Tongue Ulceration in Woman With Prior “Lung Infection”

The Case: A 46-year-old woman complains of generalized weakness and fatigue that have been slowly worsening for 3 months. She has also had intermittent fever for the past month and dizziness for the past week. A deep central ulceration of about 2 cm in diameter is present on the patient’s tongue. The lesion is somewhat painful, and the pain increases significantly when she eats or drinks. The left tongue edge is macerated, and several smaller ulcerations are noted (Figure ). She also has a small, centrally located ulcer on the hard palate. There is no bleeding or drainage from the ulcers and no history of similar lesions. The patient was treated for a “lung infection” 4 years earlier. She denies using alcohol, illicit drugs, or tobacco, and she has not traveled recently. She is currently unemployed but formerly worked in a warehouse. Which of these disorders best explains the patient’s signs and symptoms? • Syphilis • Behçet disease • Disseminated histoplasmosis • Crohn disease Answer on next page , Discussion: A review of the patient’s medical records revealed that the previous “lung infection” was histoplasmosis; the tongue ulceration represents a secondary manifestation of that disease. Histoplasmosis is usually asymptomatic and self-limited; however, disseminated infection develops in approximately 1 in 2000 persons who have had the disease. Most of these persons are immunocompromised or have been exposed to a large inoculum. Patients with primary histoplasmosis typically present with fatigue, fever, and weight loss; disseminated infection may affect the CNS or pulmonary, hematologic, GI, or other systems. The results of a chest radiograph are normal in 30% of patients. The diagnosis can be established by antigen testing of urine and histopathologic examination of tissue. Blood culture results are positive in 50% to 70% of cases. Further investigation in this patient’s case revealed a markedly elevated C-reactive protein (CRP) level and erythrocyte sedimentation rate. Results of iron and anemia studies showed anemia of chronic disease. A urine test for histoplasmosis antigen and a histoplasmosis antibody test were positive. Although biopsy of oropharyngeal ulcers is usually diagnostic, results of a tongue biopsy in this patient were negative for histoplasmosis. Treatment choices include amphotericin B and itraconazole. Amphotericin is usually reserved for patients with histoplasmosis-induced meningitis. Itraconazole generally suffices for patients with less severe disease and for those with a positive response to this agent. Primary syphilis presents as a painless chancre at the site of inoculation that heals within a few weeks. Disease dissemination occurs during this period and leads to secondary syphilis, which is characterized by a rash on the palms and soles. Fever, lymphadenopathy, headache, and malaise may also be associated with secondary syphilis. Tertiary syphilis, which may appear at any time 1 year or more after the primary infection, affects the CNS and cardiovascular system. It may also present as gummatous syphilis, which consists of granulomatous nodular lesions that affect the skin, bones, and oral mucosa. Behçet disease, which affects persons of Middle Eastern or Far Eastern ancestry, is characterized by recurrent multiple oral aphthous ulcers. Because there are no laboratory studies that can definitively establish the diagnosis, it must be made clinically. Criteria include a recurrence of oral ulcers 3 times in 1 year plus 2 of the following: •Recurrent genital aphthae. •Ocular lesions (uveitis or retinal vasculitis). •Skin lesions (erythema nodosum, atypical acne, or pseudofolliculitis). •A positive pathergy test (a sterile erythematous papule 2 mm or larger that erupts 24 to 48 hours after insertion of a 20- to 25-gauge needle into the skin). Patients may also have neurologic or vascular disease or arthritis. Crohn disease is characterized by transmural mucosal inflammation. It involves the small bowel in 80% of patients, the ileum in 50%, and the colon alone in 20%. A small percentage of patients have oral manifestations, most commonly oral aphthous ulcers. Symptoms of Crohn disease include fatigue and prolonged diarrhea with abdominal pain, weight loss, and fever. It may take many years to establish the diagnosis. Radiographic and endoscopic studies delineate the distribution and severity of the disease process. Levels of CRP may be elevated. The diagnosis is confirmed by intestinal biopsy. FOR MORE INFORMATION: Friedman S, Blumberg RS. Inflammatory bowel disease. In: Braunwald E, ed. Harrison’s Principles of Internal Medicine. 15th ed. New York: McGraw-Hill Professional Publishing; 2001:1679-1691. Kaklamani VG, Vaiopoulos G, Kaklamanis PG. Behcet’s disease. Semin Arthritis Rheum. 1998;27:197-217. Lukehart SA, Holmes KK. Syphilis. In: Fauci AS, ed. Harrison’s Principles of Internal Medicine. 14th ed. New York: McGraw-Hill; 1998:1023-1033. Wheat LJ. Systemic fungal infections: diagnosis and treatment. I: Histoplasmosis. Infect Dis Clin North Am. 1988;2:841-859.