Article: Answer to Photo Quiz: Tongue necrosis (full text) - May 2018 - NJM
Issue: 2018 > May > photo quiz

Answer to Photo Quiz: Tongue necrosis



PHOTO QUIZ
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DIAGNOSIS

The patient was suffering from giant cell arteritis which caused tongue necrosis. After admission to the hospital, treatment with methylprednisolone 1000 mg once a day for the next three days was started immediately. Acetylsalicylic acid was started because of the thrombocytosis to prevent other ischaemic complications. 
Giant cell arteritis is a chronic and systemic arteritis which involves the large-sized and medium-sized vessels. Almost 60% of all patients with giant cell arteritis report non-specific symptoms such as fever, tiredness and weight loss. Half of patients have dysesthesia of the scalp and jaw claudication. Visual loss occurs in 20% of patients and is caused by anterior ischaemic optic neuropathy or central retinal artery occlusion.1 Rare symptoms of the head and neck in giant cell arteritis are dysphagia, oedema, tooth pain and necrosis of the lip. Signs of decreased vascularisation of the tongue are pain, burning sensations and tongue claudication.2 The tongue has a bilateral vascularisation from the lingual artery and a good collateral blood supply. Before tongue necrosis can occur there have to be bilateral problems in the blood supply and for this reason tongue necrosis is a rare complication (≤ 1%) in giant cell arteritis. 
Elevated markers of ESR and CRP are common (95%) in patients with giant cell arteritis.3 Anaemia of chronic disease and raised levels of alkaline phosphatase are frequently present.4 Ultrasonography of the temporal artery sometimes shows a ‘halo sign’: a hypoechoic halo around the lumen caused by oedema inside the tunica intima. MRI can show thickening of the vessel wall caused by inflammation. F-FDG PET-scan can show both the extent of inflammation and the severity. A biopsy of the temporal artery remains the gold standard for the diagnosis of giant cell arteritis.3,4
In our patient, because of the typical clinical and laboratory manifestations we immediately started treatment with methylprednisolone without a biopsy. During treatment with corticosteroids the inflammatory findings in the blood all decreased and the necrotic part of the tongue spontaneously recovered after two weeks without intervention.


REFERENCES

  1. Dejaco C, Duftner C, Buttgereit F, Matteson EL, Dasgupta B. The spectrum of giant cell arteritis and polymyalgia rheumatica: revisiting the concept of the disease. Rheumatology (Oxford). 2017;56:506-15. 
  2. Imran TF, Helfgott S. Respiratory and otolaryngologic manifestations of giant cell arteritis. Clin Exp Rheumatol. 2015;33:S164-S70. 
  3. Buttgereit F, Dejaco C, Matteson EL, Dasgupta B. Polymyalgia rheumatic and giant cell arteritis, a systematic review. JAMA. 2016;315:2442-58. 
  4. Salvarani C, Cantini F, Hunder GG. Polymyalgia rheumatic and giant-cell arteritis. Lancet. 2008;372;234-45.