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A Young Man Presenting With Tongue Lesions

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 19-year-old male presented for evaluation of painful lesions on the tongue that had been present for at least 3 months. He stated that the pain was exacerbated by spicy foods. He had initially presented to a primary care practitioner, was prescribed clotrimazole lozenges, and reported mild initial improvement followed by symptom progression. Subsequently, the practitioner referred the patient to an otolaryngologist.

The patient denied any enlarged lymph nodes, fevers, fatigue, rash, weight loss, or abnormal gastrointestinal symptoms and had no noteworthy medical history. He reported mild alcohol consumption, denied any cigarette or illicit substance use, and endorsed engaging in oral and anal intercourse.

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C. Secondary syphilis

Leukoplakia in young patients is rare1; however, it has been noted that oral squamous cell carcinoma in young patients (<40 years old) should not be missed because it is associated with aggressive disease.2 The differential diagnosis for this patient’s tongue lesions included squamous cell carcinoma,3 hyperkeratotic dysplasia, lichen planus, hairy leukoplakia, and infectious causes, eg, candidiasis, HIV, and oral syphilis. Although nonspecific, the dense plasmacytic infiltrate seen on hematoxylin-eosin staining is a characteristic histopathologic finding of mucocutaneous syphilis (Figure 1B).4,5 Of note, the inflammatory cells were morphologically typical, making neoplastic causes in the differential diagnosis unlikely.

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Article Information

Corresponding Author: Theresa Guo, MD, Department of Otolaryngology–Head & Neck Surgery, University of California San Diego School of Medicine, 3855 Health Sciences Dr, MCC 2331, La Jolla, CA 92037 (twguo@health.ucsd.edu).

Published Online: November 23, 2022. doi:10.1001/jamaoto.2022.3799

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
1.
Carrard  VC , van der Waal  I .  A clinical diagnosis of oral leukoplakia: a guide for dentists.   Med Oral Patol Oral Cir Bucal. 2018;23(1):e59-e64.PubMedGoogle Scholar
2.
Garavello  W , Spreafico  R , Gaini  RM .  Oral tongue cancer in young patients: a matched analysis.   Oral Oncol. 2007;43(9):894-897. doi:10.1016/j.oraloncology.2006.10.013PubMedGoogle ScholarCrossref
3.
Miller  C , Shay  A , Tajudeen  B ,  et al.  Clinical features and outcomes in young adults with oral tongue cancer.   Am J Otolaryngol. 2019;40(1):93-96. doi:10.1016/j.amjoto.2018.09.022PubMedGoogle ScholarCrossref
4.
Engelkens  HJH , ten Kate  FJ , Vuzevski  VD , van der Sluis  JJ , Stolz  E .  Primary and secondary syphilis: a histopathological study.   Int J STD AIDS. 1991;2(4):280-284. doi:10.1177/095646249100200411PubMedGoogle ScholarCrossref
5.
Jeerapaet  P , Ackerman  AB .  Histologic patterns of secondary syphilis.   Arch Dermatol. 1973;107(3):373-377. doi:10.1001/archderm.1973.01620180027008PubMedGoogle ScholarCrossref
6.
Schuch  LF , da Silva  KD , de Arruda  JAA ,  et al.  Forty cases of acquired oral syphilis and a review of the literature.   Int J Oral Maxillofac Surg. 2019;48(5):635-643. doi:10.1016/j.ijom.2018.10.023PubMedGoogle ScholarCrossref
7.
Leuci  S , Martina  S , Adamo  D ,  et al.  Oral syphilis: a retrospective analysis of 12 cases and a review of the literature.   Oral Dis. 2013;19(8):738-746. doi:10.1111/odi.12058PubMedGoogle ScholarCrossref
8.
Lampros  A , Seta  V , Gerhardt  P , Isnard  C , Husson  C , Dupin  N .  Oral forms of secondary syphilis: an illustration of the pitfalls set by the great imitator.   J Am Acad Dermatol. 2021;84(2):348-353. doi:10.1016/j.jaad.2020.04.089PubMedGoogle ScholarCrossref
9.
Workowski  KA , Bachmann  LH , Chan  PA ,  et al.  Sexually Transmitted Infections Treatment Guidelines, 2021.   MMWR Recomm Rep. 2021;70(4):1-187. doi:10.15585/mmwr.rr7004a1PubMedGoogle ScholarCrossref
10.
Park  IU , Tran  A , Pereira  L , Fakile  Y .  Sensitivity and specificity of treponemal-specific tests for the diagnosis of syphilis.   Clin Infect Dis. 2020;71(suppl 1):S13-S20. doi:10.1093/cid/ciaa349PubMedGoogle ScholarCrossref
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