We report a first case of tuberculosis of oral cavity affecting the left alveolus from Nepal in a 63-year-old male who came to otorhinolaryngology outpatient department with a complaint of an ulcer in the oral cavity and pain in bilateral ear and throat. An ulcer measuring 1.8 cm in diameter with irregular friable margin and bleeding on touch was found in the left upper alveolar region of the oral cavity. Biopsy from the ulcer margin revealed histological features of necrotizing granulomatous lesion. Stain for acid fast bacilli was positive.
Tuberculosis is an infectious granulomatous disease caused by mycobacterium [
A 63-year-old male farmer of a suburban area came to the otorhinolaryngology outpatient department of our hospital with complaints of a painless ulcer in the oral cavity for 10 days and pain in both the ears and throat for 3 days. On local examination, a painless ulcer measuring 1.8 cm in greatest diameter with irregular, friable margin and bleeding on touch was found affecting the left alveolar mucosa, involving premolar and molar region and extending laterally into the gingivolabial sulcus and medially into the soft palate (Figure
Ulcer in oral cavity affecting upper left alveolus.
Microscopic examination showed stratified squamous epithelium and subepithelium revealing crushing artifacts with presence of multiple necrotizing epithelioid cell granuloma and Langhans’ type of giant cell (Figure
Section showing epithelioid cell granuloma with Langhans’ type of giant cells. (H & E; X10).
Z-N staining showing acid fast bacilli (X100; in oil immersion lens).
The patient was treated with multidrug antitubercular regimen. The drug given for initial two months were isoniazid 400 mg, rifampicin 600 mg, ethambutol 750 mg, and streptomycin 1000 mg. The ulcerative lesion was completely healed after 2 months of therapy. The drugs isoniazid 400 mg and rifampicin 600 mg were continued for further four months. No recurrence was observed in the follow-up period of a two-year duration after the completion of full-course multidrug regimen.
Tuberculosis of oral cavity is a rare lesion [
In the present case, ulcerative lesion in left upper alveolar mucosa was found after one month of teeth extraction. The patient gave the subsequent history of occasional use of raw milk after the histopathological diagnosis of oral tuberculosis and chest X-ray did not reveal any lesion. Hence, in our opinion, the lesion in present case is primary and it is caused by mycobacterium bovis infection. Similar case report affecting the tongue is well documented [
Differential diagnosis included malignancy, traumatic or aphthous ulcer, syphilis, sarcoidosis, and deep mycotic infections [
Investigations done were complete blood count, sputum examination for acid fast bacilli, culture of sputum, incisional biopsy, culture of tissue, Mantoux test, polymerase chain reaction, and chest X-ray [
In the present case aphthous ulcer was excluded by the absence of initial multiple painful lesions. Syphilitic ulcer was ruled out by serology and silver stain done on tissue section. HIV was ruled out by serology. Sarcoidosis was ruled out by the absence of lung involvement on radiological examination and presence of caseation and AFB on histopathological examination.
Diagnosis of oral tuberculosis was based on histopathological examination and demonstration of acid fast bacilli on Ziehl-Neelsen staining [
All the reported cases of oral tuberculosis including the present case responded well to antitubercular drug regimen.
In cases of ulceroinflammatory lesion of oral cavity, tuberculosis should be considered as a differential diagnosis and incisional biopsy should be done in order to reach an accurate diagnosis. X-ray chest should also be done in each case for decision on the issue of primary versus secondary tuberculosis of oral cavity.