Wednesday, 23 May 2007

Rare as Hens Teeth

This patient had a diagnosis of streptococcal pneumonia on admission .

She typically had reactivation of Herpes affecting her upper right lip area.

However, she complained of a painful tongue after several days in hospital and the next day she developed a rash on her tongue.

A dermatologist was consulted and an odd diagnosis of amyloidosis was considered.

However, the history was not consistent with amyloidosis as it was too acute.

Moreover, the examination revealed separate, small vesicles on the tongue, predominantly right sided with sparing of the posterior 1/3 of the tongue and left lateral border.

The right inner lip mucosa also showed a shallow, white ulcer.

The diagnosis consistent with the preceding history would be one of Lingual Herpes Simplex infection from likely reactivation or even Varicella Zoster eruption.

HSV and VZV can be reactivated by streptococcus pneumoniae infection, fever, sunlight, stress and during menstruation in females.

The treatment involves oral aciclovir, usually at a dose of 200mg 5 x per day, or if severe then intravenous at 5mg/kg/day.

Oropharyngeal HSV is very infectious and health care workers should wear gloves if they are likely to come in contact with the oral secretions.

Labial HSV (cold sores) are very common and although reactivation can occur anywhere such as in the oesophagus in tube feed patients, pubic region (HSV2 > HSV1) etc, but to see it occur on the tongue is most unusual.

One has to consider underlying causes of immunodeficiency in such patients such as HIV or haematological malignancy being possible underlying diseases.

The posterior 1/3rd of the tongue is unaffected in this patient because the nerve supply to that area is different, being the Glossopharyngeal Nerve (IX). The left border of the tongue was equally unaffected as the HSV did not reactivate along the nerve supplying that region.

The central tongue is affected in this patient showing that the right nerve supply also crosses the midline to supply a large area of the contralateral tongue.

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