1. CASE PRESENTATION
A 43‐year‐old‐human immunodeficiency virus (HIV)‐positive male (CD4+: 231 cells/uL) presented with 7 days of tongue lesions and 3 days of worsening tongue swelling, fever, sore throat, myalgia, malaise, and headache. Blisters initially appeared on the tip of the tongue and then progressed posteriorly. He was unable to tolerate oral intake. At presentation, his temperature was 39.3°C, pulse was 124 beats/min, respiratory rate was 20 breaths/min, blood pressure was 132/101 mmHg, and room air oxygen saturation was 100%. The tongue was swollen with multiple 5‐ to 10‐mm tan, indurated, well‐demarcated lesions with central ulceration and surrounding white exudate (Figure 1). There was no cervical adenopathy or other skin lesions. Laboratory and imaging results are available in Table 1.
FIGURE 1.
Painful tongue lesions at the time of emergency department presentation
TABLE 1.
Laboratory and imaging results
| Test | Result | Reference Range | Units |
|---|---|---|---|
| White blood cell count | 7.2 | 3.4 ‐ 11.0 | K/mcL |
| Hemoglobin | 17.4 | 13.0 ‐ 17.1 | g/dL |
| Platelets | 172 | 150 ‐ 425 | K/mcL |
| Sodium | 133 | 137 ‐ 145 | mmol/L |
| Potassium | 4.1 | 3.5 ‐ 5.1 | mmol/L |
| Chloride | 95 | 98 ‐ 107 | mmol/L |
| Bicarbonate | 26 | 22 ‐ 30 | mmol/L |
| Blood urea nitrogen | 17 | 9 ‐ 20 | mg/dL |
| Creatinine | 1.00 | 0.70 ‐ 1.30 | mg/dL |
| Calcium | 8.6 | 8.4 ‐ 10.2 | mg/dL |
| Glucose | 105 | 70 ‐ 125 | mg/dL |
| Magnesium | 2.1 | 1.6 ‐ 2.3 | mg/dL |
| Bilirubin, total | 0.6 | 0.2 ‐ 1.3 | mg/dL |
| Alkaline phosphatase | 99 | 38 ‐ 126 | Units/L |
| Alanine transaminase (ALT) | 61 | ≤ 49 | Units/L |
| Aspartate aminotransferase (AST) | 58 | 17 ‐ 59 | Units/L |
| Lactic acid, venous | 2.6 | 0.70 ‐ 2.10 | mmol/L |
| Absolute CD4+ | 231 | 430 ‐ 1800 | cells/μL |
| Absolute CD3 | 496 | 570 ‐ 2400 | cells/μL |
| Treponemal antibody screen | Reactive | Non‐Reactive | |
| Rapid plasma reagin (RPR) | Positive (titer 1:8) | Non‐Reactive | |
| RPR, 38 months prior1 | Positive (titer 1:2) | Non‐Reactive | |
| RPR, 45 months prior1 | Positive (titer 1:2) | Non‐Reactive | |
| HIV viral load (PCR) | <20 | 20 ‐ 10,000,000 | copies/mL |
| COVID‐19 Rapid (PCR/NAAT) | Not Detected | Not Detected | |
| Influenza A/B (PCR) | Not Detected | Not Detected | |
| Herpes Simplex Virus Type 1 (PCR) | Not Detected | Not Detected | |
| Herpes Simplex Virus Type 2 (PCR) | Not Detected | Not Detected | |
| Monkeypox (PCR) x2 lesions | Detected | Not Detected | |
| Coxsackievirus | Single titer ≥ 1:80 may indicate past or current infection | ||
| Antibody B type 1 | 1:20 | ||
| Antibody B type 2 | 1:10 | ||
| Antibody B type 3 | 1:10 | ||
| Antibody B type 4 | 1:20 | ||
| Antibody B type 5 | <1:10 | ||
| Antibody B type 6 | <1:10 | ||
| Urinalysis | |||
| Color | Yellow | Yellow | |
| Clarity | Clear | Clear | |
| Specific Gravity | 1.005 | 1.005‐1.030 | g/cm3 |
| pH | 6.0 | 5.0 ‐ 8.5 | pH |
| Protein, glucose, ketones, bilirubin, occult blood, leukocyte esterase, and nitrite | Negative | Negative | |
| Urobilinogen | 0.2 | <2.0 | mg/dL |
| Urine Toxicology | Positive for amphetamine | ||
| Blood cultures x2 | No growth after 5 days (final result) | ||
| Chest X‐Ray | IMPRESSION: No acute pulmonary disease | ||
Abbreviations: CD, cluster of differentiation; COVID‐19, coronavirus disease 2019; NAAT, nucleic acid amplification test; PCR, polymerase chain reaction; RPR, rapid plasma reagin; WBC, white blood count.
aTreponemal antibody screen was also reactive 38 and 45 months before presentation, which reflexed to RPR titers.
2. DIAGNOSIS
2.1. Monkeypox
He was admitted for dehydration and lactic acidosis, which resolved in 2 days with intravenous fluids. The white tongue exudate worsened (Figures 2 and 3), and nystatin was prescribed. Polymerase chain reaction testing was positive for monkeypox and negative for herpes simplex virus and coxsackievirus. He was prescribed acetaminophen and viscous lidocaine for pain but preferred using tea tree oil. He was able to resume a normal diet 4 days after discharge. The patient was advised to isolate and wear a mask until all lesions healed.
FIGURE 2.
Tongue lesions (hospital day 1)
FIGURE 3.
Tongue lesions (hospital day 2)
This patient presented with isolated tongue lesions and no clear monkeypox exposure. There was no history of contact with infected skin, body fluids, or respiratory droplets, the primary routes of monkeypox virus transmission. 1 , 2 Hospitalization for inability to tolerate oral intake due to oropharyngeal pain is reported in 0.95% monkeypox cases. 3 Clinicians should consider monkeypox as a cause for isolated tongue lesions.
Penny CL, Koenig KL, Marty AM, Beÿ CK, Norton VC. Man with painful tongue lesions. JACEP Open. 2022;3:e12858. 10.1002/emp2.12858
REFERENCES
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