An 83-year-old woman presented to our hospital with a 2-month history of progressive weight loss, weakness, and recent odynophagia. Her daughter first noticed her tongue with white plaques about 2 weeks prior to our admission (Figure 1). She was admitted to another hospital, treated for thrush, and discharged. Her tongue surface then developed a whitish exudate over the tip (Figure 2) and became more painful. Most of the history was obtained from the daughter because the patient had severe dysarthria from the tongue lesions. Because the oral pain worsened, her primary physician referred her to an otolaryngologist who sent her immediately to our hospital for admission.
Her past medical history included stage 3 chronic kidney disease and stable neck pain for at least 1 year. She had been admitted with atrial fibrillation 1 month prior and started on metoprolol and apixaban. She was previously healthy, lived alone, and cared for herself. On review of system, she reported a mild stable headache, and the family reported she may have burned her tongue with hot soup.
Assessment
Physical examination was notable for bilateral palpable and pulsatile temporal arteries. Intra-oral examination revealed a large necrotic ulcer with eschar formation on the tongue tip. She was afebrile with stable vital signs. She appeared dehydrated and could not speak or eat because of the painful tongue lesions. Abnormal laboratory studies included a white cell count 12.1 thousand/mm3 (4.5-11), c-reactive protein 5.3 mg/dL (0-0.29), sodium 134 mmol/L (136-145), and an erythrocyte sedimentation rate 77 mm/h (1-12). Our preliminary differential diagnosis included tongue burn, vasculitis, and tongue cancer.
The oral surgeon suggested local wound care for possible trauma-induced ischemia (ie burn or bite). The otolaryngologist was concerned about vasculitis and less likely cancer. The chest radiograph and cervical computed tomography (CT) were unremarkable. The head and neck computed tomography angiogram showed no signs of vasculitis. Our radiology department does not do ultrasound of temporal and axillary arteries to evaluate vasculitis. Her apixaban was held for gastrostomy tube placement, and biopsies of both temporal arteries and tongue lesion were performed. Frozen sections from tongue biopsy revealed no malignancy. The temporal artery biopsies showed classic fulminant giant cell arteritis (Figure 3).
To read this article in its entirety please visit our website.
-George Cockey, MD, PhDa,, Syed Raza Shah, MDa, Troy Hampton, MDb
This article originally appeared in the May 2019 issue of The American Journal of Medicine.
