Viruses That Cause Glossitis
Herpes simplex virus type 1 (HSV-1) is the primary viral cause of glossitis, presenting most commonly as herpetic geometric glossitis with extremely painful linear fissures on the dorsal tongue, particularly in immunocompromised patients. 1, 2
Primary Viral Etiology
Herpes Simplex Virus Type 1 (HSV-1)
- HSV-1 causes herpetic geometric glossitis, characterized by painful linear central lingual fissures with a branched pattern extending bilaterally from the central fissure on the dorsum of the tongue 1, 2
- This condition occurs predominantly in immunocompromised patients (8 of 11 reported cases), though it can also affect immunocompetent individuals 1, 3
- HSV-1 can also cause chronic median glossitis with massive necrosis of the entire mucosa in severely immunocompromised patients 4
- The condition responds completely to oral antiviral therapy (acyclovir, famciclovir, or valacyclovir) within 2-14 days 1, 2
Epstein-Barr Virus (EBV)
- EBV causes oral hairy leukoplakia affecting the tongue, most commonly in patients with severely compromised immunity 5
- EBV-related oral lesions in infectious mononucleosis include erythema and diffuse injection of oral and pharyngeal mucosae, though these typically do not present with exudates 6
- Treatment involves oral antivirals when symptomatic 5
Secondary Viral Associations
Varicella Zoster Virus (VZV)
- VZV can cause encephalitis and is a relatively common cause of viral encephalitis, especially in immunocompromised patients 7
- While VZV primarily affects other mucosal surfaces (conjunctiva documented), its role in direct glossitis is less established 7
Cytomegalovirus (CMV)
- CMV occurs almost exclusively in immunocompromised hosts and can cause pericarditis and encephalitis 7
- CMV's specific role in glossitis is not well-documented in the provided evidence
Clinical Recognition and Diagnosis
Key Diagnostic Features
- Herpetic geometric glossitis presents with extremely painful cross-hatched, branched, and/or linear fissures on the dorsal tongue 2
- Diagnosis is confirmed by viral culture (most common), Tzanck preparation, or immunohistochemistry 1
- The morphology resembles corneal dendrites in herpetic epithelial keratitis, suggesting similar pathogenesis 2
Important Clinical Pitfalls
- Do not assume glossitis is only HSV-related in immunocompromised patients—it can occur in immunocompetent individuals with concurrent illness like pneumonia 3
- Distinguish viral glossitis from other tongue conditions: geographic tongue, fissured tongue, and median rhomboid glossitis (candidal) do not typically cause the severe pain characteristic of herpetic glossitis 5
- Atrophic glossitis is linked to nutritional deficiency, not viral infection 5
Treatment Approach
Immediate Management
- Initiate oral antiviral therapy immediately upon clinical suspicion: acyclovir, famciclovir, or valacyclovir 1, 2
- Symptoms resolve within 1-2 days, with complete healing of fissures within 3-12 days after starting systemic acyclovir 2
- For painful oral lesions, consider topical analgesics such as benzydamine hydrochloride rinses 6