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case_images: (a) Positron emission tomography (PET) scan demonstrates hypermetabolic lesion in the tongue, which was suspicious for malignancy. (b) PET scan demonstrates multiple cervical lymph node involvement, which was suspicious for malignancy.
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case_images: However, a positron emission tomography scan revealed hypermetabolic lesions of the anterior tongue as well as lymph nodes bilaterally in levels I, II, and III suggestive of malignancy (Figure 1).
case_images: Lymph node tissue sample with hematoxylin-eosin stain demonstrating granulomatous inflammation.
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case_images: Lymph node biopsy results demonstrated noncaseating granulomatous inflammation with no malignancy (Figure 2), while laboratory results demonstrated markedly elevated ACE (angiotensin converting enzyme) levels.
case_images: Lymph node tissue sample with immunohistochemistry demonstrating spirochetes.
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case_images: The lymph node biopsy sample was then analyzed with immunohistochemistry (IHC) revealing spirochetes (Figure 3). The patient was diagnosed with tertiary syphilis and started on doxycycline 100 mg twice daily for 30 days because of a severe penicillin allergy.
case_images: Persistent tongue cleft after antibiotic therapy.
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case_images: After receiving treatment, the patient came back to our clinic with his tongue lesion healing well but with a persistent anterior tongue cleft (Figure 4).