A 49-year-old male veteran with a history of overseas deployment to Iraq presented 7 years after his most recent deployment. He reported a several-month history of an enlarging painful ulcer in the center of his tongue, with dysphagia, odynophagia, and a 9-kg weight loss. His medical history was remarkable for scattered nonnecrotizing liver granulomas that had been diagnosed from a liver biopsy 5 years earlier as well as for elevated liver enzyme levels (alanine transaminase, 127 IU/L; aspartate transaminase, 89 IU/L; and alkaline phosphatase, 474 IU/L [to convert liver enzyme values to microkatals per liter, multiply by 0.0167]), splenomegaly, and chronic thrombocytopenia. Physical examination revealed a 3 × 3-cm, ulcerated, cavitary, and tender lesion within the central oral tongue, just anterior to the circumvallate papillae (Figure 1). There were no skin lesions. Multiple punch biopsy specimens of the tongue lesion revealed nonspecific chronic nonnecrotizing granulomatous inflammation with overlying candidiasis. When the ulcer failed to respond to oral antiseptics, antibiotics, and antifungal agents, a midline partial glossectomy with primary closure was performed. The findings of histopathologic analysis with periodic acid–Schiff–light-green staining were negative for fungi. Low-power Giemsa staining revealed mucosal ulceration and pseudoepitheliomatous hyperplasia (Figure 2). Medium-power (Figure 3) and high-power (Figure 4) views with Giemsa staining showed extensive nonnecrotizing granulomatous inflammation with large numbers of intracellular microorganisms. An enzyme-linked immunosorbent assay was positive for rK39 antigen. View LargeDownload Figure 1. View LargeDownload Figure 2. View LargeDownload Figure 3. View LargeDownload Figure 4. What is your diagnosis?
Archives of Otolaryngology - Head & Neck Surgery
– American Medical Association
Published: Aug 1, 2012
Keywords: alkaline phosphatase,antifungal agents,weight reduction,candidiasis,physical examination,deglutition disorders,ulcer,alanine transaminase,antigens,anti-infective agents, local,aspartate aminotransferases,antibiotics,granuloma,methyl green,pain,splenomegaly,tongue,liver biopsy,swallowing painful,skin lesion,giemsa stain,granulomatous inflammation,mucosal ulcer,tongue lesions,liver enzyme,periodic acid schiff stain,biopsy, punch,transaminitis,military deployment,medical history,enzyme-linked immunosorbent assay,glossectomy,iraq,veterans,fungus,liver,microorganisms