Untitled Document

CASE REPORTS

Year : 2020  |  Volume : 3 |  Issue : 2 |  Page : 20-23 |  DOI : https://DOI-10.46319/RJMAHS.2020.v03i02.006

 

Drug induced allergic glossitis – Report of a rare case

Roopavathi KM1, Suhas S2, Sanjay Venugopal3

1Senior Lecturer, Department of Periodontics, 2 Professor & Head, Department of Oral Medicine & Radiology, 3 Professor & Head, Department of Periodontics, Sri Siddhartha Dental College & Hospital, Tumakuru, Sri Siddhartha Academy of Higher Education, Tumakuru.

DOI-10.46319/RJMAHS.2020.v03i02.006
Abstract
Allergic glossitis is a rare disorder, which may pose a challenge to dentists in diagnosis. Allergic reactions occurring in the oral cavity can be attributed to the use of various materials such as chrome cobalt dentures, gold crowns, denture soft lining material, chewing gum, dental amalgam, acrylic dentures, toothpaste, benzocaine, impression material, medications etc.  In this article we are presenting a unique case of allergic glossitis in an adult female patient aged 35 years who presented with depapillation and erythematous areas with pseudomembrane on the dorsum of tongue, associated with burning sensation on intake of food. On the basis of patients history and clinical observations, it was inferred to be a case of allergic glossitis. Since these lesions produce symptoms acutely, its severity ranging from moderate to severe, early identification and initiation of treatment with the help of topical steroid rinses will alleviate symptoms of this self-limiting condition.
Key words: Allergic glossitis, Depapillation, Burning sensation, Steroid rinses.

Introduction
Many contributing factors like systemic conditions or consumption of medications are attributed to cause oral diseases or conditions. According to World Health Organization an adverse drug reaction is defined as a response to a drug which is noxious and unintended, and which occurs at doses normally used in man for the prophylaxis, diagnosis, therapy of diseases or for the modification of physiological function.[1]
When an allergen (defined as an antigen that reacts specifically with a specific type of Ig E reagin antibody) enters the body, an allergen-reagin reaction takes place and a subsequent allergic reaction occurs resulting in clinical symptoms (allergy). [2]
Allergy can occur when allergen locally contacts the sensitive area or when the allergen is introduced systemically. The present case reports a systemically induced antigenic response manifested as a local lesion on the dorsum of tongue.
Case report
A 35 year old female, reported with a chief complaint of burning sensation accompanied by pain and discomfort on tongue while eating, followed by the peeling of tongue surface, with appearance of red lesion which was gradually worsening on the dorsal surface since five days. She gave history of intake of an antibiotic with the contents of Norfloxacin 400 mg + Tinidazole 600 mg + Lactic acid bacillus 120 x 106 spores for the treatment of stomach upset seven days ago. Gastrointestinal disturbances included muscle cramps followed by loose motions. The patient was on antibiotics twice daily for three days, lesions on the tongue started to appear a day after the consumption of the drug.
Past dental history revealed appearance of similar lesion two years ago, when she had consumed the same antibiotic. The severity of the lesion was less when compared to the present lesion and it had subsided with use of benzocaine mouth rinse. Systemic review of the patient was done and no significant medical history was revealed by the patient.
On intraoral examination, dorsum of tongue revealed irregular, raised, multiple bright red patches with areas of depapillation surrounded by erythematous zones (Figure 1).
On palpation the lesion was soft and tender, other areas of the oral mucosa were unremarkable. Based on the history and clinical features, a provisional diagnosis of allergic glossitis was made.
  
Figure 1: Before treatment (Day- 0)    Figure 2: Day two                     Figure 3: Day three
 
                              Figure 4: Day  four                                    Figure 5: Day five

Figure 6: Post treatment (Day-08)
On palpation the lesion was soft and tender, other areas of the oral mucosa were unremarkable. Based on the history and clinical features, a provisional diagnosis of allergic glossitis was made.
Management  
During treatment (0-5 days) patient was advised to dissolve 10 mg of prednisolone tablet in 20ml of water and use it as a mouth rinse (swish around & spit) for a minute three to four times a day, to alleviate the symptoms. During the follow- up visit, over the next five days the severities of the redness, the size of the lesion (Figure 2, 3, 4, and 5) as well as burning sensation reduced.
Patient was advised to continue the medications for three more days, following which lesions healed completely (Figure 6). At the end of the treatment patient was also counseled and advised not to use the same antibiotics again.
Discussion
Glossitis is an inflammatory condition associated with depapillation of the dorsal surface, leaving a smooth and erythematous surface. Various causes for allergic reaction include use of toothpaste, mouthwashes and various medications like ACE inhibitors, bronchodilators and antibiotics. The incidence of 23% geographic tongue due to allergy to drugs, food and others was reported.[3] Drug allergy is described as an immunologically mediated response to a pharmaceutical and / or for formulation agent (allergen) in a sensitized person.[4] It is reported that the flavouring agent rather than the antibiotic itself is the cause of such reaction.[5]
One of the manifestations of allergic reaction caused by systemic medication is Fixed drug eruption also called stomatitis medicamentosa. These appear clinically as localized hypersensitivity reactions which reappear at the same site each time the patient takes the medication. Common areas where these lesions occur in oral cavity are buccal mucosa, lips and tongue, but occasionally it is seen on the palate and gingiva also. It occurs on oral mucosa in the form of localized, sharply demarcated erosion, with thick pseudomembranes. These fixed drug eruptions are commonly seen within 24 hours after consumption of the medication and the lesions spontaneously resolves once the medication is stopped. (Table 1)
Table 1.  Medications commonly associated to cause fixed Drug Eruptions.[6]


Ampicillin

Lignocaine

Barbiturates

NSAIDs

Chlorhexidine

Penicillamine

Dapsone

Salicylates

Gold

Sulphonamides

Ibuprofen

Tetracyclines

Indomethacin

 

Mechanism of action of allergic lesions on the dorsum of the tongue
Glossitis is an allergic reaction that affects individuals who have been previously sensitized to allergen. It is a type IV hypersensitivity reaction. It becomes evident several hours or even days after exposure to antigen. It is a delayed hypersensitivity reaction and involves a cascade of cellular events. The process has two phases, an induction phase sensitizes the immune system to the allergen, and an effector phase during which the immune response is triggered.[7] Allergens bind to epithelial proteins and infiltrate mucosal epithelium. The epithelial protein allergen complexes have immunogenic properties.[8] These complexes are phagocytocized by macrophages and migrate towards regional ganglia in induction phase and recognized by helper T cells. During stimulation and division phase, two other types of T lymphocytes, memory and cytotoxic T lymphocytes are produced. On subsequent contact with antigen, memory T lymphocytes are stimulated leading to beginning of the entire previous cycle. Since memory T lymphocytes remain in the body for life, more aggressive and rapid immune response is triggered.[8]
Some local conditions like eosinophilic granuloma, auto mutilation, facial hemiatrophy cranial arteritis, and chronic candidiasis can cause depapillation of the tongue. Systemic causes for tongue depapillation include iron deficiency anemia, plummer Vinson syndrome, pernicious anemia, Niacin deficiency, systemic lupus erythematosis, dermatomyositis, diabetes, syphilis, zoster infection, tuberculosis.
Chronic atrophic candidiasis is commonly seen on the dorsum of tongue and because of similarity with median rhomboid glossitis it is challenging to clinically differentiate but by scrapping and cytological examination it can be diagnosed. Many systemic causes like iron deficiency anemia, Plummer Vinson syndrome, pernicious anemia are also attributed to cause this which can be confirmed by checking blood parameters. We can also observe depapillation of the tongue in zoster infections which occurs due to herpes zoster virus but in these conditions multiple vesicles are seen on the ventral surface of the tongue.[9]
Allergic glossitis is difficult to differentiate from traumatic glossitis, erythema, edema and ulceration in severe cases at the site of contact are the characteristic features of the allergic glossitis.[10] In 68.6% of patients, location of glossitis is on lateral border of the tongue which is similar to our case.[3] Cathy Nikdel, et al reported a case similar to present case with erythematous lesion and absence of filiform papilla on the body & lateral borders of the tongue due to pea nut allergy.[11]
Elimination of the causative allergic agent is the primary management of allergic glossitis. The allergic properties may be confirmed by the reappearance of inflammatory lesions on re-introduction of the agent. Patients who experience more severe symptoms may in addition need to be prescribed a topical corticosteroid either in form of ointment, gel or mouthwash to promote faster healing.[12]  The primary objective of glossitis management is to minimize inflammation which can be achieved by maintaining good and clean oral hygiene by meticulous brushing of teeth twice a day without fail.[13] Complete resolution of the lesion can sometimes take upto two weeks. Along with these measures additional use of antihistamine suspension in a swish and swallow method is shown to provide advantage of both local and systemic actions. [14]
Conclusion
Allergic glossitis sometimes can be confused with benign migratory glossitis. Careful history taking and a high degree of suspicion is essential to establish a cause and effect relationship. Medical management will include the use of antihistamines and glucocorticoids. Early and accurate diagnosis relieves the patient from symptoms and discomfort.
Financial support and sponsorship: Nil
Conflict of interest: Nil
References
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10. Martin S Greenberg, Michael Glick. Burkitt's Oral Medicine Diagnosis and treatment10th Edition, Philadelphia: Elsevier, 2003. p. 23
11. Cathy Nikdel, et al. A Rare Case of Peanut Allergy Manifesting as Benign Migratory Glossitis. J Dental Sci 2018;3(9):1-6.
12. Regezi J, Sciubba J, Jordan R. Oral pathology: clinical pathologic correlations, 4thedition. Philadelphia: W.B. Saunders; 2003.p. 448.
13.  Ana Pejcic. Emerging Trends in Oral Health Sciences and Dentistry.
14.  Lokesh P, Rooban T, Elizabeth J, Umadevi K, Ranganathan K. Allergic Contact Stomatitis: A Case Report and Review of Literature. IJCP. 2012; 22(9):458-462.
Address for Correspondence: Dr. Roopavathi KM, Senior Lecturer, Dept of Periodontics, Sri Siddhartha Dental College & Hospital, Tumkur-572107, Karnataka, India. Email: roopavathikm@gmail.com


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