What diseases or disorders can cause tongue lesions?

Diseases and Disorders Causing Tongue Lesions

Multiple infectious, inflammatory, nutritional, and neoplastic conditions can cause tongue lesions, with the most common being candidiasis, herpes simplex virus, nutritional deficiencies (particularly vitamin B12, iron, and folate), oral lichen planus, and squamous cell carcinoma.

Infectious Causes

Fungal Infections

• Candidiasis presents as white plaques that can be removed, leaving a bright red tongue underneath, particularly in immunocompromised patients 1
• Median rhomboid glossitis is associated with candidal infection and symptomatic lesions typically improve with antifungal therapy 2

Viral Infections

• Herpes simplex virus and varicella-zoster virus can cause painful vesicular and ulcerative lesions on the tongue 3
• Oral hairy leukoplakia, caused by Epstein-Barr virus, presents as white corrugated lesions on the lateral tongue borders, most commonly in severely immunocompromised patients (particularly those with HIV/AIDS) 2, 3
• Herpes zoster oticus (Ramsay Hunt syndrome) causes severe otalgia, facial paralysis, and loss of taste on the anterior two-thirds of the tongue 1

Bacterial Infections

• Scarlet fever produces the characteristic "strawberry tongue" with a white-coated tongue that becomes bright red with prominent fungiform papillae, accompanied by fever, sore throat, and sandpaper-like rash, most common in children aged 5-15 years 4

Inflammatory and Autoimmune Conditions

Vasculitic Disorders

• Kawasaki disease presents with strawberry tongue identical to scarlet fever, along with erythema, dryness, fissuring, peeling, cracking, and bleeding of the lips, plus diffuse oropharyngeal erythema (notably WITHOUT oral ulcerations or pharyngeal exudates) 4
• Untreated Kawasaki disease leads to coronary artery aneurysms in up to 20% of cases, making prompt diagnosis critical within the first 10 days 4

Chronic Inflammatory Conditions

• Oral lichen planus is a chronic inflammatory disorder affecting the tongue, best treated with topical or systemic corticosteroids and calcineurin inhibitors 2
• Lichen sclerosus rarely affects the oral cavity, but when present, occurs on sites with cornified stratified squamous epithelium (tongue, gingiva, hard palate) 1

Other Inflammatory Lesions

• Geographic tongue (benign migratory glossitis) presents as annular lesions on the dorsal tongue surface and does not require treatment 2, 3
• Burning mouth syndrome presents with bright red tongue and burning sensation, predominantly affecting peri- and post-menopausal women, often accompanied by dry mouth, abnormal taste, and depression 1, 2

Nutritional Deficiencies

Vitamin and Mineral Deficiencies

• Vitamin B12 deficiency causes atrophic glossitis and lingual linear lesions (LLLs) on the dorsum, lateral borders, and/or ventral surface of the tongue; 98.25% of patients with LLLs have severe vitamin B12 deficiency 5
• Iron deficiency produces glossodynia, papillary atrophy, tongue swelling, and surface ulceration 6
• Folate deficiency causes similar glossitis and tongue inflammation 6
• Patients commonly suffer from multiple nutritional deficiencies simultaneously, complicating the clinical picture 6

Diagnostic Approach for Nutritional Deficiencies

• Hematologic screening should include complete blood count, red-cell indices, serum iron, vitamin B12, and folate levels to establish specific deficiencies 6
• Do not diagnose nutritional deficiency on clinical impression alone 6

Neoplastic and Premalignant Lesions

Malignant Lesions

• Squamous cell carcinoma is the most common malignancy of the tongue and requires biopsy for diagnosis 2, 3
• Upper aerodigestive tract cancers can present with referred tongue pain, particularly in older patients with tobacco and alcohol use history 1
• Kaposi sarcoma and lymphoproliferative diseases can also affect the tongue 3

Premalignant Lesions

• Leukoplakia and erythroplakia are premalignant lesions requiring biopsy to differentiate from benign conditions 2, 3
• Lichen sclerosus has a remote risk of progression to squamous cell carcinoma, particularly in patients with thickened epidermis 1

Traumatic and Reactive Lesions

• Traumatic ulceration results from sharp food, dental appliances, or iatrogenic causes 7
• Recurrent aphthous ulceration presents as well-demarcated ulcers with yellow/white base and erythematous border 7
• Traumatic fibromas and squamous cell papillomas are benign growths requiring biopsy to differentiate from malignancy 2

Systemic Disease Manifestations

• Hyperthyroidism can cause tongue erythema associated with other thyroid dysfunction symptoms 4
• Systemic amyloidosis may present with tongue involvement 3
• Vasculitis can present with bright red tongue as part of multiorgan involvement, associated with conditions like sarcoidosis 4

Critical Diagnostic Pitfalls

Distinguishing Similar Presentations

• Differentiating Kawasaki disease from scarlet fever is crucial: the absence of pharyngeal exudate favors Kawasaki disease, while blood cultures and rapid strep testing help identify bacterial causes 4
• Missing the diagnosis of Kawasaki disease within the first 10 days can result in irreversible coronary artery complications 4

When to Biopsy

• Biopsy is essential for oral ulcers persisting beyond 2 weeks despite treatment or when there is clinical doubt about the diagnosis 1, 7
• For difficult and complicated oral ulcers with course over 2 weeks or those not responding to 1-2 weeks of treatment, biopsy should be considered 1
• Blood tests (full blood count, coagulation, fasting blood glucose, HIV antibody, syphilis serology) are necessary before biopsy to exclude contraindications and provide diagnostic clues 1

Overlooking Systemic Conditions

• Failure to screen for blood disorders (anemia, leukemia) in patients with persistent tongue lesions can delay diagnosis of serious systemic disease 1
• Early identification of vitamin deficiencies through oral symptoms can forestall development of serious and irreversible systemic and neurologic damage 6