Journal of Postgraduate Medicine
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CASE REPORT
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Year : 1991  |  Volume : 37  |  Issue : 4  |  Page : 238-40  

Median rhomboid glossitis: secondary to colonisation of the tongue by Actinomyces (a case report).

RB Deshpande, MA Bharucha 
 Department of Pathology, P. D. Hinduja National Hospital and Medical Research Centre, Veer Savarakar Marg, Mahim, Bombay, Maharashtra.

Correspondence Address:
R B Deshpande
Department of Pathology, P. D. Hinduja National Hospital and Medical Research Centre, Veer Savarakar Marg, Mahim, Bombay, Maharashtra.

Abstract

Median rhomboid glossitis is an inflammatory lesion of the tongue, now believed to be secondary to candidiasis. We document a case of median rhomboid glossitis with heavy colonisation by Actinomyces in a 60-year-old male. We propose that Actinomyces, like Candida, induces pseudoepitheliomatous hyperplasia of the mucosa of the tongue and florid inflammatory hyperplasia of the underlying connective tissue, resulting in the characteristic elevated lesion. Actinomyces has not earlier been implicated as a cause of median rhomboid glossitis.



How to cite this article:
Deshpande R B, Bharucha M A. Median rhomboid glossitis: secondary to colonisation of the tongue by Actinomyces (a case report). J Postgrad Med 1991;37:238-40


How to cite this URL:
Deshpande R B, Bharucha M A. Median rhomboid glossitis: secondary to colonisation of the tongue by Actinomyces (a case report). J Postgrad Med [serial online] 1991 [cited 2022 Aug 12 ];37:238-40
Available from: https://www.jpgmonline.com/text.asp?1991/37/4/238/744


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  ::   IntroductionTop


Median rhomboid glossitis is a diamond shaped, elevated, inflammatory lesion of the tongue, covered by smooth red mucosa. It is situated anterior to the circumvallate papillae, at about the junction of the anterior two-third and posterior one-third of the tongue [3]. It occurs exclusively in adults. Clinically it may be mistaken for malignancy. Even histologically, the marked pseudo-epithe-liomatous hyperplasia that accompanied it may mislead an unwary pathologist to a diagnosis of carcinoma. On the other hand, though it is not considered to be a pre-malignant lesion, there are reports of carcinoma arising in it[2].

Median rhomboid glossitis was thought to be a developmental anomaly caused by failure of the lateral lingual tubercles to cover the tuberculum impar. In 1971, Baughman[1] questioned this long held belief. He argued that if median rhomboid glossitis is a developmental anomaly, it should have occurred more frequently in children. He convincingly showed that it is an inflammatory, infectious or degenerative process. In 1975, Cooke[4] found colonisation of the mucosa of the tongue by Candida albicans in all the biopsies taken from ten patients with median rhomboid glossitis. Morphologic changes of experimentally induced candidiasis of the tongues of rats[5] are similar to the changes seen in median rhomboid glossitis, which further supports candidial infection as an etiological agent for the lesion.

We report here a case of median rhomboid glossitis caused by actinomyces. Such an etiologic association has not been recorded earlier.


  ::   Case reportTop


A 60-year-old man presented with a history of an ulcer on his tongue, and excessive salivation of 6 months' duration. This was followed by the appearance of a growth around the ulcer. Soon the ulcer was no more visible but the excessive salivation persisted. The growth was increasing in size but remained painless.

On examination, there was a roughly diamond shaped, elevated swelling just anterior to the circumvallate papillae, in the midline. It measured 5 cm x 3 cm x 2 cm and was formed by two kidney shaped halves on either side of the midline. The concave edge of each half faced the other, and partly concealed an irregular ulcer crater in the midline. The ulcer measured 2 cm x 1 cm. The floor was covered by an inflammatory granulation tissue, yellow flakes and granular debris. (See [Figure:1])

The entire lesion was excised along with a rim of normal mucosa and some underlying muscle tissue.

Histological examination of the two elevated lateral halves showed marked pseudo-epitheliomatous hyperplasia of the lining mucosa. There was profuse proliferation of fibroblastic and inflammatory granulation tissue underneath. The irregular crater in the midlinc showed ulcerated mudosa covered by an acute inflammatory exudate and multiple "ray fungus" colonies of Actinomyces. The colonies comprised radially arranged, branching, Gram positive, nonacid-fast filaments with peripheral club shaped structures. These club shaped structures were formed by deposition of eosinophilic material around the tips of filaments (Splendore-Hoepple phenomenon). Many of the colonies showed neutrophils adherent to the periphery. The inflammatory exudate and fibroblastic granulation tissue extended underneath to the muscle tissue. "Ray fungus" colonies were seen only superficially on the ulcerated mucosa. Some colonies were embedded in the inflammatory exudate. However, these colonies were not seen in the deeper portions.

Multiple sections failed to reveal Candida. There was no epithelial dysplasia or malignancy.

Post-operatively the patient had an uneventful recovery. The lesion had not recurred six months later.


  ::   DiscussionTop


Actinomyces is a common oral commensal organism found on unhygienic oral mucosa, carious teeth and crypts of tonsils. These act as sources of infection in cervico-facial actinomycosis. Involvement of the tongue by Actinomyces is very rare[6]. Unlike cervico-facial actinomycosis, the colonisation in this patient was restricted to the ulcerated mucosa inducing pseudoepitheliomatous hyperplasia and profuse proliferation of fibroblastic granulation tissue.

The possibility of Actinomyces being just commensal organism on the ulcerated tongue, as commonly seen in the crypts of tonsils, was considered. The lesion had started as an ulcer covered by flakes and granules of Actinomyces. Clusters of neutrophils adherent to the periphery of the colonies and the Splendore-Hoepple phenomenon around some of the colonies indicate a pathogenetic role of Actinomyces.

References

1 Baughman RA. Median rhomboid glossitis: A developmental anomaly? Oral Surg, Oral Med, Oral Pathol 1971; 31:56-65.
2Burkes EJ, Lewis JR. Carcinoma arising in the area of median rhomboid glossitis. Oral Surg, Oral Med, Oral Pathol 1976; 41:649-652.
3Cherrick HH. The mouth and oropharynx. In: "Surgical Pathology" vol. 1. WIF Coulson, editor. 2nd edition. Philadelphia: JB Lippincott Company; 1988, pp 1.
4Cooke BE. Median rhomboid glossitis. Candidiasis and not a developmental anomaly. Brit J Dermatol 1975; 93:399-405.
5Jones JH, Russell C. The histology of chronic candidial infection of the rats' tongue. J Pathol 1974; 113:97-100.
6Rippon JW. In: Medical Mycology." 3rd edition. Philadelphia: WB Saunders Company; 1988, pp 30-52.

 
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