COM March 2009

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March 2009: Dark blue to black flat lesion anterior ventral tongue

Dolphine Oda, BDS, MSc
doda@u.washington.edu

Contributed by
Drs. Francis Collins & JR Craig Webster

Oral Surgery & General Dentistry, Wenatchee, WA

Case Summary and Diagnostic Information

This is an 84-year-old white female referred by her dentist for the evaluation of a flat bluish black lesion on the anterior ventral surface of tongue (Figure 1). The lesion was of unknown duration and was asymptomatic.

Diagnostic Information Available

History of present Illness

This is an 84-year-old white female referred by her dentist for the evaluation of a flat bluish black lesion on the anterior ventral surface of tongue (Figure 1). The lesion was of unknown duration and was asymptomatic.

Figure 1 Clinical photograph of the lesion taken at the first visit. Note the flat, irregular, dark blue to black lesion on the anterior ventral surface of tongue. Also note the purplish-red flat or slightly raised blebs on the lateral ventral surface of tongue

Medical History

This patient’s past medical history is significant for arthritis, hypothyroidism, high blood pressure and osteoporosis. She is taking Levoxyl, Crestor, Avapro and Fosamax.

Clinical and Radiographic Findings

The left lateral border of tongue showed evidence of an ulcer surrounded by a rim of white plaque (Figure 1). The dorsal and right lateral border of tongue showed no evidence of similar lesions. The central part of right buccal mucosa was white and rough (Figure 2). It had white striae interlacing to produce a reticular pattern. There was no evidence of ulceration. The left buccal mucosa appeared relatively normal with a hint of white striae.

Figure 1 Clinical photograph of the lesion taken at the first visit. Note the flat, irregular, dark blue to black lesion on the anterior ventral surface of tongue. Also note the purplish-red flat or slightly raised blebs on the lateral ventral surface of tongue.

Excisional Biopsy

Histologic examination of the H & E section revealed small clusters of a granular brownish black material deposited on delicate collagen fibers of the surrounding connective tissue, small blood vessels and skeletal muscle fibers (Figure 2 & 3). This material was surrounded by sheets of macrophages and occasional multinucleated foreign body type giant cells (Figure 3). The immunohistochemistry stain with CD68, an antibody for macrophages, was uniformly positive with some cells containing small black granules (Figure 4).

Figure 2 Low power (x100) histology shows H & E stained section with surface epithelium and underlying fibrous connective tissue containing brownish black granular material deposited on collagen fibers. and skeletal muscle bundles.

Figure 3 Higher power (x200) histology shows H & E stained section demonstrating macrophages and foreign body giant cells with black particles and one small clusters of that foreign material.

Figure 4 Higher power (x200) Immunohistochemistry stain with CD68 demonstrating positively stained macrophages and foreign body giant cells. Note the foreign material within some of these cells.

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