A 39-year-old male patient from 1991 at the Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán (INCMNSZ) in Mexico City was diagnosed with HIV infection.
The patient was evaluated in 1999 for weight loss, fever, diaphoresis, generalized lymphadenopathy and PPD of 35 mm. The viral load (CV) was 12 254 copies/ml and CD4+ count 356 lymphocytes.
Cervical lymph node biopsy showed granulomatous lymphadenitis with caseous necrosis and Langhans type multinucleated giant cells, consistent with the diagnosis of lymph node tuberculosis, cultures for mycobacteria were negative.
Antiphymic treatment was administered for four months with rifampicin (600 mg/d), isoniazid (300 mg/d), pyrazinamide (1200 mg/d), and isoniazid (300 mg/d), followed by rifampicin/600 mg/d).
During follow-up, oral candidosis and hairy leukoplakia were identified.
In December 2001, the CV was 52 800 copies/ml and CD4+ 141 cells/mm3, without antiretroviral treatment initiation on the basis of the patient's decision.
In May 2003, the patient came to the consultation for presenting a painful superficial ulcer in the tongue, of 4 months of evolution, with a diameter of 0.7 cm, well circumscribed, crateriform, with slightly elevated borders.
Laboratory studies showed a decrease in the CD4+ lymphocyte count to 113 cel/mm3.
Histopathological study showed chronic granulomatous inflammation with multinucleated giant cells.
Ziehl-Neelsen stains, Gram staining and Schiff periodic acid and culture were negative.
An attempt was made to perform a PCR test for identification of mycobacteria in paraffin-embedded tissue; however, DNA was not extracted from the scarce remaining tissue.
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Although there was no isolation or identification of mycobacteria, the histopathological findings were considered to be highly suggestive of recurrence of tuberculosis with lingual involvement, thus rifampicin (600 mg/day isoniazid) and pyrazinamide (1200 mg/day),
In June 2003, the patient started highly active antiretroviral therapy (HAART), which included zidovudine (600 mg/d), lamivudine (300 mg/d) and efavirenz (600 mg/d).
Lingual lesion resolved favorably, with partial healing in the first week and total healing 45 days after starting antifimic treatment.
During follow-up, 7 months after the onset of tongue disease, the clinical response was satisfactory, without injury.
