Benign migratory glossitis, geographic stomatitis.

Symptoms


Chapter 38. Geographic Tongue
 

 

Patient Story

A 23-year-old male medical student presents to the physician's office complaining of his tongue's “strange appearance.” He denies pain or discomfort and is unsure how long the lesions have been present. The lesions seem to change areas of distribution on the tongue. The examination reveals large, well-delineated, shiny and smooth, erythematous spots on the surface of the tongue (Figure 38-1). The diagnosis is geographic tongue (benign migratory glossitis). The physician explains that it is benign and that no treatment is needed unless symptoms develop.

FIGURE 38-1

Geographic tongue (benign migratory glossitis). Note the pink continents among the white oceans. (Reprinted with permission from Gonsalves WC, Chi AC, Neville BW. Common oral lesions: part II. Am Fam Phys 2007;75(4):501-508. Copyright © 2007 American Academy of Family Physicians. All rights reserved.)

Introduction

Geographic tongue is a recurrent, benign, usually asymptomatic, inflammatory disorder of the mucosa of the dorsum and lateral borders of the tongue. Geographic tongue is characterized by circinate, irregularly shaped erythematous patches bordered by a white keratotic band. The central erythematous patch represents loss of filiform papillae of tongue epithelium. Geographic tongue can, although rarely, present as symptomatic.

Synonyms

Benign migratory glossitis, geographic stomatitis.

Epidemiology

  • Geographic tongue has an estimated prevalence of 1% to 3% of the population.1
  • It may occur in either children or adults, and exhibits a female predilection.
  • Geographic tongue in the United States has a greater prevalence among white and black persons than among Mexican Americans.2

Etiology and Pathophysiology

  • Geographic tongue is a common oral inflammatory condition of unknown etiology.
  • Some studies have shown an increased frequency in patients with allergies, pustular psoriasis, stress, type 1 diabetes, fissured tongue, and hormonal disturbances.3
  • Histopathologic appearance resembles psoriasis.4
  • Oddly, geographic tongue has an inverse association with cigarette smoking.2,5

Diagnosis

Signs

Image not available.

A mild asymptomatic case of geographic tongue. Note the atrophic filiform papillae and the subtle white halo. (Richard P. Usatine, MD.)

Differential Diagnosis

 

  • Erythroplakia or leukoplakia—May be suspected when lesions affect the soft palate (see Chapter 42, Leukoplakia).
  • Lichen planus—Reticular forms are characterized by interlacing white lines commonly found on the buccal mucosa, or erosive forms, characterized by atrophic erythematous areas with central ulceration and surrounding radiating striae (see Chapter 154, Lichen Planus) (Figure 38-3).
  • Psoriasis—Intraoral lesions have been described as red or white plaques associated with the activity of cutaneous lesions (see Chapter 152, Psoriasis) (Figure 38-4).
  • Reactive arthritis—A condition characterized by the triad of “urethritis, arthritis, and conjunctivitis,” may have rare intraoral lesions described as painless ulcerative papules on the buccal mucosa and palate (see Chapter 155, Reactive Arthritis).
  • Fissured tongue—An inherited condition in which the tongue has fissures that are asymptomatic. Although it has been called a scrotal tongue in the past, the term fissured tongue is preferred by patients (Figure 38-5).

 

 

 

Pyelonephritis is caused by a bacterium or virus infecting the kidneys.

The bacterium Escherichia coli is often the cause. Bacteria and viruses can move to the kidneys from the bladder or can be carried through the bloodstream from other parts of the body.

 

Risk Factors

People most at risk for pyelonephritis are those who have a bladder infection and those with a structural, or anatomic, problem in the urinary tract.

The flow of urine may be blocked in people with a structural defect of the urinary tract, a kidney stone, or an enlarged prostate.

Urine can also back up, or reflux, into one or both kidneys.Vesicoureteral reflux (VUR), happens when the valve mechanism that normally prevents backward flow of urine is not working properly. VUR is most commonly diagnosed during childhood.

Pregnant women and people with diabetes or a weakened immune system are also at increased risk of pyelonephritis.

 

 

 

 

 

 

Geographic tongue is characterized by circinate, irregularly shaped erythematous patches bordered by a white keratotic band. The central erythematous patch represents loss of filiform papillae of tongue epithelium. Geographic tongue can, although rarely, present as symptomatic.

  • Geographic tongue is a recurrent, benigncommon oral inflammatory condition of unknown etiology.
  • Some studies have shown an increased frequency in patients with allergies, pustular psoriasis, stress, type 1 diabetes, fissured tongue, and hormonal disturbances.3
  • Histopathologic appearance resembles psoriasis.4
  • Oddly, geographic tongue has an inverse association with cigarette smoking.2,5

 

 

 

 

 

 

 

 Most individuals are asymptomatic and do not require treatment (Figure 38-6).

  • For symptomatic cases, several treatments have been proposed but not proven effective with good clinical trials:6,7
    • Topical steroids such as triamcinolone dental paste (Oralone or Kenalog in Orabase). SOR C
    • Supplements such as zinc, vitamin B12niacin, and riboflavinSOR C
    • Antihistamine mouth rinses (e.g., diphenhydramine elixir 12.5 mg per 5 mL diluted in a 1:4 ratio with water). SOR C
    • Topical anesthetic rinses.6,7SOR C

Geographic tongue can rarely present as persistent and painful (Figure 38-7). In one case report, 0.1% tacrolimus ointment was applied twice daily for 2 weeks with significant improvement of symptoms.8SOR C

Geographic tongue with more severe symptomatology, including pain and a burning sensation when eating spicy foods. The contrast between the normal tongue tissue and the pink atrophic papillae is striking. (Courtesy of Ellen Eisenberg, DMD.)

No treatment has been proven to be uniformly effective.9

 

 

 

Most people with pyelonephritis do not have complications if appropriately treated with bacteria-fighting medications called antibiotics.

In rare cases, pyelonephritis may cause permanent kidney scars, which can lead to chronic kidney disease, high blood pressure, and kidney failure. These problems usually occur in people with a structural problem in the urinary tract, kidney disease from other causes, or repeated episodes of pyelonephritis.

Infection in the kidneys may spread to the bloodstream—a serious condition called sepsis—though this is also uncommon.

 

 

Content 3

Content 13

Content 11

A 23-year-old male medical student presents to the physician's office complaining of his tongue's “strange appearance.” He denies pain or discomfort and is unsure how long the lesions have been present. The lesions seem to change areas of distribution on the tongue. The examination reveals large, well-delineated, shiny and smooth, erythematous spots on the surface of the tongue (Figure 38-1).

Geographic tongue (benign migratory glossitis). Note the pink continents among the white oceans. (Reprinted with permission from Gonsalves WC, Chi AC, Neville BW. Common oral lesions: part II. Am Fam Phys 2007;75(4):501-508. Copyright © 2007 American Academy of Family Physicians. All rights reserved.)

The diagnosis is geographic tongue (benign migratory glossitis). The physician explains that it is benign and that no treatment is needed unless symptoms develop.

 

A

A 75-year-old triathlete complains of gradually worsening vision over the past year. It seems to be involving near and far vision. The patient has never required corrective lenses and has no significant medical history other than diet-controlled hypertension. He takes no regular medications. Physical examination is normal except for bilateral visual acuity of 20/100. There are no focal visual field defects and no redness of the eyes or eyelids. Which of the following is the most likely diagnosis?

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The correct answer is A. You answered A.

Age-related macular degeneration is a major cause of painless, gradual bilateral central visual loss. It occurs as nonexudative (dry) or exudative (wet) forms. Recent genetic data have shown an association with the alternative complement pathway gene for complement factor H. The mechanism link for that association is unknown. The nonexudative form is associated with retinal drusen that leads to retinal atrophy. Treatment with vitamin C, vitamin E, beta-carotene, and zinc may retard the visual loss. Exudative macular degeneration, which is less common, is caused by neovascular proliferation and leakage of choroidal blood vessels. Acute visual loss may occur because of bleeding. Exudative macular degeneration may be treated with intraocular injection of a vascular endothelial growth factor antagonist (bevacizumab or ranibizumab). Blepharitis is inflammation of the eyelids usually related to acne rosacea, seborrheic dermatitis, or staphylococcal infection. Diabetic retinopathy, now a leading cause of blindness in the United States, causes gradual bilateral visual loss in patients with long-standing diabetes. Retinal detachment is usually unilateral and causes visual loss and an afferent pupillary defect.

 

Mr. Jenson is a 40-year-old man with a congenital bicuspid aortic valve who you have been seeing for more than a decade. You obtain an echocardiogram every other year to follow the progression of his disease knowing that bicuspid valves often develop stenosis or regurgitation requiring replacement in middle age. Given his specific congenital abnormality, what other anatomic structure is important to follow on his biannual echocardiograms?

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The correct answer is A. You answered A.

The answer is A. (Chap. 282) Bicuspid aortic valve is among the most common of congenital heart cardiac abnormalities. Valvular function is often normal in early life and thus may escape detection. Due to abnormal flow dynamics through the bicuspid aortic valve, the valve leaflets can become rigid and fibrosed, leading to either stenosis or regurgitation. However, pathology in patients with bicuspid aortic valve is not limited to the valve alone. The ascending aorta is often dilated, misnamed “poststenotic” dilatation; this is due to histologic abnormalities of the aortic media and may result in aortic dissection. It is important to screen specifically for aortopathy because dissection is a common cause of sudden death in these patients.

 


 

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