The ubiquitous smartphone became a helpful diagnostic tool when a patient used one to snap a photograph of her tongue. Although her symptoms were vague and nonspecific, her photograph facilitated the diagnosis of a serious, potentially debilitating illness.
A generally healthy 63-year-old woman presented with a 1-week history of sore throat and periodic burning tongue pain associated with white discoloration. She experienced fatigue but not cough, rhinorrhea, dyspnea, or fever. Her examination results were normal, and rapid streptococcal antigen testing was negative. Supportive therapy with oral hydration and acetaminophen, recommended for suspected pharyngitis, provided no improvement.
On 2 subsequent visits with different providers over the ensuing 10 days, she reported that episodes of pain occurred variably in multiple areas of the tongue, were provoked by eating or drinking, and resolved within minutes if she stopped eating. Her examination results remained normal. Results from a complete blood count, basic metabolic panel, thyroid-stimulating hormone level, vitamin D level, and Lyme antigen test were all normal, and the diagnosis remained elusive.
One month before the onset of her tongue symptoms, the patient had received a facial botulinum toxin injection for cosmetic purposes. She had undergone several similar injections in the past and typically experienced a mild periorbital headache for a few days after administration. After the most recent dose, she had a more persistent low-grade periorbital and occipital headache. Because of worsening of the headache and her ongoing tongue symptoms, she consulted her dermatologist, who reassured her that her symptoms were not related to the botulinum toxin. The headache became severe, and she developed dysgeusia, nausea, and an 8-lb weight loss, prompting another appointment with her primary care physician. On review of systems at that time, the patient denied vision changes, jaw claudication, scalp tenderness, myalgias, weakness, or fevers.
Her medical history included osteoporosis, nephrolithiasis, multiple medication and environmental allergies, osteoarthritis, and gastroesophageal reflux disease. She was taking simvastatin and omeprazole daily but had recently stopped both because she was concerned that the medications might be triggering her symptoms. She drank alcohol in moderation and had no history of tobacco or illicit substance use.
Assessment
On physical examination during the follow-up primary care visit, the patient appeared anxious and fatigued but otherwise well. There were no tongue or oral lesions and no tenderness or palpable abnormalities of the scalp. The remainder of the examination results were normal. The patient shared a smartphone photograph of her tongue, taken during a recent symptomatic episode. It demonstrated a sharply demarcated region of pallor on the tip of the tongue (Figure 1). The history and photograph, which suggested lingual ischemia, in the context of a persistent, worsening headache, aroused suspicion for giant cell arteritis. Laboratory testing identified inflammatory markers that were notable for an erythrocyte sedimentation rate of 84 mm/h and a C-reactive protein level of 52.5 mg/L. Prednisone, 60 mg daily, was administered to the patient, and she was referred to a vascular surgeon for an urgent temporal artery biopsy.
To read this article in its entirety please visit our website.
-Sijie Jason Wang, MD, Nicholas J. Olson, MD, Kelly A. Kieffer, MD
This article originally appeared in the September 2016 issue of The American Journal of Medicine.
