Differential Diagnosis for White Painful Tongue in HIV Positive Patient

• Single most likely diagnosis
  • Oral candidiasis (thrush): This is the most common oral infection in HIV-positive patients, characterized by white patches on the tongue and mucous membranes, which can be painful and may bleed when scraped off. The immunocompromised state of HIV patients makes them more susceptible to fungal infections like candidiasis.
• Other Likely diagnoses
  • Oral hairy leukoplakia: This condition, often associated with Epstein-Barr virus, presents as white patches on the lateral surfaces of the tongue and is common in immunocompromised patients, including those with HIV. It is usually asymptomatic but can be painful if there is secondary infection.
  • Lichen planus: An autoimmune condition that can affect the mucous membranes, including the tongue, leading to white, lacy patches and erosions, which can be painful. While not exclusive to HIV patients, the immune dysregulation in HIV might contribute to its development or exacerbation.
  • Geographic tongue: Characterized by areas of depapillation on the tongue, giving it a "geographic" appearance. It can be painful and is more common in individuals with HIV, possibly due to the immune system's altered state.
• Do Not Miss diagnoses
  • Squamous cell carcinoma: Although less common, oral cancer can present with a painful tongue and should not be missed, especially in HIV-positive patients who have an increased risk of various malignancies due to their immunocompromised state.
  • Histoplasmosis: A fungal infection that can cause oral ulcers and lesions, including on the tongue, and is more severe in immunocompromised individuals. It's crucial to consider this diagnosis due to its potential for serious morbidity if not treated.
• Rare diagnoses
  • Pemphigus vulgaris: An autoimmune disease that can cause blistering of the skin and mucous membranes, including the tongue, leading to painful erosions. It's rare but can be life-threatening if not recognized and treated promptly.
  • Aphthous ulcers: While common in the general population, in the context of an HIV-positive patient with a white painful tongue, they might be considered less likely but still possible, especially if the patient has other risk factors or if other diagnoses have been ruled out.