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  Table of Contents    
Year : 2021  |  Volume : 64  |  Issue : 2  |  Page : 250-253
Oro-facial tuberculosis - Is it still an enigmatic entity?

1 Department of Pathology and MAMC, New Delhi, India
2 Department of Pathology, Katurba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India
3 Department of Otorhinolaryngology, MAMC, New Delhi, India

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Date of Submission18-Apr-2020
Date of Decision25-May-2020
Date of Acceptance27-Jul-2020
Date of Web Publication9-Apr-2021


Background and Aims: The objective of this study was to analyze and review the clinical and histopathological aspects of oro-facial tuberculosis. Methods: Sixteen cases of oral mucosal biopsies diagnosed as granulomatous pathology consistent with tuberculosis were retrieved from the data base and clinical information and histopathological findings were analyzed retrospectively. Results: Of the total 16 cases, 12 were males while 4 were females. The age ranged from 15-70 years (mean of 39.6 years). Buccal mucosa, as an involved site, was seen in 31% of cases, while tonsil and soft palate constituted 3 cases each. Duration of symptoms ranged from 01-12 months (mean of 5.3 months). Oral examination revealed ulceroproliferative lesions in majority of the cases. Of sixteen cases, six cases (37.5%) each primarily as well as secondarily involved oral cavity while in 25% (4/16) of cases the status could not be evaluated. On histopathology, caseating granulomas were seen in 7 of 16 cases (43.75%) and non-caseating granulomas were seen in rest 56.25% of cases. Ziehl Neelsen stain for acid fast bacilli was positive in 31.25% (5/16) of cases. Conclusion: Though unusual, tuberculosis should always be included in the differentials of oral lesions in a country endemic to tuberculosis like India. Histopathological evaluation of the biopsy remains the indispensible tool to diagnose oro-facial tuberculosis.

Keywords: Acid fast bacilli, caseating, granulomatous, oral cavity, tuberculosis, Ziehl- Neelsen stain

How to cite this article:
Gupta L, Bhatt AS, Mallya V, Rana D, Khurana N, Singh I. Oro-facial tuberculosis - Is it still an enigmatic entity?. Indian J Pathol Microbiol 2021;64:250-3

How to cite this URL:
Gupta L, Bhatt AS, Mallya V, Rana D, Khurana N, Singh I. Oro-facial tuberculosis - Is it still an enigmatic entity?. Indian J Pathol Microbiol [serial online] 2021 [cited 2021 May 8];64:250-3. Available from: https://www.ijpmonline.org/text.asp?2021/64/2/250/313292

   Introduction Top

Extra-pulmonary tuberculosis involving head and neck is rare and involvement by oral cavity is still rarer. Incidence of oral tuberculosis among the cases of extra-pulmonary tuberculosis accounts for only 0.2-1.5%.[1] Oral cavity involvement by tuberculosis can be primary or secondary, with primary being the less common form.[2] Oral tubercular lesions can manifest in a number of ways which often mimic malignancy clinically.[3] Our study therefore aims to emphasize the importance of histopathology in the diagnosis of oro-facial tuberculosis which largely remains clinically unsuspected. We also highlight that oral tubercular lesions can simulate malignancy and thus tuberculosis should always be considered as a differential diagnosis while examining the oral biopsies.

   Methods Top

Cases with histopathological diagnosis of granulomatous inflammation consistent with tuberculosis were searched from the data base at the department of Pathology, Maulana Azad Medical College, New Delhi. These cases were collected over a time frame of five years (September 2012- August 2017) and were analysed retrospectively. Clinical information regarding age, gender, duration of illness, site of biopsy, examination findings and clinical suspicion were analysed [Table 1]. All the oral mucosal biopsies were processed as per standard protocols. Histopathological examination was done on sections stained with hematoxylin and eosin (H and E). Ziehl Neelsen and periodic acid Schiff (PAS) staining were done in all the biopsies. The histological sections were observed for presence of ill or well defined epithelioid cell granulomas along with presence or absence of caseous necrosis.
Table 1: Clinico-pathological characteristics of the cases included in the present study

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   Results Top

A total of 22 cases were found to have granulomatous inflammation in oral mucosal biopsies. Of these 22 cases, 16 cases (72.7%) were diagnosed to have granulomatous inflammation consistent with tuberculosis and hence were included in the study. The mean age was 39.6 years (ranging from 15-70 years). Of the 16 cases, 4 were females and 12 males (M:F-3:1). The duration of illness ranged from one month to 12 months (mean of 5.3 months). Buccal mucosal involvement was seen in 31.25% cases (5/16), tonsil and soft palate involvement was seen in three cases each (18.75%) while gingiva, hard palate, alveolus, tongue and retromolar trigone constituted one cases each.

On oral examination, ulceroproliferative growth was seen in eleven cases, constituting 63.75%. Two cases (12.50%) showed ulcer with undermined edges while induration and leukoplakic patch was seen in one case each. In 10/16 cases (62.5%), a clinical suspicion of malignancy was considered. In 18.75% (3/16) and 12.5% (2/16), clinical diagnosis of tuberculosis and aphthous ulcers was considered. Leukoplakia was clinically diagnosed in the case which presented with whitish patch.

Primary oral involvement was seen in 37.5% (6/16) cases and all the cases were young adults of less than 30 years of age. Secondary involvement of oral cavity was seen in 37.5% of cases and in all these cases primary site of tuberculosis was lung. All the patients with secondary involvement of oral cavity were elderly and more than 30 years of age. In 25% (4/16) of cases, primary or secondary involvement by oral cavity could not be evaluated. However, one case among these four cases showed AFB positivity and rest three cases showed positive tubercular culture on follow up and hence these cases were included under the study.

Histopathological findings on oral biopsies

The biopsies predominantly showed ulcerated lining epithelium (62.5%) [Figure 2]b while hyperplastic stratified squamous epithelium was seen in 25% of cases. Two cases (12.5%) cases showed normal stratified squamous epithelium [Figure 1]e. None of the biopsies showed any evidence of dysplasia or malignancy. Non-caseating epitheliod cell granulomas were seen 56.25% (9/16) of cases [Figure 2]c and rest 43.75% (7/16) of cases showed caseating, confluent epitheliod cell granulomas [Figure 1]f. Acid fast bacilli by Ziehl Neelsen staining was positive in 31.25% (5/16) of cases [Figure 1g]. None of the cases showed any fungal elements on PAS staining.
Figure 1: Case 2: (a) Clinical photograph demonstrated swelling in the right cervical region; (b and c): CECT neck revealed asymmetrical soft tissue thickening in the right tonsillar fossa extending to the epiglottis and right ary-epiglottic fold; (d) CECT chest revealed bilateral pleural effusion; (e) Histopathology revealed normal stratified squamous epithelium with subepithelial granulomas, H and E, 40×; (f) The granulomas are confluent and caseating, H and E, 100×; (g) Ziehl Neelsen stain demonstrated few acid fast bacilli, ZN, 1000×

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Figure 2: Case 8: (a) Clinical photograph demonstrating the ulcero-proliferative lesion on the lateral border of the tongue simulating malignancy; (b) Histopathological examination revealed partly ulcerated stratified squamous epithelium with subepithelial granulomas, H and E, 40×; (c) The granulomas are non-caseating (H and E, 200×)

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   Discussion Top

Tubercular involvement of oral cavity is a rare occurrence with incidence being 0.5-5% of total tuberculosis cases.[4] While saliva and intact oral mucosa serves as a protective agent, the local factors which predisposes for oral tuberculosis include poor oral hygiene, repetitive local trauma, leukoplakia, tooth extraction and mucosal lacerations.[3] Systemic predisposing factors include nutritional and immunodeficiencies,[5] however, in the present series none of the cases had any significant history of immunocompromised state.

Tubercular involvement of oral cavity can be primary or secondary.[1],[2] Primary oral lesions presents as painless ulcer with or without lymph node enlargement. In secondary cases pulmonary disease is seen along with associated oral lesions which are usually indurated, irregular ulcers.[6] Also, secondary involvement of oral cavity by tuberculosis is more common when compared to the primary form. In the series presented, however, an equal number of cases showed primary as well as secondary involvement of the oral mucosa.

In the present series males as compared to females were more commonly affected which was also observed by other authors.[7] The mean age of the patients' affected was 39.6 years in the present series which is in concordance with the age group of the published case reports from Indian subcontinent.[8] However, study reported by Wang et al. shows that majority of the patients affected were elderly when considering the western population.[9] When compared the age group of primary versus secondary tuberculosis of oral cavity, primary involvement was seen in young adults while secondary involvement was seen in the elderly. This finding was also mentioned by Krawiecka et al. in their review article.[2]

Within oral cavity, most common sites affected are tongue, gingival and palate.[10] However, in the present series buccal mucosa was seen to be the most common site involved followed by tonsil and soft palate. Tubercular lesions of oral cavity may manifest as nodules, fissures, ulcers, patches, plaques, indurations and papillomas among which ulcers and papillomas are most common presentations.[1] In the present series majority of the oral lesions were ulceroproliferative or ulcerative in nature. Elderly age, concominent lymph node involvement and ulceroproliferative lesions in oral cavity led the clinicians to suspect malignancy rather than tuberculosis due to rare involvement of oral cavity by tuberculosis.

Considering the prevalence of tuberculosis in Indian population, Pandit et al. reported that presence of epitheliod cell granulomas is indicative of tuberculosis unless proven otherwise.[11] Dimitrakopoulos et al. also reported that based on history and histological presence of granulomas and giant cells, a diagnosis of primary oral tuberculosis can be confirmed even if the smear, sputum and culture are negative for AFB.[12] In all the biopsies of the present series, well formed epitheliod cell granulomas were seen with or without caseous necrosis.

However, in few biopsies due to hyperplasia of overlying epithelium or presence of abundant acute inflammatory granulation tissue, deeper and serial sections were needed in order to identify the granulomas. Thus, our study emphasizes the importance of serial and deeper sections in oral biopsies when there is marked inflammatory exudate and reactive changes in the overlying tissue.

According to various studies, only 7.8% of histopathology specimens stain positive for AFB.[6] However, in the present series 31.25% of cases showed AFB positivity. All of these AFB positive cases showed caseous necrosis, and hence it is important to make a diligent search for AFB positive bacilli in caseating epithelioid cell granulomas which not only confirms the diagnosis but also alleviates the need for culture and other molecular based techniques like PCR which are time consuming and expensive. Sputum examination and chest X- ray should always be simultaneously carried out in cases presenting with oral tuberculosis to rule out the primary pulmonary foci.

Sarcoidosis, syphilis, fungal infections, foreign body giant cell reaction, Wegener's granulomatosis, syphilis etc. are other causes of granulomatous inflammation within the oral cavity.[13] In the present series, 16 cases of the 22 were due to tubercular infection. Of the remaining 6 cases, one case was a known and follow-up case of chronic granulomatous disease, 2 cases showed granulomatous inflammation secondary to dentures, 2 cases showed fungal hyphae, and in one case, definite etiological factor could not elucidated and was negative on tubercular or fungal culture. Hence, that particular case was thus excluded from the study.

Treatment of oral TB includes administration of systemic antitubercular drugs based on the standard treatment guidelines. Local therapy like topical anti-inflammatory ointments and mucosal protecting agents can be given. Local factors causing repetitive trauma should be eliminated and oral hygiene should be improved.

To the best of our knowledge the present work represent third largest series on orofacial tuberculosis and probably the second largest series from India. Previously Mignogna et al.[14] clinically evaluated 42 cases of oral tuberculosis and Neelam et al.[15] along with clinical symptoms emphasized the importance of histopathology in diagnosis of orofacial tuberculosis.

   Conclusion Top

Oral tuberculosis is uncommon and is often overlooked clinically due to non- specific presentations. Since clinically it simulates malignancy the role of histopathologist is of utmost importance in diagnosis of tuberculosis in oral biopsies. Deeper biopsies as well as deeper sections are always advocated to prevent misdiagnosis which not only delays early treatment but also leads to spread of the infection.

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Conflicts of interest

There are no conflicts of interest.

   References Top

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Correspondence Address:
Varuna Mallya
Department of Pathology, MAMC, New Delhi - 110 002
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJPM.IJPM_413_20

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