Journal scan: A review of images in clinical medicine of immediate clinical significance, harvested from major international journals

From the desk of the Editor-in-chief

Images in Clinical Medicine

(1). Lead Poisoning in a Child

Shalini H. Shah et al, Published June 4, 2025, N Engl J Med 2025;392:2150, DOI: 10.1056/NEJMicm2501209,VOL. 392 NO. 21

Abstract

A 7-year-old girl was referred to the ED for an elevated lead level. An abdominal radiograph showed intraluminal radio densities throughout the colon.

(2). Aspiration Thrombectomy for Coronary Stent Thrombosis

Habib A. Dakik etal, Published May 31, 2025, N Engl J Med 2025;392: e52,DOI: 10.1056/NEJMicm2416427,VOL. 392 NO. 21

Abstract

A 73-year-old woman presented with severe chest pain. She had undergone multivessel percutaneous coronary intervention 2.5 years earlier. Angiography revealed a large thrombus in an LAD artery stent

(3). Cardiac Injury Detected by Smartwatch

Thomas R. Basala et al,Published June 7, 2025,DOI: 10.1056/NEJMicm2500438

Abstract

A 76-year-old retired cardiovascular nurse presented to the ED with 2 hours of chest pain triggered by severe emotional distress and associated with changes in the electrocardiogram on her smartwatch.

(4). Ramsay Hunt Syndrome

Jiangtao Guo  et al, N Engl J Med 2025;392: e53,DOI: 10.1056/NEJMicm2500293,VOL. 392 NO

Abstract

A 48-year-old woman presented with a 1-day history of a rash on her right ear that was preceded by 2 days of ear pain and an inability to move the right side of her face.

(5). Tongue Atrophy and Fasciculations in Advanced Motor Neuron Disease

Harikrishnan Premdeep, N Engl J Med 2025;392: e54, DOI: 10.1056/NEJMicm2416155, VOL. 392 NO. 23

Abstract

A 32-year-old woman was brought to the hospital with a 3-year history of progressive weakness of the limbs and trunk. On examination, marked atrophy of the tongue with scalloping and fasciculations (shown in a video) was noted.

(6). Generalized Pustular Psoriasis

Su-Chi Ku, Published June 18, 2025, N Engl J Med 2025;392:2367,DOI: 10.1056/NEJMicm2500173,VOL. 392 NO. 23

Abstract

A 54-year-old woman with well-controlled chronic plaque psoriasis presented with a 2-day history of painful rash and fever. Widespread erythematous patches with overlying, coalescing pustules were seen on examination.

(7). Cutaneous Extramedullary Plasmacytoma after Bone Fracture

Madeline Conlon, Published June 21, 2025, DOI: 10.1056/NEJMicm2500986

Abstract

A 69-year-old man with multiple myeloma presented with an enlarging purple skin mass on his right shoulder at the surgical site of a recent intramedullary nailing of a humerus fracture.

(8). Boerhaave Syndrome

Penghui Wei et al, Published June 25, 2025, N Engl J Med 2025;392:2458.DOI: 10.1056/NEJMicm2500300,VOL. 392 NO. 24

Abstract

A 59-year-old man presented with a 5-hour history of severe, pleuritic chest pain after vomiting. CT of the chest revealed air in the mediastinum extending up to the neck and perforation of the esophagus.

(9). Diffuse Alveolar Hemorrhage in ANCA-Associated Vasculitis

Irene S. Lee, Published June 28, 2025, DOI: 10.1056/NEJMicm2416576

Abstract

A 57-year-old man presented with a 2-week history of worsening shortness of breath. Radiography and CT showed perihilar airspace opacities in both lungs, and bloody aliquots of fluid were obtained by bronchoalveolar lavage.

(10). Tongue Lesions While Undergoing Cancer Therapy

Kendall Lin et al, JAMA Oncol,Published Online: July 3, 2025,doi: 10.1001/jamaoncol.2025.1864,

– A woman in her 40s with well-differentiated grade 3 neuroendocrine tumor of the pancreas with liver metastases undergoing treatment with oral cabozantinib presented to a routine oncology appointment with tongue lesions for 1 week. She reported mild tongue sensitivity, especially with spicy food, but denied pain or dysphagia. The dorsal and lateral tongue exhibited multiple well-demarcated, annular erythematous macules and patches with white borders (Figure). No other oral ulcers, gingival lesions, lymphadenopathy, or mucocutaneous findings were noted. She had been taking the same dose of cabozantinib (40 mg once daily) for 3 months prior. The only other medication was apixaban for venous thromboembolism, initiated 2 years prior. The cancer-directed treatment prior to cabozantinib was capecitabine/temozolomide (discontinued 4 months prior).

What is Your Diagnosis?

  • Pellagra
  • Oral mucositis
  • Oral candidiasis
  • Geographic tongue
  • Discussion
  • Diagnosis
  • Geographic tongue

 

 

Discussion

The diagnosis of geographic tongue (benign migratory glossitis) is supported by the characteristic appearance of the tongue lesions as minimally symptomatic, well-demarcated, erythematous patches with hyperkeratotic borders in the absence of other cutaneous findings. The lesions may appear alarming, particularly in the context of cancer treatment, but are typically harmless. They frequently do not require intervention although topical analgesics can be offered to patients who are symptomatic. The patchy tongue lesions are inconsistent with the diffuse erythema of pellagra-associated glossitis (choice A), and the patient lacks the hallmark pellagra triad of dermatitis, diarrhea, and dementia. While oral mucositis associated with cabozantinib is a consideration—the incidence of any grade oral mucositis is 48%1—pausing cabozantinib is unwarranted as the minimally symptomatic lesions do not align with the typical presentation of oral mucositis, characterized by painful ulcerations and fibrinous exudate, favoring nonkeratinized mucosal surfaces (choice B).2 The absence of a cheesy white exudate that can be scraped off, with an underlying red patch, makes oral candidiasis unlikely (choice C).

Geographic tongue is an inflammatory condition of unclear etiology, characterized by erythematous, multifocal, patches circumscribed by white, elevated, hyperkeratotic margins along the dorsolateral aspect of the tongue.3,4 These lesions result from the loss of filiform papillae, often coalesce, and exhibit intermittent relapsing and remitting patterns with exacerbations ranging from days to years.3,4 Recurrent lesions often affect new areas, producing dynamic migratory patterns as epithelial proliferation and exfoliation at different sites create a maplike appearance. While most cases are asymptomatic, up to 25% of patients report a burning sensation (or irritation, soreness, or pain) over atrophic patches, typically triggered by hot, spicy, or acidic foods.3,5 The diagnosis is primarily clinical.

The prevalence of geographic tongue in the general population is estimated to be between 1.0% to 2.5%.3,4 The condition is most frequently seen in children and young adults, decreases in frequency with age, and may have a female predominance.6 Increased prevalence with family history and associations with human leukocyte antigen (HLA) alleles suggest a possible genetic component.7 Geographic tongue has been associated with various conditions, including psoriasis, juvenile diabetes, allergies, anemia, endocrinopathies, Down syndrome, and reactive arthritis. Geographic tongue may represent an oral manifestation of psoriasis, given the reported presence in up to 14% of individuals with psoriasis, the frequent psoriasiform histologic features, and the presence of shared HLA-Cw6 marker.7 Differential diagnoses, such as leukoplakia, lichen planus, candidiasis, and herpes simplex virus, can usually be ruled out based on history (lack of migratory patterns), examination, and histopathologic findings if needed. A biopsy is indicated only if the diagnosis is in doubt.

Histologically, geographic tongue resembles psoriasis. The white, elevated areas of the lesions exhibit a predominantly neutrophilic infiltrate at times undergoing exocytosis with subsequent microabscess and pustule formation as well as acanthosis and parakeratosis. The smooth, erythematous regions contain a predominantly lymphocytic infiltrate with vascular ectasia and loss of filiform papillae, as demonstrated by scanning electron microscopy.

Geographic tongue has been reported alongside the use of angiogenesis inhibitors, including anti–vascular endothelial growth factor agents and receptor tyrosine kinase inhibitors such as bevacizumab, sorafenib, and sunitinib.8 Prior case series have reported geographic tongue occurring on average 6 months after bevacizumab initiation, primarily in female individualss.9 The temporal association here—a first and hitherto only episode of geographic tongue occurring 3 months after initiating cabozantinib— makes cabozantinib a plausible etiology of geographic tongue in this case. Drug-associated geographic tongue does not have known oncologic ramifications, does not typically require drug modification or discontinuation, and does not typically require specific treatment.8

Reassurance is critical for patients given the dramatic appearance of the lesions, especially in the context of cancer and cancer treatment. Topical analgesics such as lidocaine can be offered to manage burning/pain, alongside avoiding triggering foods. No specific treatments are typically indicated, although tacrolimus swish-and-spit treatment has shown promising data in patients with resistant disease.3 Antihistamines, gabapentinoids, topical corticosteroids, and antifungals lack consistent evidence.3

The patient was counseled and reassured regarding the condition, no changes to cabozantinib were made, and no specific treatment was initiated. The lesions spontaneously resolved after 2 weeks. The patient continued cabozantinib. No recurrent lesions were noted at last follow-up 5 months later.

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