Summary- A 58yr old female came with complaints of painful, non-healing ulcer onleft side of tongue of 5 months duration. She also had productive cough,weakness, weight loss and difficulty in opening mouth. The symptoms aggravatedwith passage of time. She had history of pulmonary TB one year back for whichshe had taken complete anti tuberculosis therapy (ATT).She had no history ofdental trauma or any oral surgery or tobacco chewing. Her Complete blood count(CBC) was normal. Erythrocyte sedimentation rate (ESR) was raised. Chest X-rayrevealed widespread fibro caseous infiltrate. Sputum for AFB was negative. TheHIV antibody test was negative. A biopsy was obtained from the margin of thelesion. It was confirmed as Mycobacterium tuberculosis on ZN stainingand other biochemical tests. She was referred to DOTS center (NRS MedicalCollege) for ATT. Patient’s oral tuberculous lesion as well as general symptomsimproved within three months.
Presenting features- A 58yr oldfemale came to a Charitable Clinic (KMC ward-55) with complains of non-healingpainful ulcerative lesion on left side of tongue of five months duration. Theoral ulcer was initially small and enlarged gradually over a period of fivemonths. She also had productive cough, weakness, weight loss and difficulty inopening mouth. These symptoms gradually progressed over a period of fivemonths. The treatment she received during this period brought no improvement.Write introduction-few sentences about such unusual forms of TB and theirsignificance for public health work
Past History-She had history of pulmonary TB one year back forwhich he had taken complete anti tuberculosis therapy (ATT) with Isoniazid 600mg, Rifampicin 450 mg and Pyrazinamide 1500mg, Ethambutol 1200mg for two monthsfollowed by Rifampicin and Isoniazid for four months. She had no history ofdental trauma or any oral surgery or tobacco or beetle nut chewing. No History of tobacco chewing or smoking
Family History-Her Husband is immuno-compromised and currentlyreceiving ART from School of Tropical Medicine. No other significant familyhistory.
Clinical Examination- On clinical examination it was found that her BP was 128/72mm Hg, pulse rate- 74/min , regular, weight 45kgs,all peripheral pulses werepalpable. She had mild pallor. On examination of her chest basalcrepitation was found on left lowerside. Abdomen and cardiovascular system was within normal limit. Oralexamination revealed shallow ulcer of size 1 ? 1.5 cm with irregular margins,covered with mucopurulent discharge and slough. On palpation ulcer was tender,indurated and with undermined margins. Local examination showed diffuseswelling of left side of face. Cervical lymph nodes were neither enlarged norfixed to surrounding tissue.
Investigations Suggested-
• Blood-CBC,ESR,HIV-1&2
• Sputum for AFB
• CXR-PA view
• Biopsy oflesion
Differential diagnosis-
• Apthous ulcer
• Squamous cell carcinoma of tongue
• Traumatic ulcer
• Pyogenic granuloma
• Focal Fibrous hyperplasia
• Folliate papillitis.
Outcome- Counseling was done andinformed consent was obtained. Complete blood count (CBC) was normal.Erythrocyte sedimentation rate (ESR) was raised. Chest X-ray revealedwidespread fibro caseous infiltrate. Sputum examination for AFB was negative.The HIV antibody test was negative. The patient was referred to theMicrobiology and Pathology laboratory for confirmatory diagnosis. A biopsy wasobtained from the margin of the lesion. It was confirmed as Mycobacteriumtuberculosis on ZN staining and other biochemical tests.The patient was confirmed as a caseof oral (buccal) mucosal TB with the recurrence of pulmonary TB. She wasreferred to DOTS center (NRS Medical College) for ATT. ATT (category IIregimen) was given after consultation with TB medical officer. Regimen consistof Isoniazid 600 mg, Rifampicin 450 mg, Pyrazinamide 1500mg, Ethambutol 1200 mgand Streptomycin 750mg for two months then Isoniazid, Rifampicin, Pyrazinamideand Ethambutol for one month in intensive phase. This was followed by Isoniazid,Rifampicin , Ethambutol for five months.
Follow up- Patient’soral tuberculous lesion as well as general symptoms improved within threemonths.
Discussion- The incidence of tuberculosis in the oral cavity isquite rare. It could be either primary or secondary to pulmonary disease.[4] Thereare about 1–1.5% cases of pulmonary tuberculosis with associated oral cavitylesions. The oral sites most frequently affected are the tongue, palate,tonsil, pharynx, and buccal mucosa.[5] The vulnerability to TB in developingcountries results from poverty, economic recession and malnutrition.[2, 3] Theepidemic of HIV infection and development of multi drug resistant bacteria alsocontributes to increase in number of tuberculosis cases. With increasing numberof tuberculosis cases, unusual forms of the disease are also likely toincrease. Oral lesions have a non-specific presentation varying from ulcers togranulomas, fissures and may be overlooked.[4,6,7] Incidence of oral tubercularinfections is quite rare, occurring in 0.05% - 5% of all tuberculosis cases.[9]In our case, tongue is involved. A break in the epithelial continuityfacilitates inoculation by the bacilli present in sputum. Both local andsystemic predisposing factors exist for the occurrence of oral lesions.[6]Local factors include poor oral hygiene, local trauma, presence of preexistinglesions such as leukoplakia , periapical granulomas, cysts, abscesses andperiodontitis.[4,6].Systemic predisposing factors include primary or secondaryimmune suppression and nutritional deficiencies. Orofacial tuberculosis usuallyresults from autoinoculation of the infectious agent in patients with advancedinternal tuberculosis of the lungs, gastrointestinal or genitourinary tract.Hematogenous or lymphatic dissemination from another active source oftuberculosis has also been described.[9] Most of the TB cases occurring in theoral cavity are secondary to pulmonary infections, though other primary lesionsare not unknown.[4]Clinicians should also search and investigate for symptomsassociated with primary TB (active source for secondary TB) which act as asource for orofacial involvement. Aird [10] has described five pathologicaltypes of oral tuberculous lesion as ulcers, tuberculoma, fissure, papilloma andcold abscess. Shallow ulcerative growth with undermined edges was thepresentation in our case. The histopathology and culture of biopsy specimen wasdone for confirmation of oral (buccal) mucosal TB. The mucosal involvement wassecondary to pulmonary TB. Health careworkers and the contacts of patients are at risk due to aerosol transmission.There is delay in diagnosis due to rarity of the condition. So clinician shouldbe aware of mucosal TB and do the further investigations for favorable outcomein such cases. A major concern about the cases of TB is the risk oftransmission of tuberculosis in the community. Clinicians, especially dentists,ENT surgeons and general surgeons are involved in diagnosis and treatment oftuberculosis in rare presentation of oral mucosal TB. They are also exposed tothe TB bacilli as occupational health hazard. Therefore it should be consideredas differential diagnosis in chronic mucosal lesion in developing country likeIndia. Clinicians’ awareness will help in early diagnosis and prevent complications.
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