Can a patient with a history of Rheumatoid Arthritis (RA) and potential Sjögren's syndrome, presenting with deep ridges along the tongue and a smooth, red tongue, be diagnosed with atrophic glossitis due to a vitamin B12 deficiency?

Atrophic Glossitis and Vitamin B12 Deficiency

Yes, deep ridges (fissures) along the tongue combined with a smooth, red appearance is consistent with atrophic glossitis, and vitamin B12 deficiency is a well-established cause of this condition, particularly in patients with autoimmune conditions like rheumatoid arthritis and Sjögren's syndrome. 1, 2

Clinical Presentation and Diagnosis

The tongue findings you describe represent two distinct but related features:

• Smooth, red tongue (atrophic glossitis): This occurs due to partial or complete loss of filiform papillae on the dorsal tongue surface, creating a "beefy red" appearance that is characteristic of vitamin B12 deficiency 2, 3
• Deep ridges (fissured tongue): While fissured tongue can be a benign anatomical variant, when combined with glossitis and a smooth red appearance, it suggests underlying nutritional deficiency 4

The combination of these findings in a patient with RA and potential Sjögren's syndrome strongly suggests atrophic glossitis secondary to vitamin B12 deficiency. 2, 3

Why This Matters in Your Patient Population

Patients with autoimmune conditions face multiple risk factors for B12 deficiency:

• Sjögren's syndrome is specifically listed as a risk factor for vitamin B12 deficiency due to associated autoimmune gastritis 1
• Autoimmune atrophic gastritis occurs in up to 20% of patients with autoimmune conditions and destroys parietal cells needed for B12 absorption 1
• Gastric parietal cell antibodies are present in 26.7% of patients with atrophic glossitis 2
• Patients with one autoimmune condition (like RA) have increased risk of developing additional autoimmune conditions including pernicious anemia 5

Diagnostic Workup

Order these tests immediately to confirm B12 deficiency and identify the underlying cause: 1, 2

1. First-line testing: Serum vitamin B12 (total cobalamin) - this is the most cost-effective initial test at £2 per test 1
2. If B12 is indeterminate (180-350 pg/mL): Order methylmalonic acid (MMA) for confirmation, as up to 50% of patients with "normal" B12 have metabolic deficiency when measured by MMA 6
3. Complete blood count: Look for macrocytic anemia (though oral symptoms often appear before anemia develops) 3, 7
4. Serum iron, folate, homocysteine: These are commonly deficient alongside B12 in atrophic glossitis patients 2
5. Autoantibody panel: Check gastric parietal cell antibodies and intrinsic factor antibodies to diagnose autoimmune atrophic gastritis 1

Critical caveat: Oral manifestations of B12 deficiency often appear months or years before anemia develops, so normal hemoglobin does not rule out deficiency 7. The neurological damage from untreated B12 deficiency is reversible only if caught early 7.

Additional Considerations for Sjögren's Syndrome

If Sjögren's syndrome is confirmed, additional nutritional deficiencies are common:

• Vitamin D3 deficiency is significantly decreased in Sjögren's syndrome patients compared to controls and correlates with autoimmune disease activity 8
• Iron deficiency occurs more frequently in patients with hyposalivation and may relate to oral/gastroesophageal mucosal health and absorption problems 8
• Riboflavin deficiency also causes glossitis with similar oral-buccal lesions (cheilosis, angular stomatitis) and should be considered if B12 supplementation doesn't fully resolve symptoms 1

Treatment Approach

Once B12 deficiency is confirmed, initiate treatment immediately without waiting for antibody results if neurological symptoms are present: 1, 5

• For confirmed deficiency with neurological symptoms: 1000 μg vitamin B12 intramuscular injection every other day for one week, then monthly for life 6, 5
• For deficiency without neurological symptoms: Either intramuscular (1000 μg monthly) or oral supplementation (1000-2000 μg daily) is effective 6
• Concurrent hematinic supplementation: Correct any identified deficiencies in iron, folate, or other B vitamins simultaneously 2

Monitor treatment response: Complete remission of oral symptoms and atrophic glossitis can be achieved in some patients within 1-3 months with appropriate supplementation 2, 3

Common Pitfalls to Avoid

• Don't dismiss symptoms as "burning mouth disorder" without first ruling out nutritional deficiencies - this is a common misdiagnosis that delays appropriate treatment 3
• Don't wait for anemia to develop before testing B12 - oral manifestations precede hematologic changes 7
• Don't assume normal B12 levels exclude deficiency - if clinical suspicion is high, order MMA testing 1, 6
• Don't forget to screen for thyroid disease in patients with autoimmune atrophic gastritis, as these conditions frequently coexist 1, 5