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 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.