A 45-year-old female presented with a chief complaint of painful ulcer on the palate for the last 1 year, which gradually increased to the present size. She had received antibiotics (amoxicillin plus clavulanate) prescribed by local practitioners, but there was no response. She did not have any systemic complaints such as cough, fever or weight loss and had no history of any allergy. There was no cervical lymphadenopathy or any other abnormal findings. Intraoral examination revealed gingival ulcerations involving marginal and attached gingiva in relation to 11–14 and mucosa of the anterior hard palate. The ulcer is indurated, irregular, having an undermined margin and a yellowish granular necrotic base []. Owing to suspicion of a malignant lesion, an incisional biopsy was undertaken from anterior mucosa of hard palate following the baseline investigations which were within normal limits. Histopathological examination (HPE) of the surgical specimen showed a conserved epithelium covering the subepithelial layers, with widespread caseating granulomas surrounded by lymphocytes, epithelial cells and Langhans-type giant cells []. No neoplastic changes were observed. Ziehl–Neelsen staining was negative. With all these data, the diagnosis of oral TB was suggested and systemic analyses were performed to determine its primary or secondary origin. The Mantoux test showed a positive reaction. Chest X-ray did not show any lesion suggestive of pulmonary TB. Three sputum specimens were smear negative and culture negative. Although the first clinical impression raised suspicion of a malignant or traumatic process, these were both dismissed based on the pathology results. In fact, the presence of caseating granulomas surrounded by lymphocytes, epithelial cells and Langhans-type giant cells confirmed the diagnosis of TB. The patient was referred to the department of infectious diseases for further management. Treatment was started with isoniazid (300 mg/day), rifampicin (600 mg/day), pyrazinamide (1500 mg/day) and ethambutol (900 mg/day) for 2 months and the patient was asked to continue with the first two drugs for the next 4 months. No pulmonary signs and symptoms were present. The oral lesions resolved within 4 weeks of treatment []. The patient was followed for 9 months after the treatment with no recurrence of lesion.
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.