 2). There is no pain on palpation, induration, or limitations of tongue function. An incisional biopsy was performed and the specimen was submitted for histologic assessment.

Figure 1. Slight enlargement of the posterior left lateral aspect of the tongue.

Figure 2. Closer view demonstrating translucent vesicles creating a pebbly surface.

Histopathologic Findings Histologic sections show a papillary mucosal soft tissue fragment exhibiting numerous superficial subepithelial cavernous to deeper small irregular dilated lymphatic vascular channels lined by bland flattened endothelial cells. The vascular lumens contain pink proteinaceous material. There is a supporting fibrous connective tissue stroma with mild chronic inflammation. The thinned stratified squamous surface epithelium displays focal parakeratosis.

Figure 3. Low power histologic section showing a papillary mucosal soft tissue fragment exhibiting numerous superficial bleb-like subepithelial cavernous lymphatic vascular channels. The specimen is surfaced by thin stratified squamous surface epithelium with focal parakeratosis.

Figure 4. High power histologic section showing irregular dilated lymphatic vascular channels lined by bland flattened endothelial cells. The vascular lumens contain pink proteinaceous material. There is a supporting fibrous connective tissue stroma with mild chronic inflammation.