|Year : 2015 | Volume
| Issue : 1 | Page : 95-97
Oral tuberculosis mimicking malignancy
Ajay Kumar Verma, Ved Prakash, Rashmi Upadhyay, Surya Kant, Ankit Bhatia
Department of Pulmonary Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India
|Date of Web Publication||8-Dec-2014|
Department of Pulmonary Medicine, King George's Medical University, Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
The presentation of a non-healing friable ulcerated growth in the oral cavity with cervical lymph nodes in an elderly patient, would in all possibilities, raise the first suspicion of malignancy. We present a case of an ulcerative nonhealing growth over the hard palate and left gingivobuccal sulcus, the biopsy of which revealed granulomatous lesions, leading to the suspicion of oral tuberculosis. The importance of early diagnosis and treatment lies in the fact that it can be easily confused with neoplastic or traumatic etiologies
Keywords: Malignancy, oral, tuberculosis
|How to cite this article:|
Verma AK, Prakash V, Upadhyay R, Kant S, Bhatia A. Oral tuberculosis mimicking malignancy. Muller J Med Sci Res 2015;6:95-7
|How to cite this URL:|
Verma AK, Prakash V, Upadhyay R, Kant S, Bhatia A. Oral tuberculosis mimicking malignancy. Muller J Med Sci Res [serial online] 2015 [cited 2019 Jun 20];6:95-7. Available from: http://www.mjmsr.net/text.asp?2015/6/1/95/146478
| Introduction|| |
Mycobacterium tuberculosis , the causative agent of tuberculosis is one of the most prosperous pathogens, which continues to harm and kill more people than ever before worldwide, particularly in developing countries like India. The oral cavity is an uncommon site to be affected in tuberculosis and is generally a result of secondary infection.
The present communication describes a case of a tuberculous ulcer at the hard palate and left gingivobuccal sulcus, which was initially presumed as a neoplasm of the buccal mucosa.
| Case Report|| |
A 56-year-old male attended our Outpatient Department (OPD) after being referred by an oral surgeon for recurrent oral ulcers since the past two years, the latest one persisting for the past four months and progressively increasing in size. Some of the previous ulcers healed by themselves after being aided by broad spectrum antibiotics, Vitamin B and C supplementations, and supportive care. general examination of the patient showed several small firm cervical lymph nodes in the upper cervical region. The medical history was noncontributory. There was no history of fever, weight loss, cough or expectoration. The routine blood examinations were within normal limits. Serology was negative for human immunodeficiency virus (HIV).
Examination of the oral cavity revealed the presence of a growth, 5 × 4 cm [Figure 1], with ulceration. The ulcer had a shallow ulcerated base surrounded by rolled margins covered with slough in the left palatobuccal recess, with healthy mucosa surrounding the lesion. There were two more ulcers [Figure 2] in the gingivobuccal sulcus measuring 5 cm in the midline. The ulcers were painful and occupied a large area on the left hard palate posing difficulty in swallowing and speaking and eventually, restricting him to a fluid diet. With this background a possible malignant pathology was suspected, an incisional biopsy was done and sent for histopathology, which revealed the presence of granulation tissue surrounded by epithelioid cells [Figure 3]. Acid Fast Bacilli (AFB) staining was negative. A chest skiagram showed no obvious lesion suggestive of pulmonary tuberculosis. On probing, we could elicit the history of tuberculosis in one of his brothers, who was a frequent visitor to his place and was undergoing treatment for the past four months.
|Figure 3: Histopathology of oral lesions showing a presence of granulation|
tissue surrounded by epithelioid cells
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The patient was advised Rifampicin, Isoniazide, Ethambutol, and Pyrazinamide, along with antioxidants and lanoxazol-based ointments for topical application, to facilitate the healing process and for symptomatic relief. The patient is kept on follow-up every month. The ulcers have started to heal with anti-tubercular treatment (ATT) [Figure 4]. No new ulcers have appeared since five months of starting the treatment.
| Discussion|| |
Tuberculosis is a specific granulomatous disease with a worldwide distribution. In 2012, globally, an estimated 8.6 million people developed tuberculosis and 1.3 million died from the disease.  Tuberculosis involving organs other than the lungs are termed as 'extrapulmonary tuberculosis'. The diagnosis of extrapulmonary tuberculosis is more difficult because of the difficulties in obtaining the tissue, the paucibacillary nature of disease, and the uneven distribution of the disease.  Oral tuberculosis accounts for 0.2 to 1.5% of all cases of extrapulmonary tuberculosis. 
Tuberculosis of the oral cavity is an uncommon clinical entity, because of the intact mucosa, which is resistant to tuberculous infection, the protective effect of saliva, the presence of saprophytes in the oral cavity, and the resistance of stratified muscles to bacterial invasion. 
Tuberculous lesions of the oral cavity may be either primary or secondary to pulmonary tuberculosis - The latter being more common.  The common presentation of oral tuberculosis is an ulcerative lesion of the mucosa and the common site is the tongue, however, other sites such as the palate and gingiva can be involved in some cases [Table 1].
|Table 1: List of some cases of oral tuberculosis reported in recent years from India|
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The common clinical characteristics of oral tuberculosis include chronicity, hyperemic changes, and multiple or satellite lesions.  The general factors that favor the infection of tuberculosis in the oral cavity include lowered host resistance and increased virulence of the organisms. Under general conditions the organisms cannot invade the mucosa because of the body's natural resistance. Erosions and abrasions due to any trauma damage the natural barrier and facilitate the invasion of microorganisms. The local factors that contribute include, local trauma, poor oral hygiene, leukoplakia, periapical granulomas, dental cysts, dental abscess, jaw fractures, and periodontitis.  Our patient had poor oral hygiene, which could have contributed to the disease process. The habit of performing 'datoon,' that is, brushing of the teeth with neem twigs, in rural India, which our patient uses regularly, at times causes trauma to the palate, thus predisposing to seeding of the wound Mycobacterium tuberculosis.
The differential diagnosis of a tuberculous ulcer of the oral cavity includes aphthous ulcers, traumatic ulcers, syphilitic ulcers, and malignancy, including primary squamous cell carcinoma and lymphoma metastases. 
There was difficulty in the microscopic detection of the tubercle bacilli, which may have been due to the good immune status of the patient, resulting in the destruction of the bacilli, their enclosure by local tissue reaction, and the very small numbers of tubercle bacilli in the oral lesions. 
Tuberculosis is a treatable disease. Oral tuberculosis is usually not considered by clinicians in the differential diagnosis of patients presenting with oral ulcer; resulting in instances of wrong and missed diagnosis, hence the treatment is delayed in many cases
| Conclusion|| |
The importance of early diagnosis and treatment lies in the fact that it can be easily confused with neoplastic or traumatic etiologies. Our case is significant, as the nonhealing ulcers gave an impression of malignancy, coupled with no other features suggestive of tuberculosis. Hence, caution is needed while dealing with such ulcers, not only to misdiagnose this clinical presentation, but also to exercise precautions to prevent the transmission of the disease through infected droplets.
| References|| |
Sharma SK, Mohan A. Extrapulmonary tuberculosis. Indian J Med Res 2004;120:316-53.
Ebenezer J, Samuel R, Mathew GC, Koshy S, Chacko RK, Jesudason MV. Primary oral tuberculosis: Report of two cases. Indian J Dent Res 2006;17:41-4.
Prada JL, Kindelan JM, Villanueva JL, Jurado R, Sánchez-Guijo P, Torre-Cisneros J. Tuberculosis of the tongue in two immunocompetent patients. Clin Infect Dis 1994;19:200-2.
Eng HL, Lu SY, Yang CH, Chen WJ. Oral tuberculosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;81:415-20.
Aggarwal P, Saxena S, Reddy V, Sharma P, Aggarwal V. Tuberculosis, the culprit behind nonhealing oral lesions: Report of two cases. Indian J Med Sci 2012;66:280-5.
Vishwakarma SK, Jain S, Gupta M. Primary lingual tuberculosis presenting as cold- Abscess tongue: A case report. Indian J Otolaryngol Head Neck Surg 2006;58:87-8.
Gupta PP, Fotedar S, Agarwal D, Sansanwal P. Primary tuberculous glossitis in an immunocompetent patient. Hong Kong Med J 2007;13:330-1.
Kumar V, Singh AP, Meher R, Raj A. Primary tuberculosis of oral cavity: A rare entity revisited. Indian J Pediatr 2011;78:354-6.
Dogra SS, Chander B, Krishna M. Tuberculosis of oral cavity: A series of one primary and three secondary cases. Indian J Otolaryngol Head Neck Surg 2013;65:275-9.
Mani NJ. Tuberculosis initially diagnosed by asymptomatic oral lesions. Report of three cases. J Oral Med 1985;40:39-42.
Von Arx DP, Husain A. Oral tuberculosis. Br Dent J 2001;190:420-2.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]