Fissured Tongue associated with Hypothyroidism in a Young Patient

Abstract

Fissured tongue is a benign oral condition characterized by grooves or fissures on the dorsal surface of the tongue and is often considered idiopathic. However, it has occasionally been reported in association with systemic disorders, including endocrine abnormalities. We report the case of an 18-year-old male who presented with fatigue, cold intolerance, weight gain, and progressive fissuring of the tongue over several years. Intraoral examination revealed multiple prominent fissures on the dorsal surface of the tongue with mild macroglossia. Laboratory investigations demonstrated elevated thyroid-stimulating hormone levels with borderline low free thyroxine and mildly raised antithyroid peroxidase antibodies, findings suggestive of hypothyroidism possibly related to autoimmune thyroid disease. The patient was started on levothyroxine therapy, resulting in improvement of systemic symptoms and normalization of thyroid function tests within 6 months. However, the fissured appearance of the tongue persisted despite biochemical euthyroidism. This case is noteworthy because the patient was a young adult with progressive tongue fissuring preceding diagnosis, a positive family history of thyroid disease, and persistence of fissures despite appropriate thyroid hormone replacement therapy. The report highlights the potential association between oral findings and systemic endocrine disorders and emphasizes the importance of careful oral examination in patients presenting with suggestive systemic symptoms.

INTRODUCTION

Fissured tongue, also known as lingua plicata, scrotal tongue, furrowed tongue, cerebriform tongue, or grooved tongue, is a benign oral condition characterized by multiple grooves or fissures on the dorsal surface of the tongue.[1,2,3] The condition is often asymptomatic, but may occasionally cause discomfort, burning sensation, or halitosis due to the accumulation of food debris within the fissures. Although fissured tongue is commonly considered idiopathic or hereditary, it has also been reported in association with several systemic conditions, including Down syndrome, Melkersson–Rosenthal syndrome, Sjögren’s syndrome, psoriasis, and certain endocrine disorders.[4,5,6,7] Hypothyroidism is a common endocrine disorder characterized by reduced production of thyroid hormones and elevated serum thyroid-stimulating hormone (TSH) levels. Thyroid hormone deficiency can affect multiple organ systems and may also influence oral health. Several oral manifestations have been described in patients with hypothyroidism, including macroglossia, delayed tooth eruption, xerostomia, and altered tongue morphology.[8,9] However, the relationship between hypothyroidism and fissured tongue remains incompletely understood, and such oral findings are often overlooked during routine clinical evaluation. Early recognition of oral manifestations may provide useful clues for identifying underlying systemic disorders. In some patients, subtle oral changes may precede or accompany systemic symptoms and prompt further medical investigation. In this report, we describe a case of a young patient having common symptoms of hypothyroidism presenting with prominent fissuring of the tongue, highlighting the potential association between oral findings and thyroid dysfunction and emphasizing the importance of careful oral examination in clinical practice.

CASE REPORT

History

An 18-year-old male presented to the outpatient department of the thyroid clinic (department of nuclear medicine) at a tertiary care center with complaints of progressive weight gain, persistent fatigue, and the development of deep grooves on the surface of his tongue over the past few years. The patient reported increased sensitivity to cold, dry skin, and occasional discomfort in the neck region. His body weight at presentation was 72 kg. The patient had no prior history of systemic illness and was not taking any regular medications. He was a nonsmoker and nondiabetic. A relevant family history was noted, as his mother had been diagnosed with hypothyroidism and was receiving levothyroxine replacement therapy.

Clinical examination

General physical examination revealed a patient who was clinically stable, with a regular pulse rate of 72 beats/min. No visible swelling in the anterior neck suggestive of goiter was observed, and there were no hand tremors. Intraoral examination revealed multiple prominent fissures and grooves of varying depth on the dorsal surface of the tongue, extending in both longitudinal and transverse directions, characteristic of fissured tongue [Figure 1]. The tongue appeared mildly enlarged but was nontender, with no signs of ulceration, inflammation, or secondary infection. The surrounding oral mucosa appeared normal, and oral hygiene was assessed to be fair. Given the presence of systemic symptoms such as fatigue, weight gain, and cold intolerance along with the oral findings, further laboratory investigations were advised to evaluate possible systemic causes.

Figure 1.

Multiple fissures and grooves of variable depth on the dorsal surface of the tongue, running in both longitudinal and transverse directions

Investigations

Thyroid function tests revealed an elevated serum TSH level of 11.51 µIU/mL (reference range: 0.35–5.5 µIU/mL) and a borderline low free thyroxine (FT4) level of 11.37 pmol/L (reference range: 11.5–22.7 pmol/L). Antithyroid peroxidase antibodies were mildly elevated at 69 IU/mL (reference range: 0–60 IU/mL). These findings were suggestive of hypothyroidism, possibly related to autoimmune thyroid disease.

Routine hematological investigations showed a hemoglobin level of 16.3 g/dL, total leukocyte count of 5820 cells/mm³, red blood cell count of 5.35 million/mm³, and platelet count of 239,000/µL. The erythrocyte sedimentation rate was 15 mm/h, which falls within or close to the normal range for this age group. Additional nutritional parameters were assessed to exclude other potential causes of tongue changes. Serum Vitamin B12 level was 420 pg/mL (reference range: 200–900 pg/mL), serum ferritin was 110 ng/mL (reference range 30–400 ng/mL), and serum folate level was 8.5 ng/mL (reference range: 3–17 ng/mL).

Management

Based on the clinical and laboratory findings, the patient was started on oral levothyroxine therapy at a dose of 25 µg daily. The patient was advised to maintain good oral hygiene and to attend regular follow-up visits for monitoring of thyroid function.

Outcome and follow-up

At the 6-month follow-up visit, the patient reported improvement in fatigue and overall well-being. Repeat thyroid function tests demonstrated normalization of thyroid parameters, with a TSH level of 3.7 µIU/mL and an FT4 level of 19.14 pmol/L. His total cholesterol level was 187 mg/dL, which was within normal limits. Despite the improvement in systemic symptoms and normalization of thyroid function tests, the fissured appearance of the tongue remained unchanged on clinical examination [Figure 2].

Figure 2.

Dorsal surface of the tongue showing persistent fissures and grooves at the 6-month follow-up, despite normalization of thyroid function after levothyroxine therapy

DISCUSSION

Fissured tongue is a relatively common benign oral condition characterized by multiple grooves or fissures on the dorsal surface of the tongue. The reported prevalence in the general population ranges from approximately 1% to 5%, although higher rates have been described in certain populations.[10,11] In most cases, the condition is asymptomatic and is often detected incidentally during routine oral examination. However, it may occasionally be associated with symptoms such as burning sensation, halitosis, or irritation due to the accumulation of food debris within the fissures. The etiology of fissured tongue is considered multifactorial. Genetic predisposition is believed to play an important role, as the condition has been reported to occur more frequently among family members. In addition, fissured tongue has been described in association with several systemic conditions, including Down syndrome, Melkersson–Rosenthal syndrome, psoriasis, and autoimmune disorders.[4,5,6,7] Endocrine abnormalities such as hypothyroidism have also been reported to present with various oral manifestations. Hypothyroidism is known to influence oral tissues through metabolic and structural changes. Patients with thyroid hormone deficiency may develop oral findings such as macroglossia, xerostomia, delayed tooth eruption, and alterations in tongue morphology.[8,9] The exact mechanism underlying the association between hypothyroidism and fissured tongue remains unclear. However, reduced thyroid hormone levels may affect tissue metabolism and contribute to the accumulation of mucopolysaccharides within soft tissues, potentially leading to tongue enlargement and altered surface morphology. Xerostomia and reduced salivary flow, which may occur in hypothyroid patients, could also contribute to the development or accentuation of tongue fissures. Although fissured tongue has been described in association with hypothyroidism, reports highlighting its role as a clinical clue in young individuals remain limited. In the present case, several features make the observation noteworthy. The patient was only 18 years old and presented with progressive fissuring of the tongue that had developed over several years before diagnosis. In addition, the presence of a family history of thyroid disease raised suspicion of an underlying endocrine disorder. These findings emphasize that oral manifestations, when accompanied by systemic symptoms such as fatigue, weight gain, and cold intolerance, may prompt further investigation for thyroid dysfunction. Early recognition of such oral findings may therefore assist clinicians in identifying underlying endocrine disorders at an earlier stage. An additional observation in this case was the persistence of tongue fissures despite normalization of thyroid function following levothyroxine therapy. This finding suggests that the fissured appearance of the tongue may represent long-standing structural changes rather than a reversible manifestation of active thyroid dysfunction. Similar observations have been reported in other oral conditions where morphological alterations may persist even after correction of the underlying systemic disorder.

Certain limitations should be considered when interpreting this report. The follow-up period was limited to 6 months. Future studies with longer follow-up and broader evaluation may help clarify the potential relationship between fissured tongue and thyroid dysfunction.

Overall, this case highlights the importance of careful oral examination as part of routine clinical assessment. Recognition of oral findings such as a fissured tongue, particularly when associated with systemic symptoms, may assist clinicians in identifying possible underlying endocrine disorders and prompt appropriate medical evaluation.

CONCLUSION

This case highlights a possible association between fissured tongue and hypothyroidism in a young patient presenting with systemic symptoms such as fatigue, weight gain, and cold intolerance. Recognition of oral findings during routine examination may provide useful clinical clues that prompt further evaluation for underlying endocrine disorders. Although thyroid hormone replacement improved the patient’s systemic symptoms and normalized thyroid function tests, the persistence of tongue fissures suggests that such morphological changes may represent long-standing structural alterations. Careful oral examination may therefore contribute to the early identification of systemic conditions in appropriate clinical settings.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.v