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Journal of the Formosan Medical Association (2016) xx, 1e2

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CORRESPONDENCE

Oral tuberculosis
Yu-Hsueh Wu a,b, Julia Yu-Fong Chang a,b,c, Andy Sun a,b,
Chun-Pin Chiang a,b,c,*

a
Graduate Institute of Clinical Dentistry, School of Dentistry, National Taiwan University, Taipei,
Taiwan
b
Department of Dentistry, National Taiwan University Hospital, College of Medicine, National Taiwan
University, Taipei, Taiwan
c
Graduate Institute of Oral Biology, School of Dentistry, National Taiwan University, Taipei, Taiwan

Received 9 October 2016; accepted 18 October 2016

Tuberculosis is a chronic infectious disease caused by
Mycobacterium tuberculosis. It is estimated that about 9
million people are affected and tuberculosis causes millions
of deaths each year.1 Lung is the most common involvement
site but extrapulmonary involvement may occur at any
organ. Here, we reported a case of oral tuberculosis in an
immunocompromised elderly man with severe systemic
diseases.
An 81-year-old man came to our outpatient department
for evaluation of discomfort and pain in the tooth 27 area
for 2e3 weeks. There was a swelling with focal surface
ulceration around tooth 27, especially at the palatal side.
The patient also had fever, weight loss, and persistent dry
cough for several weeks. Periapical radiography revealed
severe alveolar bone destruction around the tooth 27 area.
The patient had a medical history of myelodysplastic syn-
drome, diabetes mellitus, and chronic monocytic leuke-
mia. To make a definite diagnosis, an incisional biopsy was
performed after platelet transfusion. Histologically, it
showed an oral mucosal tissue with focal surface ulceration
Conflicts of interest: The authors have no conflicts of interest
relevant to this article.
* Corresponding author. Department of Dentistry, National
Taiwan University Hospital, 1 Chang-Te Street, Taipei 10048,
Taiwan.
E-mail address: cpchiang@ntu.edu.tw (C.-P. Chiang).
and a dense small blue cell infiltrate in the lamina propria
(Figure 1A). Multiple caseating granulomas composed of
few multinucleated Langerhans giant cells at the center
and numerous histiocytes and lymphocytes at the sur-
rounding areas were observed (Figure 1B and 1C). Acid-fast
stain demonstrated the presence of scattered aggregates
of small red rods of mycobacterial organisms in the tissue
section (Figure 1D). No fungal infection was seen in peri-
odic acideSchiff-stained and Grocott’s methenamine
silver-stained tissue sections. M. tuberculosis organisms
were also found in the cultured sputum. Based on the
histopathological findings, the presence of mycobacterial
organisms by acid-fast stain, and the positive sputum cul-
ture result, the diagnosis of oral tuberculosis was
confirmed.
Multiple organs can be infected by M. tuberculosis, but
the incidence of oral tuberculosis is relatively low, repre-
senting only 0.1e5% of all tuberculosis infections.1 Primary
infection of tuberculosis in the oral cavity is rare and often
appears as a single ulcer with regional lymph node
enlargement. Secondary inoculation can be caused by
either expectoration or lymphatic/vascular spread and
these lesions are usually accompanied with pulmonary
symptoms and signs of tuberculosis. The tongue is the most
frequently involved site, followed by palate, buccal mu-
cosa, gingiva, salivary glands, and floor of the mouth.1 The
clinical features of oral tuberculosis include painful ulcers,
nodules, and swelling. M. tuberculosis-caused osteomye-
litis has also been reported in the jaw bones. Nevertheless,

http://dx.doi.org/10.1016/j.jfma.2016.10.016
0929-6646/Copyright ª 2016, Formosan Medical Association. Published by Elsevier Taiwan LLC. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Please cite this article in press as: Wu Y-H, et al., Oral tuberculosis, Journal of the Formosan Medical Association (2016), http://
dx.doi.org/10.1016/j.jfma.2016.10.016
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2 Y.-H. Wu et al.

Figure 1 Histological microphotographs of our case of oral tuberculosis. (A) Hematoxylin and eosin (H&E)-stained tissue section
showing oral mucosal tissue covered by stratified squamous epithelium and a dense small blue cell infiltrate in the lamina propria
(original magnification, 4). (B) Medium-power microphotograph exhibiting multiple caseating granulomas composed of a few
multinucleated Langerhans giant cells at the center and many histiocytes and lymphocytes at the surrounding areas (H&E stain;
original magnification, 10). (C) High-power microphotograph demonstrating typical multinucleated Langerhans giant cells and the
surrounding histiocytes (H&E stain; original magnification, 40). (D) Acid-fast stain showing the presence of an aggregate of small
red rods of mycobacterial organisms in the center of the tissue section (original magnification, 40).

these clinical manifestations of oral tuberculosis mimic References

other diseases, such as squamous cell carcinoma, syphilis,
and deep fungal infection. Microscopically, granulomatous
inflammation is a typical finding but not pathognomonic for
tuberculosis. An acid-fast stain of the tissue section is
necessary to show the presence of mycobacterial organ-
isms. Although immunohistochemical stain is frequently
used to help identify the specific cell types or tumors,2e5
there is no need for immunochemistry for the diagnosis of
oral tuberculosis. A medical history that highlights an
immunosuppressive condition and systemic symptoms are
important in the differential diagnosis of tuberculosis. Once
the diagnosis of tuberculosis has been made, the patient
should be referred for further treatment.
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early diagnosis. J Clin Diagn Res 2014;8:ZE18e21.
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Please cite this article in press as: Wu Y-H, et al., Oral tuberculosis, Journal of the Formosan Medical Association (2016), http://
dx.doi.org/10.1016/j.jfma.2016.10.016