|Year : 2012 | Volume
| Issue : 4 | Page : 650-651
Oral tuberculosis following successful treatment of oral malignancy
Preeti Bagga, Abhinav Dewan, Pankaj Agarwal, Charu Garg, Niloy R Datta
Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Centre, Delhi, India
|Date of Web Publication||29-Jan-2013|
St. Andrews Hospital Cancer Care Centre, 280 North Street,Toowoomba - 4350 QLD, Australia
Source of Support: None, Conflict of Interest: None
Coexistence of tuberculosis and neoplastic lesion in the oral cavity is a rare phenomenon. Till date, only three such cases have been reported in the English literature. A case of oral tuberculosis manifesting 3 months following the successful treatment of cancer of the oral tongue with chemoradiotherapy is presented. The diagnostic dilemma it posed, and its eventual successful control by anti-tubercular treatment, is discussed.
Keywords: Tubercular ulcers, oral malignancy, oral tuberculosis, chemoradiotherapy
|How to cite this article:|
Bagga P, Dewan A, Agarwal P, Garg C, Datta NR. Oral tuberculosis following successful treatment of oral malignancy. J Can Res Ther 2012;8:650-1
| > Introduction|| |
Oral tuberculosis (TB) following successful treatment of oral cavity malignant lesions is an uncommon event. As per the published English literature, three cases, having co-existing oral malignancy and oral TB, have been reported. These include a case of tuberculoma of the buccal mucosa with concomitant adenoid cystic carcinoma and two cases of a tubercular osteomyelitis co-existing with a central mucoepidermoid carcinoma of the jaw, which had not healed despite anti-tubercular treatment. ,,3]
The present case has been presented to highlight a rare development of tubercular ulcers in the oral cavity in a patient of cancer of the tongue following successful treatment with concurrent chemoradiotherapy. The diagnostic dilemma and its management is presented.
| > Case Report|| |
A 31-year-old male, chronic tobacco chewer presented in July 2010 with the complaint of a non-healing ulcer on the right lateral border of the tongue. The ulcer was 4.2 cm × 1.8 cm × 2.6 cm, tender with surrounding induration. On biopsy, it was reported as moderately differentiated squamous cell carcinoma. Following work up, it was staged as the cancer of the oral tongue, T 3 N 0 M 0 .
He was treated with concurrent chemoradiotherapy to a dose of 70 Gy in 33 fractions delivered over a period of 6½ weeks along with weekly chemotherapy with cisplatinum (50 mg) and 5-flurouracil (500 mg). Following teletherapy, he received high-dose-rate interstitial brachytherapy boost to a dose of 14 Gy in four fractions. He tolerated the entire treatment well except for grade II–III mucositis of the oral cavity and hyperpigmentation of the skin. The entire treatment was completed by the end of September 2010. By 3 weeks from the end of brachytherapy, the tumor had completely resolved and reactions healed.
In December 2010, he developed ulcers on the hard palate, associated with severe burning, non-radiating pain, exacerbated on eating food, cough with slight purulent expectoration, occasional low-grade fever, and loss of appetite. On examination, there were bilaterally symmetrical, painful superficial oval ulcers, 2 × 3 cm 2 , at the junction of hard and soft palate, with central necrotic base, surrounded by erythematous margins but without induration or cervical lymphadenopathy [Figure 1].
|Figure 1: Bilaterally symmetrical ulcers above the anterior tonsillar pillars and extending toward the hard palate|
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Swab smear from the ulcer showed heavy growth of Streptococcus sanguinis. Considering the differential diagnosis of infective (bacterial or mycotic), inflammation, or apthous ulcer, he was prescribed topical analgesics, antibiotics, antifungal, multivitamins, and steroids, sequentially, but to no respite. On the contrary, there was a progressive increase in the size of the ulcers, which led to his agony.
Toward the end of January 2011, PET scan reported bilateral multiple hypermetabolic pulmonary nodules along with increased uptake in the bilateral palato-tonsillar region. Erythrocyte sedimentation rate (ESR) was 66 mm at 1 h (Westergreen method) while other hematological parameters were within the normal range. Sputum for acid fast bacilli (AFB) was positive, while the serum mycobacterium IgG, IgM, and IgA titers were in normal limits. Furthermore, punch biopsy from the ulcer neither demonstrated any evidence of malignant cell nor acid fast bacilli but showed underlying granulation tissue and mixed inflammatory infiltrate. A polymerase chain reaction (PCR) on the biopsy specimen was also reported as negative. On enquiring further, he eventually revealed that his mother was treated for pulmonary TB 1 year back.
Subsequently, the patient was started on anti-tubercular treatment with a four-drug regimen consisting of rifampicin, isoniazid, pyrazinamide, and ethambutol. After 2 months of this treatment in April 2011, his ulcers had completely resolved.
| > Discussion|| |
According to WHO consensus, around one-third of the population has a latent TB infection which undergoes resurgence in those with a compromised immune system.  Involvement of the oral cavity is exceedingly rare and there is limited English literature published on this. 
The natural resistance conferred by the intact mucous membrane prevents the direct penetration by bacilli. Various reasons for the sparse levels of mycobacteria in the oral cavity are the cleansing effects of saliva, the relatively lesser lymphoid tissue, and the antagonist oral commensals.  However, an increased concentration of Mycobacterium tuberculosis in the mouth can be due to pulmonary inoculation, whereas a breach in the oral mucosa because of tobacco intake, trauma, inflammation, or poor oral hygiene explains route of entry. 
In our patient, this can be contributed to multiple factors, like radiation-induced fragile oral mucosa, xerostomia, tobacco intake, positive close family contact, as well as immunosuppression due to malignancy.
TB can affect any part of the oral cavity in the form of ulcerative lesions. Ulcers are mostly single, rather than multiple, with indurated, ill-defined margins and a hard necrotic base or covered with greyish or yellow slough. According to the systematic review on oral TB,  hard palate is the rarest site of oral involvement (5%). It manifests mainly as pain and odynophagia; other symptoms included a burning sensation, reflux, excessive salivation, halitosis, and intra-oral bleeding and the mean duration of symptoms before a diagnosis is established have been reported to be about 6 months. 
Traditional methods like detection of AFB in these oral lesions or a culture usually yield a sensitivity of around 52–58% and hence the diagnosis and treatment of these lesions are usually based on the high index of suspicions after excluding other causes.  This can be attributed to the growth inhibitory effect of oral bacteria on M. tuberculosis strains. Nested PCR have been reported to have a higher detect ion rate of around 89–100%. 
In the above patient, although a scrape cytology, a punch biopsy, and PCR from the lesion were all reported to be negative for TB, the demonstration of AFB in his sputum lead to a high index of clinical suspicion. Moreover, the dramatic improvement within 2 weeks of instituting anti-tubercular treatment led us to believe that these ulcers were indeed secondary to his pulmonary TB. To the best of our knowledge, and based on our literature survey, we have not come across this condition in a patient of cancer tongue following successful treatment with concurrent chemoradiotherapy. It may therefore be a rare event that may be kept in mind especially in patients of developing countries having a relatively higher prevalence of TB.
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