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.
A 33-year-old black female attended the oral medicine clinic at the Medunsa Oral Health Centre, University of Limpopo, complaining of a painful sore on the upper left labial mucosa of about 3 weeks duration. She appeared to be in good health. The patient did not smoke or drink alcohol, and she claimed to be HIV-seronegative as she had been tested for HIV infection about three months previously.\nThere were two ulcers surrounded by a wide area of erythema, one on the upper left labial mucosa that was painful, and one on the ventral surface of the tip of the tongue (). The margins of both ulcers were slightly elevated and indurated. The dorsal surface of the anterior margin of the tongue was hyperaemic with a lobulated appearance ().\nHistological examination of the labial mucosal ulcer showed necrotic tissue and chronically inflamed granulation tissue. Scattered epithelioid cells were present, and Ziehl-Neelsen staining revealed the presence of acid fast bacilli leading to the final diagnosis of oral tuberculosis (Figures and ).\nThe patient was referred to the Department of Internal Medicine at the Dr. George Mukhari Hospital. She proved to be HIV-seropositive with a CD4+ T cell count of 429 cells/mm3. The general physical examination was unremarkable, the chest radiograph did not show any evidence of tuberculosis, and other laboratory investigations that were deemed necessary were all within the range of normality. A nine-month anti-TB drug regimen of isoniazid, rifampicin, pyrazinamide, and ethambutol, was prescribed.\nThe patient did not receive antiretroviral treatment for a reason to be explained below.\nFour weeks after initiation of the anti-TB treatment the oral lesions were strikingly improved (Figures and ), and 8 weeks later the previously affected lip and tongue looked normal.