A 78-year-old male was brought to our department with the complaint of painful, progressive, and nonhealing ulcerated lesion of the tongue for 2 months. He did not give any history of fever, night sweats, cough, decreased appetite, or significant weight loss. There was no history of change in voice or choking. He did not give history of traumatic episode preceding the development of that wound. He denied any history of similar lesions in the past. He was a known case of hypertension taking antihypertensive medications. Besides having hypertension he denied history of other systemic illnesses including pulmonary tuberculosis. He admitted to smoking and drinking alcohol occasionally. The rest of his medical and surgical history was unremarkable. His past dental history was not significant. There was no history of TB in his family members. He was repeatedly treated in a local hospital with topical antiseptics and oral antibiotics (ampicillin plus cloxacillin and metronidazole) and analgesics but the lesion did not subside so he was referred to our hospital for the further management.
On general examination he was thin built with general conditions being fair, while, on examination of oral cavity, there was an indurated ulcer measuring 1.0 cm x 0.5 cm on the left lateral border of tongue on the anterior two-third part of tongue (Figure 1). It was tender with irregular border. It did not bleed on touch. The remaining part of the tongue was normal in texture and color. Mobility of tongue was normal. It was not deviated to either side on protrusion. He had poor orodental hygiene along with sharp tooth adjacent to the ulcerated lesion although the multiple teeth were absent. There were no palpable cervical lymph nodes and no similar ulcers in any other body parts.
Provisional diagnosis of traumatic ulcer was made as the possibility of ulcer due to repeated trauma by the sharp tooth could not be ruled out based on the physical examination alone. As we thought it could be due to chronic trauma by the sharp looking teeth although he was unaware of any traumatic episode. Dental consultation was done as the patient had poor oral hygiene along with loss of multiple teeth and the remaining teeth having sharp edges. Dentist did the coronoplasty of adjacent sharp cusp, and since the ulcer presented for more than two months they took incisional biopsy containing ulcerated lesion along with the normal looking margin being taken under local anesthesia and the specimen was sent for histopathological examination (HPE). The patient was also given oral antiseptic gel for local application and given an appointment for oral prophylaxis. Patient then presented to Department of Otorhinolaryngology with the HPE report. Microscopically the lesion revealed the stratified squamous epithelium with granulomatous inflammation containing Langhans type giant cells, epithelioid cells, and foci of caseous necrosis, strongly suggestive of tuberculosis (Figure 2).
Chest X-ray did not reveal any evidence of active or old Koch's infection. Sputum for acid fast bacillus (AFB) of three early morning samples was negative on Ziehl Neelsen stain. Complete blood count was within normal limit. His erythrocyte sedimentation rate (ESR) value was 20 mm/hr. Serum biochemistry and renal function tests were within normal limits. Serological investigation for human immune deficiency virus (HIV) was negative. Mantoux test was not performed as the histopathological findings were strongly suggestive of tuberculosis. An enquiry was made in the family whether they had any symptoms of pulmonary tuberculosis or any other chronic illnesses. No one in the family had any form of TB in the past. They denied symptoms such as chronic cough, night sweats, loss of appetite, or significant weight loss. They were all vaccinated with BCG as per the expanded programme on immunization (EPI) schedule of Nepal. In the absence of any symptoms no further investigations were ordered for them. Mantoux test was not done as well. Because every child gets BCG vaccination at birth in our country, that can yield positive Mantoux result because of the vaccination. As the sputum for AFB was negative in the patient the chance of spread is minimum to others.
The patient was referred to directly observed treatment, short course (DOTS) clinic after having histopathological diagnosis of TB. He was then started on antitubercular therapy (ATT). The ulcer gradually started fading once drug therapy was started (ATT). The patient felt symptomatically better after the start of ATT; and the tuberculous ulcer healed completely by the 2 months of ATT containing Isoniazid, Rifampicin, Pyrazinamide, and Ethambutol (Figure 3). The patient was then advised to continue ATT containing Isoniazid and Rifampicin for another 4 months. At the end of total 6 month's ATT course there was no evidence of residual ulcer at the primary site. We emphasized oral hygiene maintenance and advised the patient to follow up at dental outpatient department. As the patient came from a remote place in the hilly region of central Nepal, he did not seek any dental consultation as he was told that he had TB.