Case for Diagnosis
Painful Tongue Ulcers
Ulceras dolorosas en la lengua
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Escoda, M. Gardiello, M.J. Muntané" "autores" => array:3 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "Escoda" "email" => array:1 [ 0 => "mescoda@salutemporda.cat" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M." "apellidos" => "Gardiello" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "M.J." 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He had a history of erosive lichen that affected mucosal surfaces but was symptom-free at the time. The first lesion had appeared 15 days earlier on the dorsum of the tongue and was followed by a further 2 lesions on the side and base 2 days later. He reported no other relevant history.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Physical Examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">Examination revealed 2 foul-smelling ulcerated lesions (dorsum and base of the tongue), measuring around 2<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>cm in diameter, with nonindurated excrescent borders and a necrotic base. A smaller ulcer, measuring around 1<span class="elsevierStyleHsp" style=""></span>cm and with well-defined borders and necrotic base, was also present on the right side of the tongue (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Additional Tests</span><p id="par0015" class="elsevierStylePara elsevierViewall">A punch biopsy at 1 edge of the ulcer revealed a moderate inflammatory component and occasional eosinophils alongside accumulations of granule-like, basophilic filamentous structures against a necrotic base (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). No neoplastic cells were observed.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">A complete blood count and biochemistry were normal, except for C-reactive protein, with a concentration of 34.4<span class="elsevierStyleHsp" style=""></span>mg/L (normal range, < 5<span class="elsevierStyleHsp" style=""></span>mg/L). Serology was negative for syphilis and the human immunodeficiency virus (HIV). Antinuclear antibody, rheumatoid factor, perinuclear antineutrophil cytoplasmic antibody, and cytoplasmic antineutrophil antibody levels were also normal.</p><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">What Is Your Diagnosis?</span></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Diagnosis</span><p id="par0030" class="elsevierStylePara elsevierViewall">Actinomycosis of the tongue.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Clinical Course and Treatment</span><p id="par0035" class="elsevierStylePara elsevierViewall">Treatment was prescribed with clindamycin, 600<span class="elsevierStyleHsp" style=""></span>mg every 8<span class="elsevierStyleHsp" style=""></span>hours, and mouth rinses of chlorhexidine digluconate. At 1 week, the lesions showed marked improvement and at 6 weeks had healed completely, leaving only depressed scars on the tongue.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Comment</span><p id="par0040" class="elsevierStylePara elsevierViewall">Actinomycosis is a chronic granulomatous disease caused by a gram-positive microaerophilic bacterium belonging to the <span class="elsevierStyleItalic">Actinomyces</span> genus; the culprit is usually <span class="elsevierStyleItalic">Actinomyces israelii</span>.</p><p id="par0045" class="elsevierStylePara elsevierViewall">This microbe forms part of the commensal flora of the oral mucosa and has also been isolated in the upper respiratory and digestive tracts and the female genital mucosa. It is not usually pathogenic and requires a previous solution of continuity (surgery, injury, inflammatory process, etc.) in order to cause infection. In our patient, the erosive oral lichen lesions may have played a key role in the development of actinomycosis, and in our review of the literature we found 2 other cases with this association.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Conditions that influence immunosuppression (diabetes, HIV infection, etc.) may favor the development of this disease.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> The patient's poor oral hygiene and septic mouth would also have facilitated development as exemplified by another case of oral actinomycosis in the literature.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Actinomycoses are classified according to their location: cervicofacial, thoracic, ileocecal, and pelvic. Cervicofacial actinomycosis, the most common form, can affect several structures: pharynx, larynx, tear ducts, oral mucosa, paranasal sinuses, jaw, and scalp. Tongue involvement, as in this case, is extremely rare; the authors of a 2006 review article found only 15 cases reported.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Clinically, actinomycosis may present as a progressive infiltration of the organ (mimicking a neoplastic process), leading to abscess and fistula formation, but ulcerative lesions, as in our patient, have also been reported.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Differential diagnosis should include chancres, granulomatous lesions such as gummas or tuberculous defects, pyogenic abscesses, and benign and malignant tumors.</p><p id="par0065" class="elsevierStylePara elsevierViewall">For diagnosis, an anaerobic culture reveals characteristic sulfur granules (formed by aggregates of thin filamentous bacilli shown by Gram or Gomori stain), while biopsy of a lesion displays filamentous aggregates with a degree of tissue response in the form of fibrosis, inflammation, or both. The pathogen was not isolated in the culture in our case, as often occurs (in up to 70% in a review of 181 cases of actinomycosis).<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Treatment consists of surgical debridement and/or antibiotics. Penicillins, cephalosporins, erythromycin, streptomycin, lincomycin, vancomycin, chloramphenicol, clindamycin, and tetracyclines have been used successfully.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of Interest</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Medical History" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Physical Examination" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Additional Tests" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Diagnosis" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Clinical Course and Treatment" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Comment" ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of Interest" ] 7 => array:1 [ "titulo" => "Bibliografía" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Escoda M, et al. Úlceras dolorosas en la lengua. Actas Dermosifiliogr.2013;104:77-8.</p>" ] ] "multimedia" => array:3 [ 0 => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1168 "Ancho" => 835 "Tamanyo" => 126601 ] ] ] 1 => array:6 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 715 "Ancho" => 1000 "Tamanyo" => 95929 ] ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1000 "Ancho" => 1335 "Tamanyo" => 300592 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin-eosin, original magnification ×20.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliografía" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The clinical spectrum of <span class="elsevierStyleItalic">Actinomyces</span>-associated lesions of the oral mucosa and jawbones: correlatins with histomorphometric analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "I. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 17 | 22 | 39 |
| 2024 Octubre | 113 | 53 | 166 |
| 2024 Septiembre | 111 | 41 | 152 |
| 2024 Agosto | 146 | 95 | 241 |
| 2024 Julio | 119 | 66 | 185 |
| 2024 Junio | 119 | 63 | 182 |
| 2024 Mayo | 106 | 58 | 164 |
| 2024 Abril | 88 | 55 | 143 |
| 2024 Marzo | 106 | 39 | 145 |
| 2024 Febrero | 164 | 35 | 199 |
| 2024 Enero | 124 | 51 | 175 |
| 2023 Diciembre | 229 | 49 | 278 |
| 2023 Noviembre | 342 | 41 | 383 |
| 2023 Octubre | 286 | 57 | 343 |
| 2023 Septiembre | 284 | 46 | 330 |
| 2023 Agosto | 305 | 32 | 337 |
| 2023 Julio | 352 | 53 | 405 |
| 2023 Junio | 331 | 35 | 366 |
| 2023 Mayo | 309 | 47 | 356 |
| 2023 Abril | 265 | 34 | 299 |
| 2023 Marzo | 340 | 46 | 386 |
| 2023 Febrero | 325 | 37 | 362 |
| 2023 Enero | 287 | 58 | 345 |
| 2022 Diciembre | 267 | 58 | 325 |
| 2022 Noviembre | 187 | 34 | 221 |
| 2022 Octubre | 169 | 39 | 208 |
| 2022 Septiembre | 157 | 47 | 204 |
| 2022 Agosto | 87 | 48 | 135 |
| 2022 Julio | 126 | 45 | 171 |
| 2022 Junio | 176 | 38 | 214 |
| 2022 Mayo | 234 | 57 | 291 |
| 2022 Abril | 241 | 45 | 286 |
| 2022 Marzo | 247 | 79 | 326 |
| 2022 Febrero | 203 | 37 | 240 |
| 2022 Enero | 226 | 73 | 299 |
| 2021 Diciembre | 191 | 47 | 238 |
| 2021 Noviembre | 152 | 45 | 197 |
| 2021 Octubre | 123 | 79 | 202 |
| 2021 Septiembre | 84 | 60 | 144 |
| 2021 Agosto | 74 | 44 | 118 |
| 2021 Julio | 62 | 31 | 93 |
| 2021 Junio | 45 | 52 | 97 |
| 2021 Mayo | 35 | 55 | 90 |
| 2021 Abril | 88 | 102 | 190 |
| 2021 Marzo | 71 | 39 | 110 |
| 2021 Febrero | 74 | 42 | 116 |
| 2021 Enero | 43 | 29 | 72 |
| 2020 Diciembre | 45 | 21 | 66 |
| 2020 Noviembre | 29 | 32 | 61 |
| 2020 Octubre | 34 | 22 | 56 |
| 2020 Septiembre | 29 | 8 | 37 |
| 2020 Agosto | 32 | 23 | 55 |
| 2020 Julio | 39 | 15 | 54 |
| 2020 Junio | 42 | 26 | 68 |
| 2020 Mayo | 25 | 21 | 46 |
| 2020 Abril | 23 | 25 | 48 |
| 2020 Marzo | 35 | 15 | 50 |
| 2020 Febrero | 3 | 8 | 11 |
| 2020 Enero | 0 | 7 | 7 |
| 2019 Diciembre | 4 | 12 | 16 |
| 2019 Noviembre | 0 | 7 | 7 |
| 2019 Octubre | 0 | 5 | 5 |
| 2019 Septiembre | 0 | 12 | 12 |
| 2019 Agosto | 0 | 10 | 10 |
| 2019 Julio | 6 | 29 | 35 |
| 2019 Junio | 0 | 32 | 32 |
| 2019 Mayo | 2 | 38 | 40 |
| 2019 Abril | 0 | 20 | 20 |
| 2019 Marzo | 0 | 9 | 9 |
| 2019 Febrero | 2 | 2 | 4 |
| 2019 Enero | 0 | 3 | 3 |
| 2018 Diciembre | 2 | 2 | 4 |
| 2018 Noviembre | 2 | 3 | 5 |
| 2018 Septiembre | 4 | 0 | 4 |
| 2018 Marzo | 12 | 0 | 12 |
| 2018 Febrero | 258 | 6 | 264 |
| 2018 Enero | 270 | 5 | 275 |
| 2017 Diciembre | 274 | 9 | 283 |
| 2017 Noviembre | 205 | 5 | 210 |
| 2017 Octubre | 250 | 3 | 253 |
| 2017 Septiembre | 189 | 3 | 192 |
| 2017 Agosto | 250 | 12 | 262 |
| 2017 Julio | 231 | 14 | 245 |
| 2017 Junio | 256 | 9 | 265 |
| 2017 Mayo | 158 | 6 | 164 |
| 2017 Abril | 87 | 15 | 102 |
| 2017 Marzo | 94 | 2 | 96 |
| 2017 Febrero | 96 | 6 | 102 |
| 2017 Enero | 222 | 6 | 228 |
| 2016 Diciembre | 175 | 12 | 187 |
| 2016 Noviembre | 302 | 25 | 327 |
| 2016 Octubre | 220 | 30 | 250 |
| 2016 Septiembre | 248 | 9 | 257 |
| 2016 Agosto | 211 | 7 | 218 |
| 2016 Julio | 130 | 1 | 131 |
| 2016 Junio | 11 | 11 | 22 |
| 2016 Mayo | 10 | 5 | 15 |
| 2016 Abril | 9 | 4 | 13 |
| 2016 Marzo | 5 | 13 | 18 |
| 2016 Febrero | 5 | 2 | 7 |
| 2016 Enero | 6 | 2 | 8 |
| 2015 Diciembre | 7 | 5 | 12 |
| 2015 Noviembre | 105 | 9 | 114 |
| 2015 Octubre | 144 | 6 | 150 |
| 2015 Septiembre | 25 | 1 | 26 |
| 2015 Agosto | 11 | 4 | 15 |
| 2015 Julio | 276 | 17 | 293 |
| 2015 Junio | 242 | 9 | 251 |
| 2015 Mayo | 309 | 12 | 321 |
| 2015 Abril | 292 | 12 | 304 |
| 2015 Marzo | 275 | 9 | 284 |
| 2015 Febrero | 224 | 15 | 239 |
| 2015 Enero | 202 | 9 | 211 |
| 2014 Diciembre | 181 | 4 | 185 |
| 2014 Noviembre | 146 | 6 | 152 |
| 2014 Octubre | 151 | 3 | 154 |
| 2014 Septiembre | 138 | 4 | 142 |
| 2014 Agosto | 135 | 7 | 142 |
| 2014 Julio | 121 | 4 | 125 |
| 2014 Junio | 122 | 4 | 126 |
| 2014 Mayo | 114 | 5 | 119 |
| 2014 Abril | 88 | 4 | 92 |
| 2014 Marzo | 87 | 8 | 95 |
| 2014 Febrero | 66 | 7 | 73 |
| 2014 Enero | 56 | 7 | 63 |
| 2013 Diciembre | 40 | 10 | 50 |
| 2013 Noviembre | 45 | 11 | 56 |
| 2013 Octubre | 37 | 5 | 42 |
| 2013 Septiembre | 20 | 3 | 23 |
| 2013 Agosto | 10 | 10 | 20 |
| 2013 Julio | 13 | 6 | 19 |
| 2013 Junio | 6 | 13 | 19 |
| 2013 Mayo | 5 | 10 | 15 |
| 2013 Abril | 6 | 8 | 14 |
| 2013 Marzo | 5 | 9 | 14 |
| 2013 Febrero | 8 | 4 | 12 |
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