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.
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.