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On-line version ISSN 1806-4841
An. Bras. Dermatol. vol.77 no.5 Rio de Janeiro Sept./Oct. 2002
Median rhomboid glossitis associated with esophagic candidiasis. A possible etiologic relation with Candida albicans*
Dr. Rubens Marcelo Souza LeiteI; Dra. Adriana Aragão Craveiro LeiteII; Dr. Horácio FriedmanIII; Dra Isabel FriedmanIV
of the Federal House of Representatives Medical Department - Brasilia-DF
IIPediatric allergist and immunologist of the Federal Supreme Court Health Service - Brasilia-DF
IIIPathologist of the Brasilia Diagnosis Laboratory and Professor of Pathology at the Universidade de Brasília - Brasilia-DF
IVPathologist of the Brasilia Diagnosis Laboratory - Brasilia-DF
Median rhomboid glossitis is an inflammatory disease involving the surface of the tongue. It develops clinically as an erythematous or white-erythematous area on the dorsal median surface of the tongue. Etiologic factors are unknown. One of the possible etiologic theories suggests a relation between median rhomboid glossitis and malformation of bronchial arches during embriogenesis. Candida albicans as an infectious etiologic factor has also been suggested. The study presents the case of a 60-year-old patient with median rhomboid glossitis associated with esophagic candidiasis. Both pathologies responded well to therapy with oral itraconazole and fluconazole. The authors argue in favor of the possibility of an etiologic relation between Candida albicans and median rhomboid glossitis.
Key words: Etiology; glossitis.
Median rhomboid glossitis (MRG) is an inflammatory disease occurring on the dorsal surface of the tongue. As well as being benign, it can be mistaken as serious processes by the patient or an inexperienced observer. The most common clinical presentation of the disease is an erythematous or white- erythematous area on the dorsal median surface of the tongue, immediately prior to Region V of the circumvallate papilla (terminal gingiva). The erythematous region of the mucose can be flat or raised. It is normally well circumscribed, with a rhomboid shape, and smooth. A nodular component is occasionally found, or the organ can be lobulated. The texture may be similar to the subjacent or firm part of the tongue, and its surface is relatively soft.1 At times, candidiasis of the palate is observed, but this is more common in immunodepressive patients. Causative factors are unknown.
The authors report the case of a patient with MRG, whose clinical form and course suggest Candida albicans as an etiological agent.
The disease is relatively rare, but what raises more doubts with respect to it is its referent theme to its etiology. We argue that the etiology of the process is related to infection by Candida albicans on the basis of the clinical case described. This shows the presence of candidiasic infection contiguous to the esophagus and in the therapeutic response to antifungal agents.
A 60-year-old female patient, a smoker, resident of Tocantins, sought help with a year-and-six-month long clinical history in the evolution of a "spot on the tongue". She experienced difficulty in eating, especially when ingesting acidic foods and condiments. Recently, the patient referred to dysphagia with solid foods and liquids, was then examined by dentists and dematologists, who judged it to be an illness of an allergic nature. Diets, local corticoids and topical tretinoin did not trigger clinical improvement. There was no report of an antecedent cutaneous or mucose illness, nor of systemic diseases.
During the general physical examination the patient was observed to be in a good state, without nutritional deficit, normal colored and hydrated. The examination of the oropharinx showed no significant alteration to dentition, and a smooth, circumscribed erythematous area, without the taste buds, in the central region of the tongue (Figure 1). There were no other buccal or dermic alterations.
The blood-cell count revealed a normal red-blood cell series and a normal count and differential for leukocytes; glucose was normal, the thyroid function unaltered, and urea, creatine and transaminases, all normal. Urine analysis and feces examination had no alterations.
A biopsy of the tongue was performed, whose histological examination showed Malpighian epithelial with few papillae, parakeratosis, atenuation of the granulous layer, acanthosis, elongating of the edges, mononuclear exocytosis and few neutrophils. In the dermis, congested vessels and discreet inflitrated mononuclear interstices were observed (Figure 2).
Diagnosis of MRG was then suggested. The high digestive endoscopy revealed whitish exsudate, partially removed by washing, which took up the whole extension of the esophagus (figure 3), except for the pangastritis and a duodenal ulcer. The culture of the removed exsudate of the esophagus walls revealed Candida albicans. The patient was scanned with ultra-sonograph and computed tomography for neoplasias or associated diseases, without other findings.
Investigation for immunodeficiencies was negative for HIV. Late reading cutaneous tests of late reading were performed, PPD positive measuring 7mm, and the candidiasis test was positive measuring 9mm.
The patient was subjected to treatment with itraconazol 100mg VO/day for 30 days, with total remission of the esophagous disorder and concomitant disappearance of the tongue lesions. The conditions returned three months later with complaints of relapsing of the tongue lesions. Fluconazol 150mg VO/week was then prescribed for four weeks, with new remission. At the end of four months, the patient returned with the reappearance of the clinical form. The authors opted to reintroduce the 150mg VO/week fluconazol, resulting in the disappearance of lesions. Since then, a monthly dose of 150mg VO fluconazol has been administered, the patient until this time has had no reincidence of the clinical form.
MRG is an uncommon stomatological problem. Prevalence in adults is less than 1%. Emergence appears in patients with an average age of 40 to 45 years. Contributing factors are unerupted teeth, use of antibiotics, smoking and occasional immunological defects.1 A study performed on more than 10,000 students was unable to detect a single case of the disease, and there are no cases described among newborns.2
The disease is normally asymptomatic, able to cause a burning sensation associated with food condiments, which led the patient in question to seek an medical assistance. Etiology is unknown, however in the past MRG was considered a developmental malformation of the bronchial arches, with persistence of tuberculum impar.2,3 Other authors have upheld the idea that tongue pressure in contact with the palate when producing sounds like g, k and j, and the friction produced by the tongue when swallowing exerts excessive pressure, justifying the stripping of the papillae in the region and the consequent formation of nodes, as occasionally observed in MRG.5
In the last 20 years, evidence of the presence of Candida albicans in the lesions shows a more probable pathogenetic association.3,4,6,7,8 AArendorf and Walker have suggested that the tongue is a primary reservoir for candidiasis and postulated that the large area of tongue papillae serve as shelter for these fungi.9 This being said, the large concentration of these organisms in the median region of the tongue in direct contact with the palate makes this region less propitious to salivary clearance, and it is in this area that alterations occur in the MRG.10 The same authors have recorded that the dorsal region of the tongue contains more fissures and folds, facilitating the growth of candidiasis. It is known that 44% of the population has candidiasis as part of its normal buccal flora. In most cases, candida can be isolated in material culture obtained from the lesions. The histological examination reveals hyphae penetrating the epithelial surface of the tongue with neutrophilic microabsesses.7 In general, MRG has to be found in many patients and cannot be diagnosed. The performing of a biopsy should be recommended, given that many lesions are nodular and can simulate a neoplasia. The case in question demonstrates that candidiasis can be one of the factors or principal etiological agents in the development of MRG. The disappearance of MRG in three subsequent oral antifungus treatments, apart from being concomitant to the presence of esophagic candidiasis, reinforces the participation of candidiasis as a factor, or one of the factors, in the genesis of tongue alteration in the patient.
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Rubens Marcelo Souza Leite
SMHN Q 2, Edifício de Clínicas, Sala 108
Brasília DF 70710-906
Tel.: (61) 327-8482
Fax: (61) 327-7576
Received in April,
23th of 2000.
Approved by the Consultive Council and accepted for publication in March, 13th of 2002.
* Work done at "Serviço de Dermatologia do Setor de Clínica do Departamento Médico da Câmara dos Deputados - Brasília-DF".