A 42‐year‐old woman presented with a 3‐month history of worsening mouth pain and weight loss. She also complained of hair loss, paresthesias, and generalized weakness. She attributed these changes to poor oral intake following her gastric bypass surgery two years previously. Her vital signs were within normal limits. Her BMI was 14.6. She was cachectic, with temporal wasting. Her tongue was deeply fissured with atrophic papillae. On her skin were violaceous patches most prominent in the supraclavicular regions and the flexor surfaces of her knees. Complete blood count demonstrated leukopenia (white blood cell count, 2.8 × 109/L) and mild anemia (hematocrit, 35.3%). Basic metabolic panel was normal except for hypoglycemia (58 mg/dL). Albumin was 2 g/dL; prealbumin was 5 mg/dL (normal range, 17–34 mg/dL); aspartate aminotransferase was 82 units/L; alanine aminotransferase was 72 units/L Levels of folate; and vitamins B2, B3, B6, and B12 were normal. Zinc and copper levels were both mildly decreased. Screening tests for anti‐nuclear antibodies, extractable nuclear antigens, serum protein electrophoresis, and urine protein electrophoresis were normal. She also had negative hepatitis B and C, HIV, and rapid plasma regain (RPR) screens. Her serum angiotensin converting enzyme level was 157 units/L (normal range, 8–53 units/L). A liver biopsy demonstrated a noncaseating granuloma, consistent with sarcoidosis. Of note, a high‐resolution chest CT did not reveal hilar lymphadenopathy or other evidence of pulmonary sarcoidosis.
Hospitalists routinely perform an initial oropharyngeal exam on all patients. Without careful inspection, diagnoses can be missed. The finding of atrophic glossitis is commonly associated with nutritional deficiencies, especially folic acid, iron, and vitamins B2, B3, and B12. Atrophic glossitis may also be associated with candidiasis, systemic infections, amyloidosis, Sjögren's syndrome, and sarcoidosis. In this case, a nutritional deficiency was strongly suspected because of the history of gastric bypass and weight loss but was ultimately not the cause of her mouth pain. Other findings, including her neuropathy and skin findings, supported a diagnosis of sarcoidosis. The granulomas of sarcoidosis can affect any organ but mostly affect the lungs, lymph nodes, skin, and eyes. Up to 10% of patients do not have pulmonary involvement. Approximately 25% of patients with sarcoidosis have neurologic involvement, and 10% have abnormal liver function tests. Sarcoidosis involving the tongue is uncommon, but glossitis and ulcerations can be seen, and tongue involvement can precede other manifestations of the disease. An abnormal tongue exam in an individual at risk should prompt clinicians to include sarcoidosis in their differential diagnosis.
Tongue abnormalities can often be a sign of systemic disease; hospitalists need to be able to identify these findings and their associated diseases.
To cite this abstract:Edwards E, Kirsch J. A Tale of the Tongue. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 381. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/a-tale-of-the-tongue/. Accessed May 22, 2019.