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CASE REPORT
Year : 2017  |  Volume : 20  |  Issue : 4  |  Page : 202-204

Tongue tuberculosis: A rare entity


1 Department of Pulmonary & Critical Care Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India
2 Department of Respiratory Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India
3 Department of Pathology, King George's Medical University, Lucknow, Uttar Pradesh, India

Date of Web Publication17-Apr-2018

Correspondence Address:
Prof. Surya Kant
Department of Respiratory Medicine, King George's Medical University, Lucknow - 226 003, Uttar Pradesh
India
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DOI: 10.4103/smj.smj_64_16

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  Abstract 


Tuberculosis (TB) of tongue is a very rare extrapulmonary manifestation of TB. A number of different pathologies can mimic this condition, and so TB is often overlooked. Diagnosis requires a high index of suspicion and a prompt clinicohistopathological examination. We report a case of tongue TB which occurred probably because of the habit of brushing teeth with neem twigs (Azadirachta indica).

Keywords: Extrapulmonary tuberculosis, primary tuberculosis, tongue tuberculosis


How to cite this article:
Verma AK, Joshi A, Mishra AR, Singh A, Kumari M, Kant S. Tongue tuberculosis: A rare entity. Sahel Med J 2017;20:202-4

How to cite this URL:
Verma AK, Joshi A, Mishra AR, Singh A, Kumari M, Kant S. Tongue tuberculosis: A rare entity. Sahel Med J [serial online] 2017 [cited 2018 Sep 24];20:202-4. Available from: http://www.smjonline.org/text.asp?2017/20/4/202/230264




  Introduction Top


Tuberculosis (TB) is a chronic granulomatous disease, which in humans is mainly caused by Mycobacterium tuberculosis, Mycobacterium bovis, and atypical mycobacteria. TB can affect any organ of body of which pulmonary TB is most common. We report a rare case of primary TB in a very uncommon location, the tongue. TB of tongue is a very rare disease even in those geographical areas where it is endemic.


  Case Report Top


A 25-year-old immunocompetent male, nonsmoker, nontobacco chewer, laborer by occupation, from a rural background presented to the dental outpatient department with complaints of fever and nonproductive cough for 2 months, loss of appetite for 1 month, a painless swelling over the right side of surface of tongue for 2 weeks, and streaky hemoptysis for 2 days. On thorough history, it was found that hemoptysis was particularly in the morning after brushing. Routine blood investigations were normal. Mantoux test showed 14 mm induration. Chest skiagram [Figure 1] was within normal limits. Sputum examination for acid-fast bacilli was not done as the patient was not raising sputum. On oral examination, there was a painless swelling with induration over dorsum of tongue measuring 5 cm × 4 cm [Figure 2]. There was no cervical lymphadenopathy. Fine-needle aspiration cytology showed epithelioid granuloma comprising epithelioid cells, lymphocytes, and Langhans giant cells [Figure 3]. Ziehl–Neelsen staining was done which was negative. Biopsy was suggestive of granulation tissue with areas of necrosis and ill-defined granuloma [Figure 4]. The patient was started on four-drug regimen of antitubercular therapy (ATT) comprising rifampicin (R), isoniazid (H), ethambutol (E), and pyrazinamide (Z). The patient is in regular follow-up and is doing well and since then his swelling is also subsided [Figure 5].
Figure 1: Chest X-ray: Within normal limits

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Figure 2: Dorsum of tongue of the patient showing painless swelling with induration measuring 5 cm × 4 cm on right side

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Figure 3: Epithelioid granuloma comprising of epithelioid cells, lymphocytes, and multinucleated giant cells H and E, ×400

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Figure 4: Biopsy tissue showing fat, muscle bundles, and granulation tissue with area of necrosis (arrow) and few ill-defined epithelioid granuloma (arrowhead) H and E, ×100

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Figure 5: Post 4 months of antitubercular therapy

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  Discussion Top


Nearly 8.6 million people around the world became infected with TB disease. India is the country with the highest burden of TB. The World Health Organization statistics for 2015 give an estimated incidence figure of 2.2 million cases of TB for India out of a global incidence of 9.6 million. The estimated TB prevalence figure for 2015 is given as 2.5 million.[1]

TB can involve any organ system in the body. While pulmonary TB is the most common presentation, accounting for nearly 75% of tubercular cases, extrapulmonary TB (EPTB) is also an important clinical problem and accounts for nearly 10–15% of all cases of TB.[2],[3] Of these 10%–15% EPTB, most common extrapulmonary sites are lymph node TB (35%), pleural effusion (20%), bones and joints (10%), and genitourinary TB (9%).[4],[5]

Oral TB lesions are very rare and it is estimated that only 0.05-5% of total TB cases may be presented with oral manifestations.[6],[7] The tongue followed by soft palate, uvula, gingivae, lips, and salivary gland are the common sites of oral TB in descending order,[8] the tongue being the most common site for TB in the oral cavity.[9] Other sites of infection in the oral cavity include the gingivae, floor of the mouth, palate, lips, and buccal mucosa.[8] TB of these sites is most commonly after extraction of tooth either by hematogenous route or by lymphatic route.[10]

TB of the tongue though documented is uncommon and is associated with TB elsewhere in the body. Primary tongue TB is a rare presentation. The cleaning action of saliva over oral mucosa is thought to be the protective mechanism. In addition to this, the presence of normal microbial flora, saprophytes, and the submucosal antibodies provides a natural barrier.[6] Moreover, tongue has very less lymphoid tissue for which tubercular bacillus has affinity.[11]

Commonly TB of tongue is secondarily to TB elsewhere in body such as lung, lymph node, or any other organ which leads to a more easy way to diagnose tongue TB on the basis of signs and symptoms, but primary tongue TB without any other systemic manifestation is a rare presentation and a diagnostic challenge for the clinicians. Primary TB of the tongue with no lesion elsewhere in the body is very uncommon. There have been reports of extraoral involvement leading to fistula,[8] sinus,[12] or ulceration.[13] In our case, there has been no such complication, and it was a solely a primary tongue TB without any other manifestation which made its diagnosis a challenge.

In one of the studies conducted by Kumar et al.,[14] it was found that most of the people having rural background who had the habit of cleaning and brushing the teeth with neem twigs (Azadirachta indica) causes abrasion of oral mucosa and palate leading to infection by Mycobacterium tuberculosis. Our patient also comes from the rural area and he also had this habit. As no other causes are attributable to developing tongue TB in this patient, this practice of brushing teeth with neem twigs that could have possibly caused tongue TB.

Most of the times, oral TB causes ulcerative lesion of the mucosa, and other lesions may be nodules, tuberculoma, and periapical granulomas.[15]

In our case, it involved a nodular swelling on the dorsum of the tongue. In the absence of any systemic signs and symptoms of TB, as in our case, histopathological examination was must and after confirmation of TB patient was started on ATT and had a dramatic response. This case highlights the fact that in a TB endemic country such as India, in a patient presenting with nonspecific complaints and tongue swelling, TB should be considered as a differential diagnosis so that appropriate treatment can be instituted.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Global Tuberculosis Control 2015, WHO, Geneva, 2015. Available from: www.who.int/tb/publications/global_report/. [Last accessed on 2016 Nov 02].  Back to cited text no. 1
    
2.
Fanning A. Tuberculosis: 6. Extrapulmonary disease. CMAJ 1999;160:1597-603.  Back to cited text no. 2
[PUBMED]    
3.
Umadevi M, Ranganathan K, Saraswathi TR, Uma R, Elizabeth J. Primary tuberculous osteomyelitis of the mandible. Asian J Oral Maxillofac Surg 2003;15:208-13.  Back to cited text no. 3
    
4.
Snider DE, Onorato M. Epidemiology. In: Rossman MD, MacGregor RR, editors. Tuberculosis: Clinical Management and New Challenges. New York: McGraw-Hill; 1995. p. 3-17.  Back to cited text no. 4
    
5.
Sharma SK, Mohan A. Extrapulmonary tuberculosis. Indian J Med Res 2004;120:316-53.  Back to cited text no. 5
    
6.
Sezer B, Zeytinoglu M, Tuncay U, Unal T. Oral mucosal ulceration: A manifestation of previously undiagnosed pulmonary tuberculosis. J Am Dent Assoc 2004;135:336-40.  Back to cited text no. 6
    
7.
Ito FA, de Andrade CR, Vargas PA, Jorge J, Lopes MA. Primary tuberculosis of the oral cavity. Oral Dis 2005;11:50-3.  Back to cited text no. 7
    
8.
Purohit SD, Mathur BB, Gupta PR, Agarwal KC, Hathi HH. Tuberculous fistula of cheek. Report of a case. Oral Surg Oral Med Oral Pathol 1985;60:41-2.  Back to cited text no. 8
    
9.
Gupta A, Shinde KJ, Bhardwaj I. Primary lingual tuberculosis: A case report. J Laryngol Otol 1998;112:86-7.  Back to cited text no. 9
    
10.
Ebenezer J, Samuel R, Mathew GC, Koshy S, Chacko RK, Jesudason MV. Primary oral tuberculosis: Report of two cases. Indian J Dent Res 2006;17:41-4.  Back to cited text no. 10
[PUBMED]  [Full text]  
11.
Gupta PP, Fotedar S, Agarwal D, Sansanwal P. Primary tuberculous glossitis in an immunocompetent patient. Hong Kong Med J 2007;13:330-1.  Back to cited text no. 11
    
12.
Gillbe GV. A tuberculous sinus of the cheek. Br J Oral Surg 1968;5:203-5.  Back to cited text no. 12
    
13.
Hathiram BT, Grewal DS, Irani DK, Tankwal PM, Patankar M. Tuberculoma of the cheek: A case report. J Laryngol Otol 1997;111:872-3.  Back to cited text no. 13
    
14.
Kumar V, Singh AP, Meher R, Raj A. Primary tuberculosis of oral cavity: A rare entity revisited. Indian J Pediatr 2011;78:354-6.  Back to cited text no. 14
    
15.
Shafer WG, Hine MK, Levy MB. A Textbook of Oral Pathology. 4th ed. Philadelphia, US: WB Saunders Co.; 1983. p. 340-440.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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