Differential Diagnosis

The patient presents with a white coating of the tongue and an erythematous raised lesion on the dorsal tongue, accompanied by pathology showing an ulcer with reactive changes, negative for fungus, dysplasia, and non-specific EBV staining in fibrinopurulent debris. Based on these findings, the differential diagnosis can be categorized as follows:

• Single Most Likely Diagnosis
  • Traumatic Ulcer: The presence of an ulcer with reactive changes and the absence of dysplasia or fungal elements make traumatic ulcer a likely diagnosis, especially if the patient has a history of trauma to the tongue, such as biting or irritation from a sharp tooth or dental appliance.
• Other Likely Diagnoses
  • Oral Lichen Planus: Although less common on the tongue, oral lichen planus can present with erythematous lesions and sometimes ulcers. The absence of pain and the specific location on the dorsal tongue could align with this diagnosis.
  • Oral Candidiasis: Despite the negative fungal culture, oral candidiasis could still be considered, especially if the patient has risk factors such as immunosuppression, antibiotic use, or wears dentures. The white coating of the tongue is suggestive of this condition.
• Do Not Miss Diagnoses
  • Squamous Cell Carcinoma: Although the pathology did not show dysplasia, any oral ulcer that does not heal within two weeks should raise suspicion for squamous cell carcinoma, especially in patients with risk factors like tobacco or alcohol use.
  • Infectious Mononucleosis (EBV): The non-specific EBV staining could suggest an EBV infection, which can cause oral ulcers and should be considered, especially in younger patients.
• Rare Diagnoses
  • Aphthous Ulcers: While more common on the buccal mucosa or floor of the mouth, aphthous ulcers can occasionally occur on the tongue and could be considered if other diagnoses are ruled out.
  • Eosinophilic Ulcer: A rare condition that can present with an ulcer on the tongue, often associated with eosinophilia and could be considered if there's a history suggestive of an allergic reaction or eosinophilic disorders.

Next Steps

• Clinical Correlation: Correlate the clinical presentation with the pathological findings to assess for any discrepancies that might necessitate further investigation.
• Additional Testing: Consider further testing based on the suspected diagnosis, such as viral cultures or PCR for EBV, fungal cultures if clinical suspicion for candidiasis remains high, or immunohistochemical stains if an autoimmune condition like lichen planus is suspected.
• Follow-Up: Schedule a follow-up appointment to monitor the healing of the ulcer and adjust the diagnosis or treatment plan as necessary.
• Risk Factor Assessment: Evaluate the patient for risk factors associated with oral cancer, such as tobacco use, and provide appropriate counseling and screening recommendations.