A 44-year-old man, smoker of 35 pack years and ex-user of intravenous drugs, came to the emergency department with a history of a painful ulcerated lesion, in the posterior third on the dorsum of the tongue with four months of evolution. In association, he reported weight loss of seven kilograms (>10 % of usual weight). The patient was evaluated by Otorhinolaryngology, who described a papillomatous, hardened and painful lesion measuring about three centimeters in the posterior third of the tongue, accompanied by bilateral cervical lymphadenopathies, with a tentative diagnosis of squamous cell carcinoma (Fig. 1).
A biopsy was performed one week after the emergency episode, along with a complete study with chest and neck computer tomography (CT) for staging. The anatomical pathology studied excluded a neoplastic lesion, instead, it showed infiltration by numerous epithelioid granulomas, some with central necrosis and frequently accompanied by giant multinucleated cells of the Langhans type (Fig. 2). Ziehl-Neelsen staining revealed the presence of occasional acid-fast bacillary structures (Fig. 3).
In view of these results, the patient was referred to the Infectious Diseases consultation. Exploring the epidemiological context, he reported having a cousin with a recent diagnosis and treatment of tuberculosis (eight months ago) with whom he had daily contact. The patient's tuberculous screening, at the time of his cousin's diagnosis, was negative. The patient denied cough or sputum more than usual (he was an active smoker), night sweats, or asthenia. He also denied anorexia but admitted weight loss, in the previous four months, of seven kilograms (weight at the first consultation of Infectious Diseases was 56 kg, body mass index of 17.8).
The chest x-ray showed an infiltrate on the left upper lobe on the chest radiograph. The chest CT showed a tree-in-bud pattern and cavitations (Fig. 4.). Analytically without leukocytosis, with sedimentation rate of 74 mm/h, mild anemia of 12.7 g/dL, normochromic and normocytic. Liver function and kidney function were normal. C-reactive protein of 23.7 mg/L (cut-off <5 mg/L).
Bronchial secretions were collected whose auramine study was positive for acid-fast bacilli, and GeneXpert  positive for Mycobacterium tuberculosis complex with negative rifampin resistance testing. Mycobacteria culture showed growth of Mycobacterium tuberculosis, whose sensitivity test demonstrated susceptibility to all first-line antituberculous drugs. It is also noteworthy to mention that the patient showed negative human immunodeficiency virus serology (HIV), had past contact with hepatitis B virus (HBV) and was diagnosed with chronic hepatitis C virus infection (HCV) (positive antibody with positive HCV ribonucleic acid (RNA)), which was staged and treated later on. The patient completed nine months of treatment (isoniazid, rifampin, pyrazinamide, and ethambutol regimen), with total resolution of the tongue lesion (Fig. 5.) and weight recovery.
Thorax computerized tomography demonstrating bilateral tree-in-bud pattern and cavitation in the left lung.