Recurrent glossitis in children

Mucosal pathology

Dr. Emmanuelle Bourrat

Saint-Louis Hospital

The clinical case
Now it's your turn!
Co-prescription and advice

Clinical case presentation

A two-and-a-half-year-old girl had been suffering from painful lingual lesions every month or so. The first episode had occurred 6 months earlier; it was more severe (hyperalgesic vesiculoerosive stomatitis), more febrile (temperature of 39°C), more prolonged (10 days) and was treated empirically with oral aciclovir for 10 days.

Since then, localized painful erosions had recurred in the same spot on the left lateral edge of the tongue, preceded by a very brief febrile episode and accompanied by hypersalivation and food refusal (only bottles were accepted), with a spontaneous duration of about 5 to 8 days. She was taking no medication and had no significant personal or family history.

Your turn

What is your diagnosis?

Select 1 answer(s) from the following choices:

Lingual herpes recurrence

Oral involvement of an autoimmune bullous dermatosis

Aphthosis

Mucosal erythema multiforme

Wrong answer!

Good answer!

Selected diagnosis

Vesiculoerosive stomatitis in children is common and is most often post-vesicular and viral in origin: primary herpetic infection, herpangina, hand-foot-and-mouth disease, varicella, etc.

In this young patient, vesicles grouped in clusters were clearly visible at the start of the outbreak. PCR testing for herpes simplex virus type 1 (HSV-1) was positive, confirming a diagnosis of lingual herpes recurrence, which wassuspected based on the recurrent nature and fixed location of the flares.

Nearly 100% of the adult population carries HSV-1 in a latent state, but only 20% of this population regularly reactivates the virus during episodes of transient immune deficiency.

Explanation of wrong answers

In the case of recurrent painful stomatitis, mucosal erythema multiforme should be considered, which can be difficult to diagnose in the absence of other mucosal lesions or characteristic skin lesions (target lesions). In this case, the diagnosis can be ruled out based on the highly localized nature of the lesions.
An aphthous ulcer is a painful ulceration not preceded by a fluid-filled lesion and does not always recur in the same place.
The inaugural oral presentation is sometimes the exclusive manifestation of an autoimmune bullous dermatosis, which also occurs in children, but the symptoms and progression are very different.

Treatment

The frequency of flares and their significant functional impact in terms of pain and food refusal prompted us to propose long-term preventive aciclovir treatment.

Message from the expert

Herpes simplex recurrence, when symptomatic, most often takes the form of characteristic labial lesions (“cold sore”). Pure intraoral recurrences are rarer and mostly localized on the hard palate or attached gingiva. Lingual localization appears to be more unusual.

References

^{Kobayashi Y et al Two cases of recurrent herpetic infection of the tongue.}^{Kurume Med J. 1996;43(3):237-41}