Cleveland Clinic Journal of Medicine 2014 GÓMEZ MOYANO 523 4
2
ELISABETH GÓMEZ-MOYANO, MD, PhD Department of Dermatology, Carlos Haya University Hospital, Málaga, Spain Erythema and atrophy on the tongue A -- was referred to the dermatology department with a 6-month history of a painful burning sensation on the tongue. Examination revealed a reddish, atrophic area on the dorsum of the tongue (FIGURE 1). She had been treated unsuccessfully with topical antifungal drugs (clotrimazole and ny- statin) for a presumed diagnosis of oral candi- diasis. Otherwise, her medical history was no- table only for occasional episodes of epigastric pain. She did not smoke or drink alcohol. Fungal culture and oral exfoliative cytol- ogy studies were negative. Laboratory results: • Red blood cell c ount 3.9 × 10 12 /L (refer- ence range 4.2–5.4) • Hemoglobin 11.3 g/dL (12–16) • Mean corpuscular volume 92 fL ( 80–99) • Mean corpuscular hemoglobin 29 pg (2 7– 34) • Iron 14 µg/dL (37–145), • Vitamin B 12 119 pg/dL (250–900) • Zinc 33 µg/dL (66–110) • Serum g astric parieta l cell antibody posi- tive • Serum creatinine and liver enzyme tests were normal. Biopsy of the gastric mucosa revealed se- vere atrophic gastritis, so the possibility of at- rophy related to gastroesophageal reflux was considered. But the laboratory results and the patient’ s presentation pointed to iron deficien- cy and pernicious anemia (due to deficiency of vitamin B 12 ). Zinc deficiency is associated with oral burning but not atrophic glossitis. Based on the patient’ s symptoms and the testing results, she was given the diagnosis of atrophic glossitis. She was treated with oral iron supplementation, intramuscular injec- CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 81 • NUMBER 9 SEPTEMBER 2014 523 tions of vitamin B 12 , and oral zinc supplemen- tation. The glossitis resolved, and the gastric symptoms improved within 2 months, thus supporting our diagnosis of atrophic glossitis. ■ ATROPHIC GLOSSITIS The diagnosis of abnormalities of the tongue requires a thorough history, including onset and duration, antecedent symptoms, and to- bacco and alcohol use. Examination of tongue morphology is also important. 1 Tongue abnor- malities related to tobacco use and to alcohol use include leukoplakia, erythroplakia, oral submucosal fibrosis, lichen planus, and oral squamous cell carcinoma. Atrophic glossitis is often linked to an underlying nutritional deficiency of iron, fo- lic acid, vitamin B 12 , riboflavin, or niacin, although other nutritional deficiencies can be implicated. As noted, zinc deficiency can cause oral burning but not atrophic glossitis, THE CLINICAL PICTURE doi:10.3949/ccjm.81a.13102 FIGURE 1. The patient’s tongue had an erythematous, atrophic patch (arrows). LUIS M. PÉREZ-BELMONTE, MD, PhD Department of Internal Medicine, County Hospital of The Axarquía, Vélez-Málaga, Málaga, Spain LEANDRO MARTÍNEZ-PILAR, MD, PhD Department of Dermatology, Carlos Haya University Hospital, Málaga, Spain DANIEL J. GODOY-DÍAZ, MD Department of Dermatology, Carlos Haya University Hospital, Málaga, Spain on September 5, 2014. For personal use only. All other uses require permission. www.ccjm.org Downloaded from
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Transcript of Cleveland Clinic Journal of Medicine 2014 GÓMEZ MOYANO 523 4
ELISABETH GOacuteMEZ-MOYANO MD PhDDepartment of Dermatology Carlos Haya University HospitalMaacutelaga Spain
Erythema and atrophy on the tongue
A983090983094-983161983141983137983154-983151983148983140 983159983151983149983137983150 was referred to thedermatology department with a 6-month
history of a painful burning sensation onthe tongue Examination revealed a reddishatrophic area on the dorsum of the tongue(FIGURE 1)
She had been treated unsuccessfully withtopical antifungal drugs (clotrimazole and ny-statin) for a presumed diagnosis of oral candi-diasis Otherwise her medical history was no-table only for occasional episodes of epigastricpain She did not smoke or drink alcohol Fungal culture and oral exfoliative cytol-ogy studies were negative
Laboratory resultsbull Red blood cell count 39 times 1012L (refer-
ence range 42ndash54)bull Hemoglobin 113 gdL (12ndash16)bull Mean corpuscular volume 92 fL (80ndash99)bull Mean corpuscular hemoglobin 29 pg (27ndash
34)bull Iron 14 microgdL (37ndash145)bull Vitamin B12 119 pgdL (250ndash900)bull Zinc 33 microgdL (66ndash110)bull Serum gastric parietal cell antibody posi-
tivebull Serum creatinine and liver enzyme tests
were normal Biopsy of the gastric mucosa revealed se-vere atrophic gastritis so the possibility of at-rophy related to gastroesophageal reflux wasconsidered But the laboratory results and thepatientrsquos presentation pointed to iron deficien-cy and pernicious anemia (due to deficiencyof vitamin B12) Zinc deficiency is associatedwith oral burning but not atrophic glossitis Based on the patientrsquos symptoms and thetesting results she was given the diagnosis ofatrophic glossitis She was treated with oraliron supplementation intramuscular injec-
CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 81 bull NUMBER 9 SEPTEMBER 2014 523
tions of vitamin B12 and oral zinc supplemen-tation The glossitis resolved and the gastricsymptoms improved within 2 months thussupporting our diagnosis of atrophic glossitis
ATROPHIC GLOSSITIS
The diagnosis of abnormalities of the tonguerequires a thorough history including onsetand duration antecedent symptoms and to-bacco and alcohol use Examination of tonguemorphology is also important1 Tongue abnor-malities related to tobacco use and to alcoholuse include leukoplakia erythroplakia oralsubmucosal fibrosis lichen planus and oralsquamous cell carcinoma Atrophic glossitis is often linked to anunderlying nutritional deficiency of iron fo-lic acid vitamin B12 riboflavin or niacinalthough other nutritional deficiencies canbe implicated As noted zinc deficiency cancause oral burning but not atrophic glossitis
THE CLINICAL PICTURE
doi103949ccjm81a13102
FIGURE 1 The patientrsquos tongue had an erythematousatrophic patch (arrows)
LUIS M PEacuteREZ-BELMONTE MD PhDDepartment of Internal Medicine County Hospital ofThe Axarquiacutea Veacutelez-Maacutelaga Maacutelaga Spain
LEANDRO MARTIacuteNEZ-PILAR MD PhDDepartment of Dermatology Carlos Haya UniversityHospital Maacutelaga Spain
DANIEL J GODOY-DIacuteAZ MDDepartment of Dermatology Carlos Haya UniversityHospital Maacutelaga Spain
on September 5 2014 For personal use only All other uses require permissionwwwccjmorgDownloaded from
524 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 81 bull NUMBER 9 SEPTEMBER 2014
TONGUE
and it resolves with correction of the under-lying deficiency2 Cobalamin deficiency is themain cause of atrophic glossitis As our patientrsquos presentation illustratedoral symptoms can be multifactorial Oral con-ditions may be an early clinical manifestationof a nutritional deficiency but they can alsoreflect an alteration of the gastric mucosa3 abacterial viral or fungal infection neoplasticdisease autoimmune disease endocrine disor-der local mechanical trauma exposure to anirritant or an allergic reaction2
REFERENCES 1 Reamy BV Derby R Bunt CW Common tongue condi-
tions in primary care Am Fam Physician 2010 81627ndash
634
2 Chi AC Neville BW Krayer JW Gonsalves WC Oral mani-
festations of systemic disease Am Fam Physician 2010
821381ndash1388
3 Sun A Lin HP Wang YP Chiang CP Significant associa-
tion of deficiency of hemoglobin iron and vitamin B12
high homocysteine level and gastric parietal cell anti-
body positivity with atrophic glossitis J Oral Pathol Med
2012 41500ndash504
ADDRESS Luis M Peacuterez-Belmonte MD Department ofInternal Medicine County Hospital of The Axarquiacutea FincaEl Tomillar sn 29700 Torre del Mar Veacutelez-Maacutelaga MaacutelagaSpain e-mail luismiguelpbhotmailcom
on September 5 2014 For personal use only All other uses require permissionwwwccjmorgDownloaded from
524 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 81 bull NUMBER 9 SEPTEMBER 2014
TONGUE
and it resolves with correction of the under-lying deficiency2 Cobalamin deficiency is themain cause of atrophic glossitis As our patientrsquos presentation illustratedoral symptoms can be multifactorial Oral con-ditions may be an early clinical manifestationof a nutritional deficiency but they can alsoreflect an alteration of the gastric mucosa3 abacterial viral or fungal infection neoplasticdisease autoimmune disease endocrine disor-der local mechanical trauma exposure to anirritant or an allergic reaction2
REFERENCES 1 Reamy BV Derby R Bunt CW Common tongue condi-
tions in primary care Am Fam Physician 2010 81627ndash
634
2 Chi AC Neville BW Krayer JW Gonsalves WC Oral mani-
festations of systemic disease Am Fam Physician 2010
821381ndash1388
3 Sun A Lin HP Wang YP Chiang CP Significant associa-
tion of deficiency of hemoglobin iron and vitamin B12
high homocysteine level and gastric parietal cell anti-
body positivity with atrophic glossitis J Oral Pathol Med
2012 41500ndash504
ADDRESS Luis M Peacuterez-Belmonte MD Department ofInternal Medicine County Hospital of The Axarquiacutea FincaEl Tomillar sn 29700 Torre del Mar Veacutelez-Maacutelaga MaacutelagaSpain e-mail luismiguelpbhotmailcom
on September 5 2014 For personal use only All other uses require permissionwwwccjmorgDownloaded from
