Photo Rounds

Mouth pain

A 52-year-old woman visited her family physician (FP) because she had severe mouth pain and found it difficult to eat. She also had some skin lesions, with superficial erosions, on her face and breast. The FP noted large mucosal erosions on her palate and buccal mucosa; her tongue had a black coating. The patient was not dehydrated, but was clearly in pain.

What's your diagnosis?


The FP suspected that this might be a case of pemphigus vulgaris and called a colleague who had additional fellowship training in dermatology. The colleague performed a shave biopsy on a skin lesion at the edge of a previous blister on the breast. He sent the blister edge for standard pathology and the perilesional skin for direct immunofluorescence. He also started the patient on prednisone 60 mg/day and gave her dexamethasone mouth solution.

He encouraged her to drink plenty of fluids and 2 days later, at a follow-up appointment, the patient was feeling better and able to eat some solid foods. The pathology reports confirmed pemphigus vulgaris and long-term management was initiated. The black coating of the tongue was secondary to poor oral hygiene related to the disease and the patient’s inability to brush her teeth while suffering from painful oral ulcers.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Usatine R, Gonsalves W. Black hairy tongue. In: Usatine R, Smith M, Mayeaux EJ, Chumley H. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:226-231.

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