A 49-year-old male was referred to our department with the complaint of painful and non-healing ulcer of the tongue for 4 months. There was no history of fever, night sweats, cough, decreased appetite and weight loss. He did not give any history of traumatic episode preceding the development of tongue ulcer. He denied any history of similar lesions in the past. He is an occasional smoker. The rest of his medical and surgical history was unremarkable. His dental history was not significant. There was no history of TB in his family members. He was repeatedly treated in a government hospital with topical antiseptics and oral antibiotics (ampicillin plus cloxacillin and metronidazole) and analgesics, but the lesion did not subside so he was referred to our hospital for the further management. On general examination, he was of average built. Intraoral examination revealed an indurated ulcer measuring 1.5 cm × 1.0 cm on the left dorsolateral border of anterior part of tongue. It was tender on palpation with irregular borders and did not bleed on touch. The remaining part of the tongue appeared normal in texture and color. Mobility of the tongue was normal. He had poor oral hygiene along with sharp tooth in relation to 34. There were no palpable cervical lymph nodes. Provisional diagnosis of chronic traumatic ulcer was made as the possibility of ulcer due to repeated trauma by the sharp tooth. Chest X-ray did not reveal any evidence of active lesion. Sputum for AFB was negative on Ziehl–Neelsen stain. Complete blood count was within normal limit. His ESR value was 20 mm/hr. Serum biochemistry and renal function tests were within normal limits. Serological investigation for human immune deficiency virus (HIV) was negative. Coronoplasty of adjacent sharp cusps was done, and since the ulcer presented for more than 2 months, an incisional biopsy was taken under local anesthesia containing an ulcerated lesion along with the normal looking margin and the specimen was sent for HPE. Microscopically, the lesion revealed the stratified squamous epithelium with granulomatous inflammation containing Langhans-type giant cells, epithelioid cells and foci of caseous necrosis, strongly suggestive of TB. The patient was then started on ATT. The ulcer gradually started fading once drug therapy was started (ATT) and the tuberculous ulcer healed completely by the 2 months of ATT containing isoniazid, rifampicin, pyrazinamide and ethambutol. The patient was advised to continue ATT containing isoniazid and rifampicin for another 4 months. At the end of total 6 month's ATT course, there was no evidence of ulcer at the primary site.
This 47-year-old male presented with a non-healing tongue ulcer of 3 months’ duration and associated pain for 2 months. He had initially noticed the asymptomatic ulcer on the ventral surface of tongue which had been increasing in size for the last 1 month. He had smoked beedis for the last 20 years and had consumed alcohol daily for past 15 years. On examination, ulcers were noticed in the tongue and buccal mucosa. A solitary ulcer (3 cm × 4 cm) with undermined edges and minimal induration was seen on right ventral surface of the tongue extending from the midline past the lateral border, up to the dorsal area of the anterior two-thirds of the tongue []. The area adjacent to the tongue ulcer appeared to be lobulated. Another ulcer (0.5 cm × 0.5 cm), also with an undermined edge was seen on the dorsal surface of tongue. In the left buccal mucosa, a single ulcer (1 × 1 cm2) covered with pseudomembrane was present, extending 3 cm from the angle of the mouth and 5 mm below the occlusal plane []. The patient was not aware of this ulcer. A single firm, non-tender (<1 cm) sub-mandibular lymph node was present on the right side.\nProvisional diagnoses of squamous cell carcinoma and lichen planus were given for the lesions of the tongue and buccal mucosa, respectively. Incisional biopsy from the edge of tongue ulcer revealed proliferating epithelium with the underlying connective tissue exhibiting chronic inflammatory cell infiltrate without evidence of epithelial dysplasia or malignant invasion. Biopsy was repeated from a different area of the tongue ulcer for further review. On examining serial sections, giant cells with peripherally arranged nucleus resembling Langerhans cells were appreciated along with caseous necrosis []. Chest radiography revealed bilateral upper lobe infiltrates [], and sputum was positive for acid-fast bacilli. HIV was negative. With anti-tuberculous therapy the lesions began to heal on a follow-up visit a month later. He was referred to local primary health care center for continuation of therapy.