Case report
Glossitis with linear lesions: An early sign of vitamin B12 deficiency

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The classic oral manifestations of vitamin B12 deficiency are considered nonspecific. We describe 4 patients with oral linear lesions associated with vitamin B12 deficiency. Patients were free of neurologic symptoms and anemia at diagnosis. We believe that glossitis with linear lesions is an early clinical sign of vitamin B12 deficiency. We recommend the determination of vitamin B12 in such patients, even in the absence of anemia.

Introduction

The classic triad of vitamin B12 deficiency consists of the presence of megaloblastic anemia, gastrointestinal symptoms or glossitis, and neuropsychiatric symptoms.1 Early diagnosis is important because neurologic signs could be irreversible.

Vitamin B12 deficiency can present with several oral manifestations, which are considered nonspecific. Hunter's glossitis (or Moeller-Hunter) is the most classic form. Hunter's glossitis, which presents in up to 25% of cases,2 is characterized by diffuse erythema and lingual atrophy. There are other oral manifestations of vitamin B12 deficiency: glossodynia, recurrent ulcers, lingual paresthesia, burning, pruritus, dysgeusia, intolerance to dental prosthesis, intermittent xerostomia, stomatitis, and cheilitis.3, 4, 5, 6, 7, 8, 9, 10 All manifestations are considered clinically nonspecific. The majority of published cases are in the odontologic literature.

We describe 4 patients with oral linear lesions associated with vitamin B12 deficiency. We suggest that this presentation is evocative of the deficit and precedes the onset of macrocytic anemia.

Section snippets

Cases

The major clinical and laboratory findings are summarized in Table I.

Patient 1 was referred in May 2003 because of stomatitis and glossitis of 1 year's duration. She had been treated for malignant melanoma in the gluteal region in 1988, without further problems. In 1995 a hysterectomy with removal of the ovaries and Fallopian tubes was performed because of squamous cell carcinoma of the cervix; as sequelae of the procedure, a ureterorectal fistula and bowel subocclusive episodes resulted. On

Discussion

Glossitis in vitamin B12 deficiency is present in up to 25% of cases2; it is traditionally described as a diffuse and clinically nonspecific atrophy of lingual papillae affecting more than half of the tongue, and it is classically known as Hunter's glossitis or glossitis of Moeller-Hunter.

The glossitis found in our patients does not correspond to the classic description. All of our cases presented with linear lesions. We think that our patients, if not diagnosed, would have developed the

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Funding sources: None.

Conflicts of interest: None declared.

This work was presented as a poster at the XXXVI Spanish National Congress of Dermatology and Venereology, Barcelona, June 11-14, 2008; it received second place award to the best poster of the Congress.

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