22 year old with recurrent dyspnea, usually preceded by pea-sized painless denuded areas on the tongue (see picture). Episodes of dyspnea have landed her in the ER multiple times, where she's treated with nebs and steroids. No ulcers anywhere else on her body, but she has had some easy bruising lately. Others describe wheezing on exam and I've heard inspiratory stridor during an episode. Normal VC movement on laryngoscopy. PFTs with mild flattening of inspiratory portion of flow-volume loop, otherwise unremarkable. Normal soft tissue film of the neck. Methacholine challenge normal. CXR normal. Allergy skin testing negative. IgE 5. TSH normal. CRP 0.4. Liver and kidney function normal. U/A normal. CBC with diff normal.
Also had an unexplained episode of weight loss last fall, approx. 20 lbs. Resolved spontaneously and weight came back.
I'm temped to call this VC dysfunction, but other docs claim definite peripheral wheezing on exam, and these tongue lesions don't ring any bells.
Any ideas?
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Behcet's? Any skin lesions? Can't tie the VC dysfunction together; patietns with rheumatoid can have involvement of the cricoarytenoid joint. Might also want to consider herpes (check Tzanck). Also, Paraneoplastic Pemphigus presents with oral lesions. Pulmonary manifestations usually include something like obiterative bronchiolitis and her cxr was normal, but respiratory failure, including upper airway has been reported. See for example Nousari HC, Deterding R, Wojtczack H, et al. The mechanism of respiratory failure in paraneoplastic pemphigus. N Engl J Med 1999;340:1406-1410.
Very interesting. I liked JJ's DDx.
It's an odd sequence for Behcet's...
Coxsackie can cause tongue ulcerations and people can have aphthous ulcers associated with various infections including HIV but I can't tie them with the episodic respiratory symptoms. I would probably check an HIV in a young person with ulcers and unexplained symptoms anyway but I doubt that is the answer...
Recurrent aphthous stomatitis is the most common cause of mouth ulcers in North America and the pathogenesis of the ulcers is not well defined so these may be unrelated to the respiratory symptoms (I think I said that already).
Red Herring!!!. Painless, denuded areas on the tongue can be a normal variant found in about 3% of the population (called geographic tongue). It can be chronic, migratory, but has no health implications.
Geographic tongue (believe it or not, this is the actual name of the condition). It's genetic. There are no cures. I have the same thing.
Silly "know-it-alls":
Geographic tongue is the body's response to a variety of issues, from genetic to infectious to auto-immune disorders.
Be careful not to take your own single example as representative of all experiences.
Peace.
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