From the Guidelines
A complete blood count (CBC) with vitamin B12 and folate levels, as well as testing for anti-intrinsic factor antibodies (anti-IFAB), would be the next appropriate blood test for a patient presenting with a smooth, glossy, erythematous tongue. These clinical findings are characteristic of atrophic glossitis, commonly associated with nutritional deficiencies, particularly vitamin B12 (cobalamin) and folate deficiency [ 1 ]. The smooth appearance results from atrophy of the filiform papillae on the tongue surface. Iron deficiency anemia should also be evaluated through the CBC with iron studies, as it can present with similar tongue manifestations. According to the espen micronutrient guideline [ 1 ], patients with glossitis should be screened for pernicious anemia with the presence of anti-intrinsic factor antibodies (anti-IFAB) regardless of cobalamin levels.
The pathophysiology involves impaired DNA synthesis due to these deficiencies, affecting rapidly dividing cells like those of the tongue epithelium. If these tests reveal deficiencies, further investigation may be warranted to determine the underlying cause, such as malabsorption disorders (pernicious anemia, celiac disease), medications affecting absorption, or dietary insufficiency. While other blood tests such as full blood count, coagulation, fasting blood glucose level, HIV antibody, and syphilis serology examination may be considered in certain contexts [ 1 ], they are not directly relevant to the primary concern of atrophic glossitis and potential vitamin B12 deficiency in this scenario. Treatment would then target the specific deficiency identified through supplementation and addressing any underlying conditions.
From the Research
Next Steps in Diagnosis
Given the symptoms of a smooth, glossy, erythematous tongue, which can be indicative of nutritional deficiencies, the next step in diagnosis would involve blood tests to determine the underlying cause.
- The patient's symptoms could be related to deficiencies in iron, vitamin B12, or folate, as these are common causes of anemia and can lead to various physical symptoms including changes in the tongue's appearance 2.
- A full blood count is typically the first laboratory test for patients suspected of being anemic, and results may suggest a nutritional deficiency of B12, folate, or iron 2.
- Further testing, such as measuring the concentration of iron, vitamin B12, and folate in the blood, can help in the differential diagnosis of anemic patients 2.
- It's also important to consider that iron deficiency anemia (IDA) can sometimes mask the macrocytosis typically seen in cobalamin/folate deficiency anemia, making diagnosis more complex 3.
- Evaluating serum vitamin B12 levels, especially in patients over 60 with IDA, can be crucial for identifying combined deficiencies 3.
- Treatment of iron deficiency anemia with pharmacological iron has been shown to increase serum folate and vitamin B12 levels, suggesting a relationship between iron deficiency and these vitamins 4.
- A comprehensive approach to evaluating suspected anemia includes a thorough history, physical examination, complete blood cell count (CBC), and may involve supplemental tests such as iron panels, vitamin B12, and folate levels 5.
- The choice of cutoff values for vitamin B12 and folate deficiency can impact the diagnosis of hematologic disorders, with some studies suggesting that lower cutoffs may be more appropriate for identifying significant deficiencies 6.
Diagnostic Tests
- Complete Blood Count (CBC)
- Iron panel (ferritin, iron levels, total iron-binding capacity, transferrin saturation)
- Vitamin B12 and folate levels
- Peripheral blood smear
- Reticulocyte count
- Lactate dehydrogenase, haptoglobin, and bilirubin levels as supplemental tests 5