A 55-year-old male patient with chronic hepatitis B was started on tenofovir. One month after initiating the new medication, he developed severe symptomatology with odynophagia and a very painful tongue. The physical examination reveals multiple erythematous patches on his tongue and a biopsy was performed. It allowed the diagnosis of benign migratory glossitis or geographic tongue. The patient was kept on tenofovir, but had to start topical corticoid therapy. Geographic tongue is a common condition that may be caused by drug idiosyncrasy, but has never before been associated to tenofovir. It is usually asymptomatic, but sometimes it causes severe symptoms, being an important impairment of quality of life.

To analyze the causes of atrophic glossitis(AG) and to explore the relationship between AG and serum cobalamin, folate levels.A total of 213 patients with AG treated from Jan.1979 to Jun. 2010 were analyzed for the causes of AG. Serum cobalamin, folate levels and complete blood count were tested in newly enrolled AG patients from Sep. 2010 to Aug. 2011. All data were analyzed with SPSS 16.0 software package for Student's t test.There were 97 AG patients (45.4%) suffering from megaloblastic anemia (MA)/ macrocytosis. Among the 72 newly enrolled AG patients, fifty had cobalamin deficiency. Meanwhile, serum folate levels were increased in cobalamin deficiency group.Cobalamin deficiency is the common cause both of MA/macrocytosis and AG, also may be the main cause of AG. Furthermore, AG may be the early clinical manifestation of cobalamin deficiency. Supported by National Natural Science Foundation of China(81170967).

Juvenile cobalamin deficiency is a rare disease in border collies and its diagnosis requires a high level of clinical suspicion. The goal of this study was to increase awareness of this disease by describing the clinical and laboratory findings in four young border collies with inherited cobalamin deficiency. The median age of the dogs was 11.5 mo (range, 8-42 mo), and two of the four dogs were full siblings. Clinical signs included intermittent lethargy (n = 4), poor body condition (n = 4), odynophagia (n = 2), glossitis (n = 1), and bradyarrhythmia (n = 1). Pertinent laboratory abnormalities were mild to moderate normocytic nonregenerative anemia (n = 3), increased aspartate aminotransferase (AST) activity (n = 3), and mild proteinuria (n = 3). All of the dogs had serum cobalamin levels below the detection limit of the assay, marked methylmalonic aciduria, and hyperhomocysteinemia. Full clinical recovery was achieved in all dogs with regular parenteral cobalamin supplementation, and laboratory abnormalities resolved, except the proteinuria and elevated AST activity persisted. This case series demonstrates the diverse clinical picture of primary cobalamin deficiency in border collies. Young border collies presenting with ambiguous clinical signs should be screened for cobalamin deficiency.

Lyme borreliosis is a multisystemic tick-borne spirochetosis, which may result in dermatologic, musculoskeletal, cardiovascular, and neurologic manifestations.Patients with suspected acute Lyme borreliosis infection may be referred for urgent dermatologic review. Canadian dermatologists should be aware of the latest information regarding the diagnosis and management of Lyme borreliosis.This review is based on a PubMed database search combining the word "Lyme" with variations of the word "Canada." Data sources included articles from the fields of ecology, epidemiology, laboratory diagnostics, and clinical management.In this review, the ecological basis of spirochete transmission by tick vectors is described. The latest available Canadian epidemiologic data are summarized. North American clinical manifestations of Lyme borreliosis are contrasted with European presentations. The Canadian Public Health Laboratory Network's diagnostic guidelines are summarized. Finally, treatment recommendations are outlined.

Patients with gastroesophageal reflux may have extra-esophageal manifestations. We report a 46 years old ex-smoker woman presenting with a sensation of burning mouth, xerostomia and glossitis. The patient had a history of heartburn, dysphonia and cough. Mouth examination showed a bad hygiene and abundant accumulation of plaque. Esophageal pH measurement was abnormal. Laryngoscopy showed a posterior laryngeal inflammation and mucous secretion. With these data, a diagnosis of gastroesophageal reflux was reached.

A 62-year-old man with diabetes and a history of ischemic coronary disease visited the emergency department complaining of acute pain and swelling of the tongue. Physical examination found subtle swelling and pallor of the right side of the tongue, and he was initially diagnosed with glossitis. However, his symptoms were progressive, and the tongue had sustained serious tissue damage before the correct diagnosis was established. Digital subtraction angiography of the cervical vessels revealed occlusion of the right external carotid artery (ECA) and lingual artery without collateral circulation to the right side of the tongue from the contralateral ECA or ipsilateral vertebral artery (VA). Endovascular revascularization was performed to restore blood flow to the tongue using balloon angioplasty of the proximal segment of the right ECA followed by deployment of a self-expanding stent. Tongue pain subsided shortly after the procedure, and configuration of the tongue returned to normal 4 months after intervention. Tongue infarction is rare and usually associated with systemic vasculitides. Tongue infarction due to unilateral occlusion of the ECA is extremely rare because of the rich collateral circulation to the tongue from the ipsilateral VA and contralateral ECA. Atherothrombotic unilateral occlusion of the ECA should be included in the differential diagnosis of tongue infarction. Revascularization of the occluded ECA is worth attempting despite substantial tissue damage because of the viability of the tongue muscles and the minimal risk of complications in experienced hands.

Diagnosis of multiple endocrine neoplasia type 1 (MEN1) is commonly based on clinical criteria, and confirmed by genetic testing. In patients without known MEN1-related germline mutations, the possibility of a casual association between two or more endocrine tumors cannot be excluded and subsequent management may be difficult to plan. We describe a very uncommon case of functioning glucagonoma associated with primary hyperparathyroidism (pHPT) in which genetic testing failed to detect germline mutations of MEN-1 and other known genes responsible for MEN1.The patient, a 65-year old woman, had been suffering for more than 1 year from weakness, progressive weight loss, angular cheilitis, glossitis and, more recently, skin rashes on the perineum, perioral skin and groin folds. After multidisciplinary investigations, functioning glucagonoma and asymptomatic pHPT were diagnosed and, since family history was negative, sporadic MEN1 was suspected. However, genetic testing revealed neither MEN-1 nor other gene mutations responsible for rarer cases of MEN1 (CDKN1B/p27 and other cyclin-dependent kinase inhibitor genes CDKN1A/p15, CDKN2C/p18, CDKN2B/p21). The patient underwent distal splenopancreatectomy and at the 4-month follow-up she showed complete remission of symptoms. Six months later, a thyroid nodule, suspected to be a malignant neoplasia, and two hyperfunctioning parathyroid glands were detected respectively by ultrasound with fine needle aspiration cytology and 99mTc-sestamibi scan with SPECT acquisition. Total thyroidectomy was performed, whereas selective parathyroidectomy was preferred to a more extensive procedure because the diagnosis of MEN1 was not supported by genetic analysis and intraoperative intact parathyroid hormone had revealed "adenoma-like" kinetics after the second parathyroid resection. Thirty-nine and 25 months after respectively the first and the second operation, the patient is well and shows no signs or symptoms of recurrence.Despite well-defined diagnostic criteria and guidelines, diagnosis of MEN1 can still be challenging. When diagnosis is doubtful, appropriate management may be difficult to establish.

Psoriasis is a multifactorial disease. Genetic and environmental factors, which determine the disease epidemiology and clinical spectrum, are heterogeneous in different populations. A few case-control studies from other countries have shown an association between psoriasis and migratory glossitis (MG). The characteristics of the association (e.g. relationship with gender, severity of psoriasis, early- versus late-onset psoriasis, etc.) have not been clearly defined.To investigate the association of psoriasis and MG by conducting a matched case-control study in India.The study was conducted on 600 patients with psoriasis and 800 age- and sex-matched controls. Patients were examined for oral lesions and psoriasis severity was assessed by overall severity index (OSI) and psoriasis area and severity index (PASI). We compared the proportions of patients and controls with oral lesions, proportions of male and female patients who had MG, psoriasis severity scores of patients with or without MG, and proportions of early- and late-onset psoriasis patients who had MG.Significantly, more patients had oral lesions than controls (P=0.0013). There was a strong association between psoriasis and MG (P<0.0001). MG and fissured tongue (FT) occurring in the same patient were also strongly associated with psoriasis (P=0.0003). There was a weak association of psoriasis with FT (P=0.0456). Significantly, higher proportion of male patients had MG compared to female patients (P=0.0246). Patients with MG had more severe psoriasis compared to those without the tongue lesions (P<0.0001). Similar proportions of patients with type 1 and type 2 psoriasis had MG (P=0.7268).The results suggest that MG is a rare manifestation of psoriasis which occurs more commonly in male patients and in those with severe disease, and that it occurs with equal frequency in early- and late-onset psoriasis. It will be interesting to follow those patients who have MG, but not psoriasis, to see whether they develop psoriasis phenotype in future.

The purpose of the study was to evaluate the oral and dental findings of uremic patients receiving hemodialysis and to compare the Results between diabetic and non-diabetic groups.A total of 100 patients undergoing hemodialysis were classified into diabetic and non-diabetic groups and examined for uremic oral manifestations, dental caries (DMFT), and periodontal status (CPITN). Mann-Whitney test of significance has been applied for analyzing DMFT score and chi-square test is used for analyzing CPITN score.Of the study group, 46% were diabetic and only 11% of them did not have any oral manifestation. Oral manifestations observed were xerostomia and uremic odor, which contributed to 47 (23%) and 37 (17%), respectively. Hyperpigmentation was present in 26 (12%), macroglossia in 23 (11%), and uremic tongue coating in 24 (11%). Mucosal petechiae were seen in 17 patients contributing to 8% of total patients. Eleven patients had tongue pallor (5%), 9 patients had glossitis with depapillation (4%), and 7 patients had dysgeusia (3%). Angular cheilitis and gingival swelling were seen in 5 patients (2%).The oral and dental manifestations were higher in prevalence in the study group. However, there was no significant difference between the two groups.