A 23-year-old girl reported to the department of oral medicine and radiology with progressive, nonpainful swelling of the gingiva on the labial aspect of the upper and lower anterior teeth with 6 months' duration. There was a history of evening rise in temperature and weakness over the last 3 months. The patient also had a loss of appetite over the last 4 months and a weight loss of about 4.5 kg during the last 8 months. There were no systemic problems, no cough with expectoration and no history of dental trauma or surgery in the affected area. Extraoral examination revealed no cervical lymphadenopathy. Intraoral examination revealed diffuse enlargement of the upper and lower gingiva on the labial surface of anterior maxillary and mandibular teeth []. On palpation, the swelling was slightly tender and firm. The rest of the OC was normal except for the few deep carious teeth. Differential diagnoses were enlargement due to drugs, infection and hematologic malignancy. The possibility of drug-induced enlargement was ruled out based on medical history. The biochemical tests were within normal limits, except for a marginal rise in leukocyte count (13 × 10 9/L) and an elevated ESR of 56 mm/h (Westergren method), which ruled out leukemia-associated enlargement and raised the possibility of one of the common causes of high ESR, TB. An incisional biopsy was carried out under LA in relation to the gingiva of the mandibular right central incisor, in collaboration with the department of periodontics and implantology. Histopathological examination was carried out that revealed clusters of epithelioid cells surrounded by a chronic inflammatory type of infiltrate. There was no evidence of caseating necrosis, but numerous Langhans giant cells were visible in the clusters of epithelioid cells suggestive of a “hard tubercle” [Figure and ]. To eliminate the possibility of localized granulomatous changes superimposed on an area of gingival enlargement, incisional biopsy was repeated in the remaining three quadrants. Histopathology showed similar granulomatous changes in all tissue specimens examined. The tuberculin (Mantoux) test was positive, suggesting tubercular infection. Chest radiography (posteroanterior view) revealed no abnormalities []. A computed tomography scan of the head and neck region was also performed to determine the status of the underlying maxilla and mandible. The scan did not reveal any bone abnormalities. A culture of the sputum, obtained by forceful coughing, was negative for M. tuberculosis. Special staining of formalin-fixed, paraffin-embedded tissue specimens for Mycobacteria, i.e., Ziehl–Neelsen and auramine–rhodamine stain, was negative. An immunologic test to detect antibodies against Mycobacterium in the patient's serum (ELISA) was positive. Polymerase chain reaction (PCR) assay was also carried out using six 5-μm sections of paraffin-embedded tissue to identify specific sequences of M. tuberculosis complex, with adequate controls. The DNA was used as an amplifying target for the sequence IS-6110, which is specific for M. tuberculosis. Positive PCR results confirmed the presence of M. tuberculosis in the tissue samples. In view of these findings, a final diagnosis of primary tuberculous gingival enlargement was made. In consultation with the patients' physicians, antitubercular therapy (ATT) was initiated. During this period, the patient was instructed not to undergo any ultrasonic scaling and polishing or surgical procedure within the OC and was warned about the chance of transmitting the disease to others via aerosol and salivary contamination. After completion of a 6-month regimen of basic periodontal therapy, which included scaling and root planning, oral hygiene instructions were instituted under CDC-issued guidelines. This resulted in significant regression of the enlarged gingivae in both the arches. Gingivectomy and gingivoplasty were performed to shape and contour the residual enlargement under universal aseptic conditions []. No recurrence of lesion occurred during 1-year follow-up [].
A 65-year-old male presented to us with a painful, progressively increasing swelling of the tongue of 8 months duration. There was no history of cough, fever, dysphagia, or weight loss. He was a nonsmoker, but a tobacco chewer for the past 15 years. He was an alcoholic since past 15 years. He was not a known case of diabetes mellitus, but a hypertensive since past 4 years and was on regular treatment for it. On examination, patient was well built with good general condition. Examination of oral cavity revealed an 8 × 6 cm firm swelling over the left side of anterior 2/3rd of tongue, crossing the midline, with smooth surface and well-defined margins. The lesion apparently looked like hemimacroglossia (). There was no deviation of tongue, with all movements being normal. No lymphadenopathy was found in the neck. Systemic examination did not reveal any abnormal findings. Clinical suspicion of submucosal carcinoma of tongue was entertained. Complete blood count was within normal limits. ESR was found raised to 35 mm in first hour. A deep punch biopsy from lateral aspect of the lesion was taken, which revealed granulomatous inflammation suggestive of tuberculosis (). Acid fast bacilli were found in Ziehl-Neelsen stained sections (). A histopathological diagnosis of tuberculosis was made. Mantoux test performed with PPD antigen measured 18 mm after 72 hours reading. ELISA test for HIV was nonreactive. Chest X-ray was within normal limits. With a final diagnosis of primary tuberculoma of tongue, patient was started on antitubercular therapy with a four drug regimen for 6 months. Dramatic improvement was observed within 2 months of therapy. Size of the lesion was significantly reduced, from an apparent hemimacroglossia to a small nodular lesion. After 6 months the patient was completely cured and is on regular followup with no residual or recurrent lesion.